The Interview | Prof. Dr. Jan Klein - Anesthesiologist and Professor of Patient Safety Engineering

Patient safety now and in the future: 'Training based on equality is key'

How can we improve patient safety, especially on hospital hotfloors? It's Klein's life's work. "Technology is not the problem, it is sufficiently available. The method of collaboration, especially between nurses, medics and technical experts, needs to be better secured."

Text | Jan-Kees Verschuure  Image | TU Delft

In the 1980s, cardiograms were sometimes not even laid out during surgeries under anesthesia; several decades later, anesthesiologists, surgeons and intensivists have access to all possible real-time data. "And yet far more goes wrong than should in ORs and ICUs," said Klein, who says he is often considered critical by colleagues and peers. "In various areas, from soft factors like professional hierarchy to hard factors like the electric knife, things go structurally wrong." We in the medical profession are too unaccustomed to sharing mistakes with each other to learn lessons, he argues. "Sometimes it is simply the hospital or the doctor responsible who does not admit his mistakes, regularly the mandatory analysis of calamities and incidents by the hospital itself falls short, because, for example, people are unconsciously incompetent in technology and do not recognize a design fault in equipment. In aviation, one shares all incidents and calamities in detail; drastic gains have been made in recent decades. In the medical world, the number of incidents is not even charted properly."

Equivalency in training and practice

The key, according to Klein, lies in culture change through training. As a professor, for example, he conducted research on the difference between education and practice in the use of the (electric) surgical knife. "Education and training, for example when it comes to the application of the commonly used surgical knife, is essential. The basis lies in the way of training. At Erasmus MC, where I worked for years as head of Anesthesiology, doctors in training and nurses in training are jointly educated and trained in patient safety and teamwork. After all, they also work together in daily practice, but we are not used to that at all from training. The key must be equality, not the doctor with the magic wand to whom everyone listens. The hot floor of a hospital is so complex that even a doctor does not have a complete overview. Hierarchical thinking has ensured that a nurse or employee from the sterilization department is sometimes not listened to at all. It sounds crude, people are used to healing like a car mechanic replaces a battery and moving on to the next treatment. Briefing or debriefing is not embedded in the medical culture. And it would help and even should be structurally shaped. Nor can a pilot do it alone. The technology to properly monitor the patient is there and there are many opportunities in this area - through the application of trend recognition and artificial intelligence, for example. Implementation of safety procedures in the context of teamwork is an area of concern, though."

IC capacity

Klein advocates the inclusion of a technical expert in the care teams on the hotfloors. "Let there be no doubt: the subgroups of a hospital, such as a Thorax Center at Erasmus MC, for example, deliver excellent performance - precisely because technical experts are part of the team from the beginning. A technical expert makes a meaningful contribution, not only for the purchase and maintenance of equipment, but especially with innovation, training, analysis of incidents and emergencies. And if this professional has a BIG registration, like the Technical Physician, even with patient-related actions. Intensive care is top sport, it is the details that make the difference."

Of course, as an anesthesiologist, Klein is also a good target for questions about how to handle the corona crisis. What does he think should happen to structural ICU capacity after and/or as the pandemic progresses? "I think it's not so much about the number of ICU slots, but about having enough specialist staff. Four ICU patients to one nurse is not sustainable. I think the staff shortage is the biggest concern in dealing with this crisis, and the situation afterwards in hospitals." In this context, too, Klein believes the technical expert could partially provide a solution. "Not only can a technical expert develop systems to remotely monitor vital data of a large number of patients in a smart way, the Technical Medical Expert himself may also monitor from a kind of air traffic control tower, and can thus relieve nurses. And perhaps separate corona hospitals can provide a solution so as not to compromise planned care and other emergency care."