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An Interesting Approach to Reducing Medical Errors

As San Diego medical malpractice attorneys, we think California hospitals can learn a lot from Dr. Donald Berwick, the current steward of the Medicare and Medicaid programs. Berwick has a unique approach to improving care and reducing medical errors by borrowing best practices from other industries, such as the automotive or airline industries.

As detailed in a recent Los Angeles Times article, hospitals can learn a lot by looking outside of medicine. For instance, safety is such an ingrained aspect of commercial aviation that the average air traveler now has a 1 in 20 million chance of dying in an accident. By contrast, 1 in 7 Medicare patients is hurt during a hospital stay, a 2010 government study found.

Berwick, a pioneer of patient safety for most of his career, is trying to change that. “We’re frail,” Berwick said. “I have four children. I mix up their names all the time. I dropped my cup of coffee and spilled it on myself. … But mistakes can be prevented by redesigning systems to protect human beings from their own frailty.”

To demonstrate his point, Berwick describes a hospital where babies were dying at an alarming rate because nurses administered epinephrine, which helps newborns with trouble breathing, instead of Vitamin E, a dietary supplement. The two medications came in virtually identical brown bottles with blue-and-beige-striped labels.

That system was “perfectly designed to kill babies by ensuring a specific, low but inevitable rate of mix-up,” Berwick said.

While at Harvard, Berwick began advocating for hospitals and doctors to protect patients by developing quality systems modeled on industry leaders like Toyota, Xerox, and Dell. He is now bringing that approach to the federal government.

Since he took the helm of the federal Centers for Medicare and Medicaid Services last year, Berwick has plunged into what he calls “bringing excellence to scale.”

He has already mobilized thousands of hospitals, doctors and others behind a new campaign to cut hospital-acquired infections and other problems by 40% by 2013 and hospital readmissions by 20%. Meanwhile, at CMS’ new Innovation Center, over 180 health policy experts are fielding and analyzing hundreds of suggestions about ways the federal government can help improve quality.

In one such initiative, Berwick’s team is looking at whether paying nurses to make house calls to very ill seniors could keep the patients out of the hospital and save money. They also are researching ways to reward caregivers who implement systems to eliminate bedsores, a preventable condition that costs millions of dollars annually.

Unfortunately for patients, Berwick’s work may be cut short, as his confirmation faces an uphill battle in Congress. In the meantime, he is setting an excellent example of the focus and ingenuity needed to improve patient care and reduce medical errors.