Medical professionals tend to be a conservative bunch who like to do things
their way, despite the fact that there may be safer and better
In 1847, Hungarian physician Ignaz Semmelweiss discovered
that handwashing by obstetricians between the treatment of one patient and
another significantly reduced the rate of deadly childbed fever. But even today,
many doctors and nurses around the world still fail to carry out this vital
elementary practice and spread nosocomial infections (infections due solely to
treatment in medical facilities). It isn’t that they don’t understand; the main
reason for this reluctance is that constantly using soap and water dries the
hands, and dispensers of alcohol gel (that doesn’t cause chafing) are not
located everywhere patients are.
Hospitals want to reduce errors and
laziness that could harm patients, but are often reluctant to appoint
independent senior staffers for this mission. Even less do they want their
errors to become public knowledge.
The Hadassah Medical Organization
annually holds a clinical presentation by its Center for Patient Safety,
inviting senior personnel and even health reporters. “Every department in our
Ein Kerem and Mount Scopus campuses presents its successes annually,” said
Hadassah Medical Organization director-general Prof. Shlomo Mor-Yosef, who
attended the presentation in the packed Ein Kerem auditorium earlier this month.
“But the Center for Patient Safety presents our failures.
other hospital in the country, we have two full professors working
independently, one – Prof. Yoel Donchin – devoted to the preventing of errors
and the other – Prof. Mayer Brezis – to improving quality.”
OF the need to encourage medical staffers to sanitize their hands regularly, the
Hadassah Medical Organization developed its own product, called Hadassol, and
packages it in small plastic bottles that can be worn on the belt. It contains
70% alcohol rub and an emollient cream that moisturizes the skin without fatty,
sticky additives. It is cheaper and better than commercial sanitizers, Donchin
said. “We make it blue so that nobody will make a mistake and drink it,” he
added. Brezis added that medical staffers’ computer screensavers display
messages reminding them to sanitize their hands between
Mor-Yosef added that he sees patient safety as a central topic.
“We are not perfect. We want to improve. We need to improve communication among
department heads and others.” The two Hadassah University Medical Centers deal
with a million patients a year. “Errors repeat themselves. Our large staff come
with different levels of education and ability. We aim to discover mistakes and
create a system with fewer errors, but one can’t run a health system that has no
Our aim,” said the director-general, “is to send patients home
healthier – or less sick in this era of chronic illness – than when they arrive.
It is not simple for an institution like hours to allow these two professors to
do whatever they want.”
DONCHIN IS a veteran anesthesiologist, firstaid
expert and author, as well as a safety expert who launched his mission two
decades ago, when it was almost non-existent in the world, let alone in Israel.
“Other hospitals have been interested primarily in risk management,” he said,
referring to efforts aimed at reducing lawsuits for negligence or malpractice,
or to covering up errors. But this is very far from concentrating on preventing
errors and promoting safety to the patient and employees.”
fail to learn from their mistakes.
For example, he cited a tragedy at
Seattle Children’s Hospital in the US state of Washington in which a fragile
child received 10 times the prescribed amount of a common drug and died. The
next year, another child died as a result of the same error.
approach is different from those in most other hospitals. We are proactive. We
conduct observations of what goes on in the departments to find out where things
are done that can harm patients, and design ways to minimize them. We look at
processes to prevent things from going wrong. We do it without fancy technology.
Talking to staffers, posting signs and using checklists can bring
HADASSAH STAFFERS do not fear that if they report an error
they or others had committed, they will be punished or even
“Friendly enforcement” encourages them to tell Donchin what
happened. Only if a patient was really harmed – by breaking an arm when falling
out of bed or worse, for example – will the error or accident be officially
reported. A nurse may have given a medication at the wrong time or at an
improper dose without harm to the patient; Donchin said he should be told about
such incidents without the informer or those involved being afraid of
“I can walk into any department, observe and ask staffers
questions. I have done it almost full time for years. I am completely
independent,” he said. “Senior managers do not intervene. Staffers tell me if
they made a mistake because they don’t want them to occur.”
involves a lot of “human engineering” to understand how the mind works and how
to change habits. It means establishing a culture of safety.
He can’t say
how many errors are committed at Hadassah hospitals.
“Nobody knows. But
we really don’t aim at statistics; we want to prevent the incidents.” The Health
Ministry, said Donchin, is the regulator of the health system and the owner of
state hospitals, and it also makes mistakes, so it doesn’t have the ability to
“I have proposed the adoption of our safety program to a
dozen health ministers and ministry directors-general, but nobody has done
anything. They say they have no money for this, but only for quality
There isn’t one ministry staffer who devotes all his time to
“THE MINISTRY has cited the figure of 2,000 patient deaths per
year from errors, but nobody has a clue. The companies that insure medical
staffers are of course very pleased to see newspaper reports of such cases, as
this enables them to raise premiums.”
