Lives in Our Hands: Overcoming Barriers to Patient Safety

OVERVIEW

• 21-minute video discusses actual case scenario
• Can be used on its own or as part of a curriculum

BACKGROUND

Lives in Our Hands is an educational video that can be used as part of a formal introduction to patient safety training for medical interns, residents, fellows and any other healthcare providers. The video tracks the course of the patients hospital journey through the perspectives of the mother and the intern involved in the case, and creates the opportunity for audiences to recognize and explore communication barriers and discuss strategies for improving patient safety and communication. This video depicts an actual, unanticipated outcome that results from a collection of preventable circumstances, and it allows the audience to observe communication and supervision issues that lead to a patient death. In 1999, the Institute of Medicine (IOM) published a report To Err Is Human: Building a Safer Health System that estimated that as many as a million people were injured and 98,000 died annually as a result of medical errors. This report concluded that the major cause of adverse events is not negligent individual performance, but poorly designed systems and patient care processes. This highlighted the need for open communication, mutual respect, and teamwork between all parties involved in patient care, including patients and their families. 

During the past decade efforts to develop and implement new safe practices and to train healthcare workers in patient safety have been initiated, but progress has been slow and uneven. National Patient Safety Foundation (NPSF) identified that while medical schools and academic medical centers do an excellent job of providing students with basic knowledge and skills, they do not impart skills, behaviors, and attitudes that are needed for practicing physicians. These include the ability to manage information, understand basic concepts of human interaction, patient safety, healthcare quality and systems theory. They do not receive instruction in skills needed to communicate effectively with coworkers and patients, lack management and teamwork ability, and do not know how to deal with their own feelings of doubt, fear, and uncertainty. The entrenched hierarchy of the medical training environment causes trainees to value their appearance to superiors more than safe patient care, illustrated by their reluctance to ask for adequate supervision, guidance, advice, or feedback. This culture of intimidation and fear deprioritizes safe patient care, and should be replaced with one of trust and respect. 

Case Scenario Highlights What Can be Learned from Medical Errors Lives in Our Hands is a 21-minute video that recounts the story of a severely injured patient who was admitted after a rollover motor vehicle accident, and how poor communication between providers, failure to escalate patient care concerns, and inadequate supervision ultimately contributed to the patients death. This video was shown at the University of Michigan during orientation to a group of new residents and fellows as part of a workshop to instill a culture of accountability, open communication, disclosure, and transparency in a healthcare setting. After viewing the video, trainees were able to identify key issues that occurred that led to a breakdown in patient care, placing emphasis on the importance of being able to ask for help from senior staff, and communicating with the patients family. In a survey that was collected after completion of the workshop to assess effectiveness of this video, trainees stated that they felt empowered to ask for help, and focus on patient care. They felt that the video added unique value to the workshop due to the candid nature of the interns testimonial and the mothers personal story of loss. 

To encourage patient safety training, the WHO has developed a Patient Safety Curriculum Guide for Medical Schools that includes training materials, and the Institute for Healthcare Improvement (IHI) created an electronic Open School program. In addition, case studies, role playing, simulation applications, and patient stories have been utilized by various institutions to promote patient safety education and provide real-time problem-solving scenarios, but there is still a lack of high quality training materials. Lives in Our Hands is a short video that has a real human element that has engaged the audiences and demonstrated that patient-centered care must come before all other concerns.

ADDITIONAL DETAILS

Short clips and a facilitator guide are available for download.