When it comes to patient safety, I like to think of the environmental slogan, “Think globally, act locally.” Yes, we want medical equipment that is safe, powerful, and easy to use; we need systems of systems so that everything works seamlessly and thus safely; and we expect our healthcare professionals to be well trained to avoid errors. But at the end of the day, we don’t think about patient safety in general. We think about the safety of each one of our patients, one individual at a time. We can have an error rate of 0.001%, but, in statistical terms, there are no degrees of freedom for that one patient in 100,000 for whom there is an adverse event—for a single patient is either 0% or 100%.
Of course, medicine is not black and white. For many years, as the medical director of the pulmonary function laboratory (prior to my emeritus status) at the University of Mississippi Medical Center, I was present for many of the cardiopulmonary stress tests performed to obtain patients’ maximum oxygen consumption, a parameter used to determine eligibility for the heart transplant list—too low, and the patient is too ill to undergo the operation; high enough, and data show that survival is better with the patient’s own heart. The test requires the willingness of the individual to exercise to the limit. That is difficult enough for a healthy person, but these patients often have heart functions one-quarter or lower that of a healthy person.
We acted as cheerleaders and patient safety detectives at the same time. We wanted that oxygen consumption to be the highest the patient could achieve. A small change could mean the difference between getting on the heart transplant list or not. On the other hand, adverse events are not uncommon when exercising such ill patients. Maximum vigilance is necessary. The respiratory therapist performs the test using sophisticated equipment. The guidelines dictate that a physician be present for such high risk patients. Everyone memorized the requirements for stopping the test for safety reasons: blood pressure dropping or rising too much, a decrease in oxygen saturation, or unexpected and dangerous EKG changes. Data on the screen change continuously and decisions have to be made in milliseconds. Do we stop the test and thus provide no useful results to the cardiologist looking to make the heart transplant decision? Or do we continue the test and put the patient in danger of an adverse event, possibly even death? Ultimately, it’s a clinical judgment call.
Such a scenario, as dramatic as it may seem, is just one small example of the everyday workings of a hospital, where hundreds of potentially life-or-death choices exist at any given moment. Is it surprising that we continuously live on the brink of disaster?
Marcy Petrini, PhD, is professor emeritus at the University of Mississippi Medical Center in Jackson. She is the immediate past chair of the AAMI Board of Directors.