By Sarah Ellerman
Illustration by Malcolm Garris/PhotoDisc
February 4, 1999

Each year, 180,000 people die as a result of preventable medical errors, and an additional 1.1 million are injured, according to a Harvard University study. In response to growing concerns about patient safety, one of the nation’s largest healthcare systems is taking the initiative to prevent medical errors.

Instead of being handed their walking papers for making a mistake, health professionals at the Veterans Health Administration (VHA) will be eligible for cash rewards if they point out a problem and suggest a solution, said Kenneth Kizer, MD, undersecretary of health for the Department of Veterans Affairs.

A cultural change

It is the culture surrounding errors that requires changing more than any one system, experts say. In recent years, researchers studying medical errors have stressed the need for health care to refocus on prevention instead of blame. Other high-risk industries, such as aviation and nuclear power, view errors as systemic problems, rather than the slip-up of an individual.

The VHA is uniquely positioned to lead the way in changing this culture, Kizer said. In addition to being national and public, the VHA is vast and represents the entire spectrum of facilities, including large academic centers, small rural hospitals, and nursing homes. The VHA is also a major research presence and trainer of health professionals, so it has the money and the personnel to effect change, all in the public eye.

The VHA’s willingness to reform is aided largely by the nation’s tort laws. Individual physicians and nurses within the system cannot be sued for malpractice, Kizer said. Instead, patients must sue the VA. In the private sector, health professionals fear being sued if they admit a mistake, which is one of the biggest barriers to improvement, he said.

Offering rewards

The most tangible evidence of the VHA’s new program is the cash rewards for front-line practitioners who come up with ways to eliminate errors. If selected to receive the Patient Safety Improvement Award, individuals can get up to $5,000 and institutions, up to $25,000.

Last year, Colmery-O’Neil VA Medical Center in Topeka, Kansas, became the first facility to receive the award. Colmery-O’Neil won it for a bar-coding system it pioneered to help reduce errors in medication administration, said Russell Carlson, RN, who helped develop the program.

The Topeka system gives nurses handheld computers into which everything is scanned—the nurses’ ID badge, the patient’s armband, and the bar code on the medication packet—in an effort to reduce human error. It has been successful; since the system started, errors in administration are down from 22 to 6.3 per 100,000 doses administered—a drop of over two-thirds. Although a few nurses are wary of the computerization, said Carlson, "any nurse that this system has prevented from making a medication error is very, very supportive of it." The award-winning system is being studied for adaptation in other VHA facilities.

Goals and milestones

What are the VHA’s goals for the program? "The key objective is to reduce preventable errors to the absolute minimum," Kizer said. Because this can occur only in an arena where errors are analyzed instead of punished, the cultural turnaround is the other goal. "We must start looking at errors as opportunities for improvement," said Kizer, adding that the goal is a system in which no one is considered infallible. information

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