Empowering Future PAs with the Systems Approach to Medical Error 

Each of our programs include curriculum focused on the prevention of medical error; not only to comply with ARC-PA standards, but because we are accountable for training future PAs that will provide safe, high-quality care. But how many of our curricula dive deeper than just an analysis of the human factors (e.g., bias, premature closure, slips, and lapses) that lead to error? Health care, as we know, is an incredibly complex system of interdependent and interconnected parts. Because of this complexity, health care professionals must be able to see the entirety of the system to identify cause and effect relationships within it. A systems-thinking approach to health care incorporates its many domains, from policy and economics to informatics and patient safety– just to name a few. Let’s focus, for a moment, on how we can help our students learn to view medical error and patient safety through a systems lens.  

Traditionally, the approach to medical error in health care has been to blame the provider- that is, the individual acting at what is called “the sharp end” of care: the surgeon performing the operation, the PA working up the patient’s chest pain, the interventionist performing the angiography, the nurse delivering the medication, and others. Since the Institute for Healthcare Improvement’s (IHI) publication of To Err is Human more than 20 years ago there has been a shift to towards acknowledging the fallibility of humans and the inevitability that we will make errors, and understanding that safety truly depends on creating systems, comprised of technology, culture, process, behaviors, that anticipate these errors and function to either prevent or catch them before they cause harm.¹  

The systems approach acknowledges that errors have more to do with a faulty system than the individuals working within that system and has long been the cornerstone of safety improvements in other high-risk industries. This approach to error highlights the need to focus on “root causes.” Root cause analysis explores not just the sharp-end error, but all the underlying conditions within a complex system that made an error possible. Systems thinking is a process of understanding the interrelatedness of these components through data collection and analysis.   

Preparing our students to view error through a systems lens primes them to identify factors within their practice environment that lend themselves to error, and as a result, prepares them to be advocates for systematic changes geared towards improving patient safety and healthcare outcomes. A recent article by Will, Mutyala, and Essary, published in the June 2023 edition of JAAPA, provides a timely call to action for PAs and PA programs, highlighting the importance of integrating and valuing the principles of health systems science.² Preparing our students to be leaders requires that we empower them to be agents of change. Here are just a couple of ideas and resources to get you started.  

•  Build analysis of the microsystems within the larger health care system that have contributed to a patient’s outcome into team-based case activities. For example, ask students to brainstorm in small groups, followed by a large group debrief. The variability in students’ backgrounds in health care will lead to a robust discussion, which can be followed by faculty-facilitated expansion into areas that students may not have considered. These may include health policy, access to services, varying delivery models, health care economics, and social determinants of health, among others.  
•  Have students complete a root cause analysis for a medical error case, individually and/or as small groups, followed by a large group discussion. A quick online search will lead you to a number of organizations, such as the Joint Commission (formerly JCAHO), the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, and the National Institutes of Health (NIH) that provide information on performing root cause analysis.

•  The American Medical Association Health Systems Science Learning Series provides several online modules on many aspects of health systems science (requires free registration): 
  
  •  Howell MD, Stevens JP. eds. Understanding Healthcare Delivery Science. New York, NY: McGraw Hill; 2020. 
  • Wachter RM, Gupta K. eds. Understanding Patient Safety. 3rd ed. New York, NY: McGraw Hill; 2017. 
  • Skochelak SE, Hammoud MM, Lomis KD, et al. Health Systems Science. 2nd ed. Philadelphia, PA: Elsevier; 2020. 

The other stories in this series can be found on the PAEA website. The first story is here, the second story is here, the fourth story is here, the fifth story is here, and the sixth story is here.

References 

1.  Committee on Quality of Health Care in America. To Err is Human: Building A Safer Health System. Institute of Medicine Washington, DC: National Academies Press; 2000. 
2.  Will KK, Mutyala J, Essary AC. Health systems science: A call to action. JAAPA. 2023;36(6): 45-46.