Since Mr. Levy had created a safe environment for his employees that made them feel comfortable reporting their medical mistakes they had made, we decided to ask him what he had done to create that safe environment. He went on to say that when someone comes up to an authoritative figure in a healthcare setting and tells them what they have done, the first natural human reaction of that authoritative figure (whether it be a doctor, another nurse, or even CEO of the hospital) is to blame someone, when it really should be to take ownership of the problem in order to fix it. As he said, "Be hard on the problem and soft on the people.". We cannot fix errors if we do not take ownership of our mistakes.
Hospitals are protective of their clinical data. Hospitals "...don't want to report their clinical data because it might be embarrassing," As Mr. Levy puts it, "When in fact it is not embarrassing at all." Mr. Levy also says that doctors are trained not to make mistakes, but in reality making mistakes will happen to them some time in their career, that's why medical error is also called "human error"- because it will happen to humans sometime in their career. If you don't make mistakes, you are not human. So when they do make mistakes, doctors are scared to report them because 'do not make mistakes' is ingrained into their brains from the first day they walk into medical school.
Mr. Levy also quoted Dave Mayer (with MedStar health) as saying "Educate the young and regulate the old". This means to teach the young that it is okay to make mistakes, while just putting regulations and rules on the older healthcare professionals as they do not know any better that it is okay to make mistakes as well, as they will make mistakes but would still be leery of telling someone because they were taught not to make mistakes.
In order to fix our mistakes, we need "Real-time data", as Mr. Levy said. If hospitals do report their data, Medicare and the insurance companies all go through a 'churning process' to process all the data, which takes two years to do. So when the data comes back, it is two years old and at that point is useless. To quote Mr. Levy, "Old data is useless.". So in order to even get a start on fixing medical errors, hospitals need to understand that reporting their data is not embarrassing. But Mr. Levy had a solution- each hospital would have their own website on the main Medicare website to report data on. They would even have their own passwords. But that idea went nowhere, due to the fact that hospitals are scared to make their data public, as they think it would be embarrassing. But as Mr. Levy puts it, sharing their data is not embarrassing. Cutting down on medical errors is something that needs to happen now- before we reach a point of no return.
The conversation with Mr. Levy was very rewarding, as we gained a wealth of knowledge talking to him. We learned about his solutions to fix medical errors, and we also learned hospitals don't want to share their clinical data for fear of embarrassment. We need to do something about this. We can no longer just sit by and watch medical errors happen and happen again, because it is killing patients that aren't supposed to die every day. We need to get a head start on fixing medical errors. Start in medical schools and teach the students that it is okay to make mistakes, so hopefully that way when the younger generation takes the lead in helping patients, they know it is in fact okay to make mistakes, and that they shouldn't be afraid of reporting their errors to an authoritative figure, or even a peer.
To visit Mr. Levy's blog, please visit http://runningahospital.blogspot.com/