After a September review found weaknesses in its patient safety standards, the Duke University Health System has taken several important steps to improve its front-line patient care. The tragic events leading to the death of Jésica Santillán, in which she received a mismatched heart and lung in a transplant, serve as poignant examples of the consequences of gaps in safety mechanisms. The changes are broad in scope, and will affect everything from data processing systems to resident physicians' working hours. Patients at the DUHS will reap benefits from these changes immediately.
One of the areas identified for improvement was the DUH's information technology system. Health care IT is the only major industry that is not federally regulated, meaning that IT systems have not been required to keep pace with recent innovations. Currently, the IT system lacks continuity, and communication of patient care between outpatient clinics and community hospitals within the DUH system is difficult. This can make it difficult for doctors to access lab results and diagnoses across treatment centers. To remedy these problems, the DUHS has turned to eBrowser, a program allowing for a common database system that can be accessed by a large cross-section of hospital staff.
In addition, DUHS recently implemented a shorter, 80-hour work week for residents. This move will decrease the stress placed on doctors. Overworking can easily lead to poor decision-making and lapses in judgement, dangerous occurrences in the medical profession. Doctors are usually expected to become accustomed to long hours, but the 100 to 120-hour work weeks typically endured by many interns and residents were unsafe.
The DUHS has also initiated a search for a full-time "patient safety officer," whose job it will be to develop IT systems. Officials are also planning on hiring more support staff, such as nurses, radiology technicians and respiratory technicians to increase efficiency.
The DUHS should also be applauded for its specific efforts to increase pediatric patient safety. Officials have created the Pediatric Safety Program, which combines personnel from several different care units to discuss, monitor and improve safety procedures and perform weekly "walk-around" to talk to patients and family members about the care they are receiving.
The DUHS has responded swiftly to the deficiencies in its patient care systems. The changes in progress, and those yet to be implemented will help to prevent tragedies like the death of Santillán, and make the DUHS a safer place for all patients who seek care there.
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