While hearing hospital doctors
discuss errors that harmed or could have hurt patients is very scary and could
induce people to avoid hospitals, Donchin insisted that “there are 500 or so
deaths on the roads every year, but nobody doesn’t decide not to travel because
of this. In most cases, everything goes well; harmful errors are a small
minority.” Donchin, who has reached retirement age, will soon stop his
anesthesiology work, but Mor-Yosef has asked him to “return” on contract to
continue his safety and error-prevention work.
AMONG THE changes that
Donchin initiated are a mandatory briefing of operating room staffers with a
printed checklist in the form of a large sign, easily read from a distance,
attached to one wall. Before each operation, the team is required to go through
the list to ensure that the patient is correctly identified, the correct organ
or side to be operated on is named, and the blood type is checked and rechecked,
noting whether the patient is allergic to a specific drug, if a biopsy needs to
be taken or an X-ray done during the procedure (which will make the surgery take
longer), the patient’s required position and other issues that if not clear
could endanger the patient. In most cases, the person to be operated on is still
awake, participates and sometimes makes comments or
Occasionally, when it’s a routine operation, staffers might
say – ‘Forget the briefing; let’s go ahead and operate!’ – but Donchin insists
on going through the procedure every time.
The Health Ministry has told
all the hospitals to use a printed checklist (not a formal briefing), “but I
don’t know much it’s enforced.”
Donchin also removed potentially harmful
potassium from departments, requiring it to be kept in a separate cabinet;
potassium is given only to certain patients, such as those undergoing
chemotherapy or those who don’t eat; if given to anyone else, it could be fatal.
In a separate cabinet, it is handled more carefully, and users are required to
make special calculations of dosage, he explained.
But he still hasn’t
managed to persuade Hadassah staffers not to use their cellphone while treating
“I taught the first safety course for doctors in the world at
Hadassah. The situation here is certainly better than it was 20 years ago, but
still, despite published studies that measure efficacy, some doctors are not
convinced that prevention will make a difference. Yet some Israeli hospitals and
the health funds are beginning to show interest.”
Years ago, Donchin “by
chance” met Prof. Dan Gopher, an industrial engineering expert at the
Technion-Israel Institute of Technology in Haifa. “I learned from him and did
two sabbaticals with him at the Technion.
We wrote a book together and
worked in Emek Medical Center in Afula and Rambam Medical Center in Haifa to
spread our ideas and reduce errors.”
DONCHIN SAYS he is planning to
establish a School for Safety in the Hebrew University- Hadassah Medical School
in Jerusalem that would be open to teaching other hospitals and medical students
about proactive prevention of errors.
Gopher, who attended the Ein Kerem
presentation, said that in the old days, only a few doctors and nurses actually
“Today, medicine is very technological and complex –
full of data. It requires a team effort, and every procedure is divided into
steps, some done simultaneously. There are employees of varying medical
backgrounds, and medical care is very expensive. There is always the desire to
purchase every new technology. But,” said the Technion engineer, “there
is little investment in an environment friendly to the medical team. They work
in a user-unfriendly environment. The solution is the engineering of human
factors to improve patient safety.”
He compared the average hospital or
clinic to the planning of an aircraft cockpit. “There is so much advance
planning to make it work and minimize errors. But you can’t say the same for
health facilities. They are built like a patchwork quilt, piece by piece. It
depends on when there was money to buy equipment.
There may be two
different monitors near a patient’s bedside, each working simultaneously but not
in coordination. There is not enough communication or clear division of labor,”
Hadassah Dr. Sigalit Mudahi reported to the audience that
much can be done to reduce errors in its labs, which process 2.5 million samples
a year. It was routine for staffers to transport vials with samples of blood,
urine, stool and other substances in the pocket of their white coats, which was
certainly not optimal. A disposable, recyclable carton was designed to replace
this. As there was a wide variety in the quality and suitability of samples
taken, she continued, staffers were sent to short courses on Hadassah’s Intranet
site to train them to do it properly so fewer would be rejected by the lab
DR. LIMOR GOLDENHIRSCH conducted observations in the emergency
room for six months for her final MD studies project. She and colleagues watched
the movement of staffers, patients and materials within a small area and listed
everything. They found cases in which patients had became disconnected from
monitors or left in the X-ray department alone, bedsides had been left down, and
patients taken to the wrong place. Many signs were not translated into languages
understood by most patients, and X-ray technicians who didn’t understand what
the doctors ordered sometimes performed a different X-ray than those desired.
Her findings led to improvements, and despite all the revelations, Hadassah
hospitals are probably safer than many of its counterparts.
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