The following article is based on a presentation given in April 2003 at the Health Policy Forum on the campus of Thomas Jefferson University in Philadelphia, Pennsylvania.The monthly Forum is hosted by the Office of Health Policy and Clinical Outcomes.
The issue of medical errors and patient safety has received a great deal of attention since November 1999, when the Institute of Medicine (IOM) released its famous report, To Err Is Human: Building a Safer Health System. A medical error, as defined in the IOM report, is “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve the aim.” The report stated that approximately 44,000 to 98,000 people die in hospitals each year as the result of medical errors. Although the actual number of deaths has been debated, most health care leaders agree the number, whatever it is, is still too high and represents a significant public health risk in the U.S.
THE lOM’S RECOMMENDATIONS
In its report, the IOM made several important recommendations to address this situation. Foremost among them were (1) to establish a national focus on the issue, (2) to develop a nationwide, mandatory error-reporting system, (3) to raise standards through oversight organizations, and (4) to create safely systems within health care organizations. canadian cialis
Significant progress has been made toward implementing the first three items. For example, the Pennsylvania Medical Care Availability and Reduction of Error Act (MCare Act) contains safety provisions requiring medical facilities and physicians to report serious events and incidents to the recently created Patient Safety Authority. Other leadership programs (legislative, administrative, and private), such as the National Quality Forum, the Leapfrog Group, and the Pittsburgh Regional Healthcare Initiative, have increased awareness of the issue of patient safety and have provided important information in an effort to raise standards and expectations for improvement. The Agency for Healthcare Research and Quality has been a major force in promoting the development and dissemination of safe medical practices.
For all concerned, however, there is still an urgent need to focus on the IOM’s fourth recommendation: creating safer systems of patient care within the delivery systems themselves. This effort is sometimes referred to as “establishing a culture of safety.” How to best establish that culture, improve the reporting of potential errors, and eliminate them within any organization remains to be determined.
Dr. Lucian Leape, a Harvard health policy expert whose work greatly inspired the IOM report, stated that most medical errors are not caused by the carelessness of physicians, nurses, or other hospital personnel but, instead, are the result of poorly designed systems. According to Dr. Leape, people will always make errors, despite their best intentions; a good system is one that will compensate for those errors so that adverse outcomes do not result. The key to reducing errors, therefore, is to shift attention away from the caregivers toward the system itself, because finding fault at the individual level only obscures the underlying source that unwittingly allows these errors to occur.
We have developed an organizational structure within an academic tertiary hospital that continuously addresses those educational gaps and infrastructural deficiencies that present a repeated danger to the patients under our care. This structure is not much different from any hospital’s administrative effort to address problems such as facility cleanliness, environmental safety, patient transport, and finances. What is unique is that the focus is on all aspects of patient safety.
Academic health centers have an important role to play in reducing medical errors and in improving patient safety. They are ideally positioned in this regard, given the multiple dimensions of their missions of education, research, and clinical care. In fact, long before the IOM published its groundbreaking report, the University of Pittsburgh Medical Center Health System (UPMC) had already made patient safety its highest priority. Our work in this area has resulted in several effective strategies designed to reduce errors.