McAuley Lecturer Addresses Patient Safety

FEBRUARY 22, 2013 - The health care industry must focus on systems improvement rather than individual performance to enhance patient safety, according to an expert in the field.

Rollin J. (Terry) Fairbanks, MD, MS, FACEP, director of the National Center for Human Factors Engineering in Healthcare at the MedStar Institute for Innovation, came to Georgetown’s campus Feb. 19 to deliver the McAuley Lecture for the School of Nursing & Health Studies.

“My goal today is to change the way you think about patient safety,” said Fairbanks, an emergency medicine physician who holds appointments at the School of Medicine and MedStar Washington Hospital Center.

‘Pockets of Improvement’

Human factors engineering is a subspecialty of safety science, Fairbanks told approximately 80 students, faculty, and staff gathered in Copley Formal Lounge.

“It’s about understanding the science of human performance,” he said.

Throughout the lecture, he established a contrast between health care and the airline industry. The latter, he said, has made considerable improvements in safety since the 1970s.

Health care has not achieved the same success. “There are pockets of improvement, but overall we aren’t getting any safer,” Fairbanks said.

A large part of the situation is that the health care culture is too focused on managing individual performance versus looking at the systems that might help prevent predictable human error, he said.

Human Error

Fairbanks said that policies, discipline, and training often do little to prevent repeat error among the health care workforce – a vast majority of which is unintended and grounded in normal human behavior.

For example, he cited a case study involving an experienced nurse and a defibrillator. After charging the unit and clearing the patient, the nurse hit the “on” button instead of the “shock” button. The defibrillator powered down.

A better machine – like he demonstrated on the audiovisual equipment in the room – might have asked the nurse if she were sure she intended to shut off the power prior to completing the requested action.

Better Systems

“It’s a predictable human error to inadvertently hit that on-off switch,” he said.

Leaders should anticipate the type of human error that might occur in their clinical settings and help create an environment to mitigate that error – such as equipment enhancements or better labeling of medication.

“The ‘try harder, do better’ method will not make us safer,” he said. “Accountability of the masses is not the answer to making us safer.”

Prominent Speaker

The McAuley Lecture Series covers topics related to health and health care and is open to students, faculty, and staff across the university's campus.

It was made possible through a gift from Brian and Jane McAuley – parents of Georgetown graduates Beth (C’98), Mary (NHS’07), and Tricia (NHS’02).

“We’re pleased to have a very prominent speaker right from our own campus,” NHS Dean Martin Y. Iguchi, PhD, said while introducing Fairbanks.

In collaboration with the dean’s office, the Department of Human Science helped coordinate the latest event.

By Bill Cessato