Acting director, Patient Safety Program, Defense Department, TRICARE Management Activity
Best known for: Every year, tens of thousands of patients die or are harmed by preventable medical errors such as pharmaceutical prescription mistakes, hospital-acquired infections and surgical missteps. Communication breakdowns among doctors, nurses and other care providers are a leading cause of these errors. Heidi King and her colleagues at the Agency for Healthcare Research and Quality (AHRQ) set out to do something about the crisis, developing a health-care provider training system known as TeamSTEPPS that has become the gold standard for eliminating preventable medical harm. King and James Battles at AHRQ developed strategies, tools and a training system for professionals who work not only in high-stress situations — such as surgical suites, emergency departments and intensive-care units — but also in ambulatory-care settings, including doctors’ offices. The training teaches medical teams about human factors that contribute to errors, such as team members giving too much deference to someone with a higher rank. King helped establish a national training infrastructure, including 11 centers across the country. More than 6,200 health-care professionals have become master trainers and instructors who return to their health-care systems to lead the implementation of the program. The program is now in use in all 50 states, reaching an estimated 25 percent of the more than 5,700 U.S. hospitals. It also has been employed in more than 80 percent of Defense Department health-care facilities worldwide.
Government service: King joined the federal government at TRICARE Management Activity in 2001, where she established the Patient Safety Program. She served as the director for the Healthcare Team Coordination Program, which evolved into the Patient Safety Solutions Center. She also was a Peace Corps volunteer in St. Kitts, West Indies.
Motivation for service: King said she was drawn to public service by colleagues and family members who invested their professional lives serving their country. She identified passion and purpose in their work and realized that she wanted to make a difference in the lives of others.
Biggest challenge: The greatest obstacle to developing the health-care training program was finding ways to cut through the bureaucracy to work across agencies and with other public partnerships, King said. “It was not only important to make it happen, but it needed to stick. Without forging true collaboration and trust, the challenges would have been insurmountable. The key to overcoming these challenges was relationship and coalition building.”
Quote: “We saw a real need for an immediate solution. Patients were losing their lives due to medical errors, and the harm was preventable. The program has now taken off like wildfire.”
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