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Reducing Medical Error Requires A Culture Change In Hospitals, Not Just A Checklist

Jill Johnson
UNT Health Science Center
Dr. Michael Williams was named President of the University of North Texas Health Science Center (UNTHSC) in 2013.

Everyone makes mistakes — even doctors in emergency rooms and anesthesiologists during surgery. Despite safety checklists and top-of-the-line technology, The Centers for Disease Control and Prevention estimates 250,000 Americans die annually due to medical errors. That’s more deaths than from lung and prostate cancer combined.

A new Institute for Patient Safety in Fort Worth aims to reduce medical errors by changing the culture in North Texas hospitals and training future health care workers.

The first time Dr. Mike Williams saw a medical mistake in the operating room, he was a surgery intern in Dallas, in his mid-20s.

“I was in the room assistin,g and this patient was having a colon surgery for a colon cancer," he recalls. "All of a sudden he starts shaking all over, and we did the surgery. After the fact, we found out he had been awake during the surgery.”

Williams said the anesthetist had mistakenly given the young man only one of two drugs: the one to paralyze him, but not the one put him to sleep.

“It was horrific to me that that would happen in the United States," Williams says. "I swore up and down that would never happen again.”

Credit Jill Johnson / UNT Health Science Center
UNT Health Science Center
Dr. Michael Williams, President of UNTHSC, helped create the new Institute for Patient Safety.

Medical errors are the third leading cause of death for Americans

In his dogged pursuit to wipe out medical errors like that one, and unnecessary infections and patient falls, Mike Williams says he hasn’t been everyone's friend. But since becoming president of UNT Health Science Center in Fort Worth he’s helped secure $4 million in funding from the State Legislature for what he calls a first-of-its-kind patient safety institute in Texas.

"We’ve got cancer institutes everywhere, cardiac institutes everywhere, but we don’t have patient safety institutes,” Williams says.

Medical errors are the third leading cause of death for Americans. Unlike treating cancer though, treating medical errors requires changing cultures among hospital staff and patients. And that means making it OK to talk about mistakes, and learn from them. To do this, Williams is bringing together people from competing hospitals like JPS Health Network and Cook Children's Medical Center. Even more importantly, the institute will train students from Texas Christian University.

"The real way I could have an impact," Williams says, "[is to] get at the place where the providers are being trained and train them differently.”

Patients should be part of their own health care team, and if they can do that, it will lead to better quality care, better safety and greater satisfaction.

'Safety checklists alone won’t be enough'

Lest you think this is all a big pipe dream, patient safety institutes can have a huge impact. Just look at the results from Johns Hopkins, where researchers at the Armstrong Institute for Patient Safety created a simple checklist protocol to prevent bloodstream infections.

“We estimate the checklist protocol has saved more than 1,500 lives and $100 million each year,” Dr. Albert Wu, professor of health policy and management at Johns Hopkins, says. He says it used to be accepted that a certain number of patients with IV catheters would get an infection. Each time it would cost tens of thousands of dollars, and sometimes the life of the patient. Then, the Armstrong Institute for Patient Safety created a step-by-step checklist to follow as part of a training program.

"In a remarkably short time, use of the checklist and of this training mechanism was able to drive the rate of bloodstream infections essentially zero. In fact, on many units at Johns Hopkins there has never been another bloodstream infection since the mid 2000s.”

So what can the Patient Safety Institute in Fort Worth learn from Johns Hopkins? Wu says it's important to remember safety checklists alone won’t be enough. Doctors have to partner with the entire health care team, and with patients.

"Patients should be part of their own health care team, and if they can do that, it will lead to better quality care, better safety and greater satisfaction.”

This is the roadmap Michael Williams says the Institute for Patient Safety at UNT Health Science Center will follow. One that puts patients at the center and builds a culture of honesty and safety around them. 

Lauren Silverman was the Health, Science & Technology reporter/blogger at KERA News. She was also the primary backup host for KERA’s Think and the statewide newsmagazine  Texas Standard. In 2016, Lauren was recognized as Texas Health Journalist of the Year by the Texas Medical Association. She was part of the Peabody Award-winning team that covered Ebola for NPR in 2014. She also hosted "Surviving Ebola," a special that won Best Long Documentary honors from the Public Radio News Directors Inc. (PRNDI). And she's won a number of regional awards, including an honorable mention for Edward R. Murrow award (for her project “The Broken Hip”), as well as the Texas Veterans Commission’s Excellence in Media Awards in the radio category.