Medical Center Uses ‘Room of Errors’ and ‘Situation Room’ in Effort to Cut Medical Mistakes; Must Balance Open Discussion with Right to Disclosure

Two new programs launched at the University of Virginia (UVA) Medical Center are attempting to improve patient safety by using a team-based approach to identify problems and work out solutions.

If early results are any indication, UVA is making strides: its Medical Center is ahead of the national average in many patient safety measures, according to a WVTF Public Radio report.

Simulation Lab Balances Technology with Teamwork

“The Room of Errors” is a pilot program that presents pediatric intensive care unit workers with a high-tech infant mannequin that’s hooked up to a typical array of monitors. The staffers know there are issues that could put the “patient” at risk and are given seven minutes to note as many problems as possible.

In a typical learning exercise, a doctor and a nurse each identify about 30 problems, but as a team, 54 issues are detected – issues such as the ventilator being incorrectly plugged in, potassium chloride running at the wrong rate, and the heater not being on.

The ability of the health-care professionals to function more effectively as a team than as individuals is known as “inter-professional education.”

“Training people from different professions together improves their ability to communicate, problem-solve, make decisions together that benefit the patient,” Dr. Valentina Brashers of the UVA Schools of Nursing and Medicine told WVTF Public Radio. “And the data is very clear that when teams work together effectively, patient safety is improved, quality care is improved.”

The Room of Errors has so far been used only to train clinicians from pediatric intensive care, but UVA plans to expand the program to all parts of the hospital.

In Situation Room, Hospital Administrators Discuss Day’s Missteps

Similar to the White House’s Situation Room where the president gathers top advisers to monitor and manage crises, UVA’s “Situation Room” – the brainchild of Dr. Richard Shannon, UVA’s Vice President for Health Affairs – is a place for top hospital administrators to meet and discuss patient safety issues that occurred in the past 24 hours.

“The Situation Room is a live place where we actually see the harm that occurred yesterday, and we can evaluate it,” Shannon told WVTF.

Fifteen top administrators join Shannon in the Situation Room each weekday morning at 7 a.m. The executive team discusses issues such as blood infections, pressure sores, and unexpected deaths, and then heads to the places where problems occurred to work out solutions.

It isn’t just an executive affair, however. All hospital staffers contribute to the goal of reducing patient harm. A receptionist, for example, discovered that patients were tripping over an entrance mat and decided to remove it on dry days to reduce accidents.

Although communication and investigation is critical to meeting patient safety goals, the desire to keep such meetings private must be balanced with patients’ rights concerning information surrounding errors.  Most hospitals rely on “Quality Improvement Protection” laws that protect the confidentiality of meetings in which hospital staff discuss errors and preventable injuries. In litigation, patients can be blocked from learning what was discussed about the negligent care, and are often barred from presenting evidence of what hospitals did or did not do in the wake of a tragedy.

“When questions surrounding internal investigations and committee meetings arise during discovery, defendants focus on the argument that the protection is intended to help improve quality and prevent error by permitting full and candid analysis of incidents without the fear of reprisal,” explains Angela Macey-Cushman, attorney at Morrow Kidman Tinker Macey-Cushman, a Washington medical malpractice lawyer who has written on this subject. On the other hand, “Plaintiffs point to the liberal discovery rules in our state, and assert that the defendant has a high burden of proof to establish that the protection applies for the particular information or documents sought in discovery.”

Sources:

• WVTF Public Radio – Room of Errors” Saves Lives
• WVTF Public Radio – Situation Room” for Patient Safety
• WVIR NBC 29 – Room of Errors” Puts Focus on Patient Safety at UVA
• Macey-Cushman, Angela.  Understanding quality improvement program discovery immunities in Washington, Trial News, October 2010, Volume 46-2