Physician leaders presented their strategies on crafting “a culture of safety” in April at the AMA Clinical Quality Improvement Seminar in Rosemont, Ill. Forum participants acknowledged that the 1999 report “To Err is Human: Building a Safer Health System” by the Institute of Medicine has heightened interest in patient safety. The report revealed that 98,000 people die as a result of medical errors annually, making medical mistakes the 8th leading cause of death in the United States.
Yet participants also emphasized that efforts to protect patient safety by physicians and the systems in which they work has been under way for some time. Physician leaders detailed their safety plans. Here are summaries of safety perspectives of the leading forum participants, as presented in a forum agenda.
Kenneth W. Kizer, MD,
President and CEO,
The National Quality Forum
“It is widely known that error is inherent to anything that human beings do, and substantial evidence exists that errors are the result of poorly designed processes or systems that fail to account for the inherent limitations of human performance. Indeed, because medical errors typically involve problematic processes or systems rather than the incompetence or malice of individual practitioners improvement strategies that punish clinicians for reporting errors are misguided.”- Congressional testimony, February 2000
Ten Recommendations
- Obtain complete data on the occurrence of therapeutic adverse events.
- Make patient safety a key strategic priority.
- Create a patient safety infrastructure (close the loop on communication in healthcare).
- Create a culture of safety, including open acknowledgement that healthcare is a high risk activity and everyone has a responsibility for risk reduction.
- Implement patient safety best practices.
- Recognize and deal with professional misconduct.
- Encourage healthcare regulators and accreditation organizations to embrace measures that enhance patient safety.
- Conduct patient safety self-assessments.
- Fund patient safety research.
- Include patient safety training in medical education.
John Eisenberg, MD,
Director, Agency for Healthcare
Research and Quality
“The issues of reducing medical errors and improving patient safety are critical and timely, but we need to make sure that the proposed solutions address the problem of errors at its root-the system-rather than blame individuals. We need to improve the system so that health care providers have an opportunity to provide high quality healthcare in a safe, effective environment.” Congressional testimony, December 1999
AHRQ Goals for FY2000
- Fund additional research on medical errors and patient safety.
- Identify tools and approaches from other industries that could be applied in the health care sector.
- Identify targets of opportunity for short-term quality improvement where overuse or underuse of healthcare services is well documented.
- Fund research on how information systems can be used to identify and, where possible, prevent medical errors and threats to patient safety.
- Support activities to translate the findings of this research into improved medical practice.
Don Nielsen, MD,
Senior VP for Quality Leadership,
American Hospital Association
AHA Medication Safety Initiative Goals
- Create/enhance member awareness and understanding.
- Increase member involvement and commitment.
- Lead change.
- Develop appropriate policy and advocacy positions.
- Communicate successfully the results of the initiative.
Initiatives of Other Healthcare Leaders
- Joint Commission on Accreditation of Healthcare Organizations. JCAHO is taking patient safety so seriously that the organization changed its mission statement to include providing safe as well as quality patient care. The organization implemented a Sentinel Event Policy, designed to encourage self-reporting of medical errors, to learn about frequencies and underlying causes of sentinel events (any unexpected occurrence involving death or serious physical or psychological injury), to share “lessons learned” and to reduce the risk of future events. The ultimate goal is to create a culture of safety, one in which individuals feel secure and are even rewarded for identifying and reporting errors and other opportunities for improvement.
- National Committee for Quality Assurance. NCQA convened in January to discuss patient safety issues. It is considering the appropriateness and feasibility of requiring managed care organizations to develop a patient safety program. The program may include standardized visits to physician practices and health care organizations to assess patient safety issues, designating centers of excellence for complex procedures and educating members about advantages to these centers. HEDIS measures addressing patient safety (i.e., inappropriate use of antibiotics and continuity and coordination of care) also may be developed. NCQA would ask MCOs to develop a meaningful patient safety programs in 2001. Beginning in 2002, NCQA standards would incorporate more specific requirements,
- Kaiser Permanente. Kaiser has developed a unique reporting infrastructure supporting patient safety issues throughout their network. The filtering committee is the Patient Safety Committee, responsible for root cause analyses, dissemination of information and best practices development. Some of the major initiatives include adverse drug event prevention, nursing quality indicators, error reporting and revision of peer review process.