VA Hires NASA to Fight Medical Errors

In a groundbreaking program, the nation’s veterans hospitals hired NASA on Tuesday to do for medical safety what it does for airline safety: Set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.

A NASA-run program that lets pilots report near collisions is widely considered so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes. It would let doctors and nurses report problems that, if fixed, could improve care in the VA’s 172 hospitals.

A stunning report by the prestigious Institute of Medicine last year concluded that medical mistakes kill 44,000 to 98,000 hospitalized Americans a year.

One of the institute’s biggest recommendations was to copy the aviation industry to improve safety. In a move health experts have called innovative, the VA has worked for months to do just that. Now the question is whether the three-year, $8.2-million experiment will work.

“It will be an experiment followed with great interest,” said Dr. Nancy Dickey, past president of the American Medical Assn., who leads that group’s own safety-improvement work.

Many medical errors are preventable if hospitals would analyze patterns of problems and install safety nets. Health workers often do not disclose errors, however, for fear they could be sued or fired.

The VA already requires employees to report certain serious errors. The new voluntary, anonymous program aims to uncover more problems, especially the near mistake that didn’t hurt a patient but might the next time.

“If you don’t know about it, you can’t fix it,” explained Dr. Thomas Garthwaite, the VA’s acting undersecretary for health.

Under the program, VA health workers can report medical mistakes they make or witness. Just as in the pilots’ program, no doctor or nurse would be held personally at fault. After questioning health workers for more details, NASA will strip identifying information from its database so bosses cannot tell who reported what.

Then NASA-hired medical experts will analyze how an error happened and seek protections to prevent it from happening again.

“This kind of reporting is absolutely essential,” said Dr. John Eisenberg, who heads President Clinton’s health quality task force. “If to err is human, it seems [that] to do nothing about our medical errors is inhumane.”

The idea is to install safeguards against mistakes instead of laying blame, said Dr. James Bagian, the astronaut and physician credited with installing escape hatches to make the space shuttle safer and who now is trying to make the VA health system safer.