Redefining and Improving Patient Safety

Summary

Objectives: The Institute of Medicine (IOM) has focused attention on patient safety in the united States. Other countries share these concerns.

Methods: Governmental agencies and professional organizations are redefining approaches to safety, calling upon the use of information and communication technology as an enabler and expanding the range of evidence admissible in documenting success.

Results: Efforts to understand medical errors have used retrospective chart review, incident reporting, and computerized surveillance; the result is an evolving picture of the number, nature, and cause of errors. Approaches used to prevent errors include computerized physician order entry, decision support tools, computerized monitoring, and evidence-based practice; varying levels of evidence document their success.

Conclusions: Technology offers challenging capabilities, not simple solutions. New evidence and new tools demand new approaches and attention to human factors.

Keywords

Patient safety - medical errors - decision support - qualitycare - medical informatics

• References

• 1 Kohn LT, Corrigan JM, Donaldson MS. (eds). To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press; 2000
• 2 Committee on Quality Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21^st Century. Washington DC: National Academy Press; 2001
• 3 Hongsermeier T. Quoted. in: Reducing Medical Errors, Improving Patient Safety: Taking the Next Step. A HeathLeaders Roundable. Special Supplement. HealthLeaders. June 2001
• 4 Chapman NE. From behind closed doors. Healthcare Informatics; 2001. (November); 37-42.
• 5 Ball MJ, Douglas JD. IT [Information Technology], Patient Safety, and Quality Care. Journal of Health Information Management. 2001 15 (4). Accessed at www.himss.org/templates/journals4/4/2002.
• 6 Vincent C, Neale G, Woloshynowych M. Adverse Events in British Hospitals: Preliminary Retrospective Record Review. Brit Med J 2001; 332: 517-9.
• 7 Blendon RJ, Schoen C, Donelan K. et al. Physicians’ views on quality of care: a five country-comparison. Health Affairs 2001; 20 (Suppl. 03) 234-43.
• 8 Joint Commission on the Accreditation of Healthcare Organizations. Chicago, IL: JCAHO; 2001
• 9 American Hospital Association. Strategies for Leadership: Hospital Executives and Their Role in Patient Safety. Chicago, IL: AHA; 2001
• 10 President’s Information Technology Advisory Committee. Transforming Health Care Through Information Technology. Washington DC: PITAC; 2001
• 11 Agency for Healthcare Research and Quality. Summary. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices 2001. Rockville, MD: AHRQ; 1-8.
• 12 Brennan TA, Leape LL, Laird NM. et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. New England Journal of Medicine 1991; 324: 370-6. Also Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324 (6): 377-84.
• 13 Thomas EJ, Studdert DM, Newhouse JP. et al. Costs of medical injures in Utah and Colorado. Inquiry 1999; 36: 255-64.
• 14 Wald H, Shojania KG. Incident Reporting. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices 2001. Rockville, MD: AHRQ; 41-50.
• 15 Wald H, Shojania KG. Prevention of misidentifications: strategies to avoid wrong-site surgery. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices 2001. Rockville, MD: AHRQ; 498-502.
• 16 Krizek T. Surgical error: ethical issues of adverse events. Archives of Surgery 2000; 135: 1359-66.
• 17 Gillespie G. I.T. helps show error of providers’ ways. Health Data Management. 2000 (September). www.healthdatamanagement.com. Accessed 1/9/2002. Also, personal correspondence, David S, Spencer to Marion J. Ball, June 22, 2001; September 6, 2001. Also, see Patient SAFE Strategies at www.PTSafe.com . Accessed 1/18/2002.
• 18 Beers JB, Berger MA. Medical error – sources and solutions. In: HIMSS Proc; 2001. CD version, vol. 1, session 17.
• 19 Bates DW, Cohen M, Leape LL. et al. Reducing the frequency of errors in medicine using information technology. JAMIA 2001; 8 (Suppl. 04) 299-308.
• 20 Bates DW, Leape LL, Cullen DJ. et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280 (Suppl. 15) 1311-6.
• 21 Bates DW, Miller EB, Cullen DJ. et al. Patient risk factors for adverse drug events in hospitalized patients. Arch Intern Med 1999; 159: 2553-660.
• 22 Agency for Healthcare Research and Quality. Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. 2001 www.ahrq.gov/qual/aderia/aderia.htm. Accessed 11/18/01.
• 23 Kaushal R, Bates DW, Landrigan C. et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114-20.
• 24 Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997; 277 (Suppl. 04) 312-7.
• 25 Kilbridge P, Classen D. A Process Model of Inpatient Medication Management and Information Technology Interventions to Improve Patient Safety. 2001 Research Series, Vol 1. Irving, TX: Voluntary Hospitals of America (VHA); 2001
• 26 California HealthCare Foundation. Innovations in Physician Prescribing. Oakland, CA: CHCF; 2001. (October).
• 27 Metzger J, Slye D. Inpatient e-ordering. Health-care Informatics. 2001 (May), 63-8.
• 28 Leape LL. Can we make health care safe?. In: Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine, Accelerating Change Today (ACT) for America’s Health. eds. S Findlay, A Keefe. February 2000. p 2-3. The National Coalition on Health Care and the Institute for Healthcare Improvement. Accessed at www.ihi.org/resources/act/medical_errors.pdf4/4/2002.
• 29 Metzger J, Tursico F. Computerized Physician Order Entry: A Look at the Vendor Marketplace and Getting Started. Washington, DC: The Leapfrog Group.; Available at www.leapfroggroup.org. Accessed 12/01/2001.
• 30 Phillips DP, Christenfeld N, Glynn LM. Increase in US medication error deaths between 1983 and 1993. Lancet 1998; 351: 643-44.
• 31 James BC. Information Technology in Support of Process Management. Presentation to the Institute of Medicine Annual Meeting. Washington DC: October 15, 2001
• 32 Weed LL. Knowledge Coupling: New Premises and New Tools for Medical Care and Education. New York: Springer-Verlag; 1991
• 33 Kuhn KA, Giuse DA. From hospital information systems to health information systems: problem, challenges, perspectives. Methods of Information in Medicine 2001; 40 (Suppl. 04) 275-87.
• 34 Fessler JM, Gremy F. Ethical problems in health information systems. Methods Inf Med 2001; 40 (Suppl. 04) 359-61.
• 35 Murff HJ, Kannary R. Physician satisfaction with two order entry systems. JAMIA 2001; 8 (Suppl. 05) 499-509.
• 36 Sim I, Gorman P, Greenes RA. et al. Clinical decision support systems for the practice of evidence-based medicine. JAMIA 2001; 8 (Suppl. 06) 527-34.
• 37 Berwick DM. Lessons from a novice. Taken from his comments at a conference in St. Paul, MN published with hi permission by the Institute for Safe Medication Practices on their web site. www.ismp.org/Pages/PatientSafety/html. Accessed 12/21/2001.