A study published last December in the Journal of the American Medical Association is a small bud on a nearly barren tree. That is because little progress has been made in reducing deadly medical errors since the surprisingly high incidence of such problems was disclosed by the Institute of Medicine in 1999. The institute had recommended an approach, called systems, used chiefly in the airline and automobile manufacturing industries. but little was achieved in the fourteen years that followed despite a widespread effort to systematize American healthcare. Estimates of the annual mortality vary but most are in the range of at least three times the number of people killed in automobile accidents annually, some say close to 150,000.
At the Boston Children's Hospital (where my cousin's son has worked recently as a pediatric fellow), an improved method for accomplishing patient handoffs between residents was associated with a reduction in preventable harms to patients. It is a systems tactic to its core. The pediatric professors gave training sessions to the residents, standardized the information transmitted, developed a mnemonic, and changed the venue in which the handoffs were done to a quiet, private space. They call all of the above "the bundle".
Several researchers had suspected that patient hand offs were a weak link in patient care partly as a result of the restrictions on resident work hours put into effect during the last few years. The hand offs had to occur more frequently because the patients changed hands more often. The resident who knew the patients best got a rest, but the patients were left to a covering doctor whose knowledge of them was incomplete. The Boston Children's group reckoned that this was due to inadequate procedures for communicating the significant data rapidly and effectively from one physician in training to another and could be overcome.
The Boston Children's authors state that they have demonstrated an association between what they did and the improvement in outcomes, not a causality. This, in the face of very good data, almost seems too modest a claim, but it is the right one.
One self criticism in the paper was about the July effect. The pre-intervention period was during the early part of the medical academic year when the interns (first year residents) were raw recruits. They were more seasoned when the new sign off procedures were put in place.
The reviewer for the journal raised a question about the Hawthorne effect. Many years ago an Illinois factory installed much brighter electric lighting and saw its productivity go way up only to sag as the initial enthusiasm for a new work environment waned. Workers make more effort when there is change and an awareness that they are being paid attention. Take away the impetus of novelty and monitoring and things regress.
In spite of these caveats, I hope that the Boston Children's study holds up not just in pediatrics, but in all of medicine.