These findings are surprising in view of previously reported findings using the MET system. Potential reasons for lack of difference between MET centers and controls include:
- Number of study sites or the duration of the study may not have been adequate for implementation or education;
- Hospitals may already be efficient in detecting and managing unstable patients;
- Patient selection criteria may have been overly restricted. For example, other studies have used 30 respirations per minute for tachypnea as a calling criterion compared with 36 breaths per minute used in this trial;
- Knowledge of the study may have leaked to control hospitals;
- Cardiac arrest teams function as METs at times: Nearly half of the calls to cardiac arrest teams in control hospitals were made without a cardiac arrest or unexpected death; and
- The selected outcomes may not be sensitive enough.
Even though this large, multicenter controlled trial was unable to show a significant benefit of METs, we should not be discouraged from performing further controlled trials in different settings. The use of METs is clearly an exciting and evolving area of medicine.
Barriers to Patient Safety
Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142:756-764
Patient safety in our healthcare system is a growing concern. One area of dialogue concerning preventable healthcare-associated harms involves the comparability of the healthcare industry with non-medical industries, such as aviation and nuclear power, that have adapted successful strategies shown to provide ultrasafe environments. Amalberti, et al. discuss risk assessment in a variety of industries and explain the need for a benchmarking approach in order to optimize or achieve safety in the healthcare field.
The authors identify five systemic barriers from literature that are fundamentally connected to the ability of the healthcare field to achieve an extremely safe environment.
Barrier 1—acceptance of limitations on maximum performance: The first barrier is the type of expected performance in the field. This is illustrated by the tradeoffs associated with ultrasafety versus productivity. The amount of risk involved was directly related to the limits placed on maximum performance. The first barrier is the acceptance that every system has limits. When a producer exceeds their limit, then safety suffers. An example used is that of blood donation: The limits of collection speed are weighed against the needed screening process.
Barrier 2—abandonment of professional autonomy: The second barrier concerns the concept of professional autonomy. While more teamwork and regulations reduce individual autonomy, this appears to improve safety in the healthcare environment. The bottom line is the importance of teamwork. The example used is that of traffic on a highway: Autonomous units work together to function safely.
Barrier 3—transition from the mindset of craftsman to that of an equivalent actor: The third barrier to achieving high levels of safety includes an equivalent actor mindset. This entails establishing a reliable standard of excellent care in lieu of focusing on individuality, similar to the notion that passengers on an airline usually do not know their pilots, but have established confidence in the airline itself.
Barrier 4—the need for system-level arbitration to optimize safety strategies: The fourth barrier identified is a need for system-level arbitration to optimize safety strategies. This need results from the pressure for justice (usually through litigation) once an accident occurs. Top-down arbitration of safety will be less successful than system level design.
Barrier 5—the need to simplify professional rules and regulations: The final barrier results from the many of layers of guidelines as they serve to create an environment of excellence. This barrier necessitates the removal of these layers to simplify the environment. Existing guidelines should be distilled down to those shown to promote quality and safety. Byzantine rules can obscure the goal of safety and glorify rules, for rules sake.