Patient Safety Exercise Shows that Greater Collaboration Across Health Disciplines Could Save Lives

Tampa, Fla., November 8, 2004 — Greater collaboration among healthcare professionals could prevent some of the tens of thousands of patient deaths and injuries that occur in hospitals and clinics each year, according to a recently concluded strategic simulation. The exercise conducted by Booz Allen Hamilton for the New Port Richey, Fla.,- based American Board of Quality Assurance and Utilization Review Physicians, Inc., is the second simulation in six months to show systems, communications, contingency planning and the involvement of a broad spectrum of stakeholders is critical in preventing patient errors.

Several participants said the simulation was extremely valuable with practical lessons learned. "I really think the two cases pointed out how important systems are, and communications between systems, in order to prevent adverse reactions from occurring," Arthur Broder, MD, Chairman of the ABQAURP, said. "These strategic simulations allow you to look at the issue from a multi-disciplinary approach, vital to preventing medicinal errors and surgical and physical adverse events."

Some of the key findings:

• Separate disciplines within hospitals or clinics, such as doctors, administrators and nurses, have a tendency to try solving problems within their own groups, rather than reaching out to the other disciplines to get a broader picture.



• Healthcare professionals may tend to find ways to work around safety processes that were cumbersome, indicating to some that the processes in place may not be working or are in need of updates and improvements.



• Staffing shortages were placing incredible burdens on entire hospital infrastructures.

These findings point out that communications with each other, and even with patient families, is often overlooked in exchange for expediency, Booz Allen Vice President Susan Penfield said.

"During the course of the exercise, the participants recognized that the immediate post-event formation of multidisciplinary teams to address and understand medical errors improves the ability of providers to respond and react to issues and fallout," Penfield said. "Although such behavior is understood as necessary, it was the first time the wargame participants had worked toward immediately responding to a medical error in a multidisciplinary team."

The goal of the patient safety wargame was to allow members of the ABQAURP to experience and deal with catastrophic errors in a safe environment, so that alternative strategies can be addressed, Booz Allen Principal Mark Frost, a gaming expert, said. "Hopefully these lessons will be carried to hospitals throughout the United States and beyond."

Booz Allen develops strategic simulations and wargames for federal and commercial clients.