Addressing medical errors: the key to a Safer Health care System. (Health Policy Update).

KEY CONCEPTS

* Patient Safety

* Adverse Events

* Medical Errors

* Ensuring A Higher Quality of Care

* National Center for Patient Safety

Patient safety has moved to the front of the health care quality agenda after a recent report on patient safety by the Institute of Medicine's (IOM) Committee on Quality of Health Care in America. The study noted that there are at least 44,000 patient deaths from medical errors each year, placing them as the eighth leading cause of death in the United States. This figure could be as high as 98,000 deaths annually. (1) Medical errors are responsible for more deaths than either motor vehicles or breast cancer. Other groups, such as the automobile and aviation industries, have taken a systematic approach to improving safety. The IOM report argues that the medical community must do the same to ensure a higher quality of care. Several policy questions emerge on how to best achieve this result.

The case for medical errors

Most health care practitioners are aware of situations where a patient has received the wrong dose of a medication, been given the wrong diet, or had an incorrect test performed. In most situations these errors result in no substantial harm to the patient. On other occasions, the wrong extremity was operated upon or another irreversible event occurred resulting in significant injury or death.

There is no doubt that medical errors occur--in fact, there are individual quality assurance, risk management, and total quality management plans in hospitals to reduce these errors and improve quality. Because the health care system is so complex and many errors are not reported, the effectiveness of these efforts is in question. There also has not been a systematic way to evaluate the scope of the problem from a national perspective, define solutions, and ensure that best practices are used to reduce these risks.

The IOM committee reviewed two large studies and found that from 2.9 to 3.7 percent of hospital admissions had an injury from medical management. They also found that more than 50 percent of these adverse events were due to a medical error. (1) The report outlines the need to implement safety measures in every setting and overhaul the health care system to improve patient safety. The committee set an ambitious goal of reducing medical errors by 50 percent in five years and made the following recommendations:

* Create a National Center for Patient Safety within the U.S. Department of Health & Human Services, Agency for Health Care Policy & Research

* Implement a comprehensive mandatory external reporting system for adverse events that cause serious injury or death

* Develop a voluntary reporting system for all medical errors and encourage research into new methods to identify and reduce adverse events

* Pass legislation to protect peer review of data reported to improve patient safety

* Raise expectations in the health care community by focusing on patient safety

* Have the health care community implement best practices related to patient safety

The National Center for Patient Safety would establish and monitor safety standards for every health care organization. It would set safety goals, track progress, and invest in research to help providers learn how to prevent medical mistakes. By mandating the reporting and study of serious medical events, the committee hopes to learn how best to prevent these problems. Also, by encouraging a voluntary system of reporting errors, the factors that cause adverse events would be more broadly assessed and better understood.

A culture of secrecy and fear of litigation has prevented a systematic understanding of medical mistakes. Quality assurance and risk management programs are designed to address these issues, however there is some concern that these systems do not get to the root cause of recurrent medical errors.

The initial response

President Clinton has asked government funded health plans and facilities to adopt procedures to report and address adverse events. Congress is also reviewing these concerns. Senator Arlen Spector (R-PA) recently held hearings on patient safety and is considering legislation to create a mandatory reporting system to collect and analyze data on adverse events that result in patient injury or death. Others, like the American Medical Association, are concerned that this form of mandatory reporting without adequate protections from litigation will be counterproductive and may oppose such legislation. (2) About one third of states already have mandatory reporting of serious errors. (3)

The State of Massachusetts has created a coalition to examine ways to prevent medical errors. Last year this group made recommendations to hospitals concerning ways to reduce medical errors. Maryland's Health Care Commission has also been asked to begin looking at hospital quality. Efforts such as these are being planned in other states.

Future policy questions

Several policy questions must be addressed if meaningful change is to occur:

1. How do you create a climate where errors are openly discussed and addressed?

2. What legal protections need to be in place to encourage full disclosure?

3. What errors should be reported?

4. How does one differentiate between a medical error and a poor outcome?

5. Should reporting be mandatory?

6. What do you disclose?

In 1997 the Veterans Administration began a program of reporting errors that identified as many as 700 patient deaths. Interestingly, one VA hospital's experience suggests that full disclosure may actually reduce litigation costs.4

Conclusion

Quality assurance efforts must focus on ensuring patient safety. Health care has undergone significant changes in the way services are delivered, who provides them, and the settings in which they are provided. New technologies have revolutionized the way providers diagnose patients' conditions, provide therapy, and manage information. But despite these advances, health care has become more complex and fragmented, inviting errors and adverse events. Other industries have taken a systematic look at safety and have dramatically reduced the number of errors. Physician executives have the opportunity to ensure health care is safe as well as effective. (1)

Note

The stated views are those of the author and do not represent those of the State of Maryland or the Department of Health and Mental Hygiene.

References

(1.) Kohn. LT., Corrigan, J.M., Donaldson, MS. (Editors). "To Err is Human: Building a Safer Health care System," committee on Quality of Health care in America. National Academy of Sciences, Institute or Medicine. Washington, D.C.: National Academy Press, 1999.

(2.) Reichard. J. (Editor). Specter PredIcts Congress will Legislate Measures to Combat Medical Errors, Medicine & Health. vol. 5. No. 49, 1999.

(3.) Senators Hear about Medical Mishaps, The New York Times, December 14, 1999.

(4.) Editorial, Fixing Medical Mistakes, The Washington Post, p. A24, December 27, 1999.

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Maryland, Baltimore. He can be reached by calling 410/767-6505 or via email at [e-mail].