Fix your systems to cut error rates

Radiology must learn from the automotive and aviation industries to eliminate errors and improve patient safety. That is the view of Dr. William R. Brody, president of Johns Hopkins University in Baltimore, who delivered Saturday's W.C. Roentgen Honorary Lecture.

"When an error occurs, it is everyone's responsibility, not just one person's," Brody said. "Our current attention has been focused on assigning blame rather than fixing the system that creates the problems. We have to begin by admitting that hospitals cause many fatalities due to serious and preventable errors."

The number one killer disease in the U.S. is not cancer or heart disease but variability in care, Brody said. Variability in the delivery of care leads to systemic errors causing up to 98,000 deaths and costing $50 billion a year. Errors are often not recorded, and complications are expected and even rewarded.

He urged radiologists to consider implementing the Toyota approach to quality. It is based on a zero-defect mentality that is driven from the bottom upwards and is built in, not contracted out or enforced from above. The company's strategy is based on empowering its workers, encouraging teamwork and communication, and simplifying every procedure. Lessons can also be learned from the aviation industry's rigorous policies on crew resource management.

Staff at Johns Hopkins identified three main problem areas: medical errors, poor communication among caregivers, and infections from in-dwelling central venous catheters. The Center for Innovation and Patient Safety was established, and small groups were set up to redesign processes. Management consultants are never used to build and implement quality systems.

"The key to reducing medical errors is to set an audacious goal of zero errors. That, after all, is what the patients expect," Brody said. "Improvements in safety represent by far the greatest opportunity to improve patient care, but hospitals must invest in safety, not cut costs."