Pushing the profession: how the news media turned patient safety into a priority

Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons' perspectives

INTRODUCTION

Transparency about the occurrence of adverse events has been a decades-long governmental priority, defining external feedback to healthcare providers as a key measure to improve the services and reduce the number of adverse events. This study aimed to explore surgeons' experiences of assessment by external bodies, with a focus on its impact on transparency, reporting and learning from serious adverse events. External bodies were defined as external inspection, police internal investigation, systems of patient injury compensation and media.

METHODS

Based on a qualitative study design, 15 surgeons were recruited from four Norwegian university hospitals and examined with individual semi-structured interviews. Data were analysed by deductive content analysis.

RESULTS

Four overarching themes were identified, related to influence of external inspection, police investigation, patient injury compensation and media publicity, (re)presented by three categories: (1) sense of criminalisation and reinforcement of guilt, being treated as suspects, (2) lack of knowledge and competence among external bodies causing and reinforcing a sense of clashing cultures between the 'medical and the outside world' with minor influence on quality improvement and (3) involving external bodies could stimulate awareness about internal issues of quality and safety, depending on relevant competence, knowledge and communication skills.

CONCLUSIONS AND IMPLICATIONS

This study found that external assessment might generate criminalisation and scapegoating, reinforcing the sense of having medical perspectives on one hand and external regulatory perspectives on the other, which might hinder efforts to improve quality and safety. External bodies could, however, inspire useful adjustment of internal routines and procedures. The study implies that the variety and interconnections between external bodies may expose the surgeons to challenging pressure. Further studies are required to investigate these challenges to quality and safety in surgery.

Human Healthcare and Its Pharmacy Component from a Safety Point of View

Healthcare plays a crucial role in public and national safety as a significant part of state activity and a component of national safety, whose mission is to organize and ensure affordable medical care for the population. The four stages of the genesis of healthcare safety development with the corresponding safety models of formation were defined: technical, human factor or security management, systemic security management, and cognitive complexity. It was established that at all stages, little attention is paid to the issues of the formation of the pharmaceutical sector's safety. Taking into account the development of safety models that arise during the four stages of the genesis of safety science, we have proposed a model of the evolution of pharmaceutical safety formation. At the same time, future research is proposed to focus on new holistic concepts of safety, such as "Safety II", evaluation and validation methods, especially in the pharmaceutical sector, where the development of this topic remained in the second stage of the evolution of science, the search for pharmaceutical errors related to drugs.

Groundhog Day in the emergency department: A systematic review of 20 years of news coverage in Australia

This study examined how the Australian news media have portrayed public hospital Emergency Departments (EDs) over the last two decades. A systematic review and media frame analysis, searching Factiva and Australia and New Zealand News Stream for digital and print news articles published between January 2000 and January 2020. Eligibility criteria were (1) discussed EDs in public hospitals; (2) the primary focus of the article was the ED; (3) focused on the Australian context; (4) were published by one of the Australian state-based news outlets (e.g., The Sydney Morning Herald, Herald Sun). A pair of reviewers independently screened 242 articles for inclusion according to the pre-established criteria. Discrepancies were resolved via discussion. 126 articles met the inclusion criteria. Pairs of independent reviewers identified frames in 20% of the articles using an inductive approach to develop a framework for coding the remaining articles. News media rely heavily on reporting problems within and with the ED, while also proposing a cause. Praise for EDs was minimal. Opinions were primarily from government spokespeople, professional associations, and doctors. ED performance was often reported as fact, with no reference to the source of the information. Rhetorical framing devices, such as hyperbole and imagery, were used to emphasise dominant themes. The negative bias inherent in news media reporting of EDs could potentially damage public awareness of ED functioning, with implications for the likelihood of the public's accessing ED services. Like in the film Groundhog Day, news media reporting is stuck in a loop reporting the same narrative over and over again.

Failure in Medical Practice: Human Error, System Failure, or Case Severity?

The success rate in medical practice will probably never reach 100%. Success rates depend on many factors. Defining the success rate is both a technical and a philosophical issue. In opposition to the concept of success, medical failure should also be discussed. Its causality is multifactorial and extremely complex. Its actual rate and its real impact are unknown. In medical practice, failure depends not only on the human factor but also on the medical system and has at its center a very important variable-the patient. To combat errors, capturing, tracking, and analyzing them at an institutional level are important. Barriers such as the fear of consequences or a specific work climate or culture can affect this process. Although important data regarding medical errors and their consequences can be extracted by analyzing patient outcomes or using quality indicators, patient stories (clinical cases) seem to have the greatest impact on our subconscious as medical doctors and nurses and these may generate the corresponding and necessary reactions. Every clinical case has its own story. In this study, three different cases are presented to illustrate how human error, the limits of the system, and the particularities of the patient's condition (severity of the disease), alone or in combination, may lead to tragic outcomes There is a need to talk openly and in a balanced way about failure, regardless of its cause, to look at things as they are, without hiding the inconvenient truth. The common goal is not to find culprits but to find solutions and create a culture of safety.

Measuring Patient Safety Culture in Romania Using the Hospital Survey on Patient Safety Culture (HSOPSC)

Purpose To explore patient safety culture among Romanian staff, using the U.S. Hospital Survey on Patient Safety Culture (HSOPSC).

MATERIAL AND METHODS

A cross-sectional study was carried out in six hospitals, located in four Romanian regions (Craiova, Cluj-Napoca, Bucharest and Brasov), based on staff census in the Units/hospitals which volunteered to participate in the study (N=1,184). The response rate was 84%. The original questionnaire designed by the American Agency for Healthcare Research and Quality was translated into Romanian (with back translation), pre-tested before application and psychometrically checked. It consists of 42 questions grouped in 12categories, covering multiple aspects of patient safety culture (dimensions). Percentages of positive responses (PPRs) by question and category were analyzed overall and by staff profession.

RESULTS

Most respondents were nurses (69%). The main work areas were surgery (24%) and medicine (22%). The highest PPRs were for Supervisor/Manager Expectations & Actions Promoting Safety (88%), Teamwork Within Units (86%), Handoffs and Transitions (84%), Organizational Learning-Continuous Improvement (81%), Overall Perceptions of Safety (80%), Feedback & Communication About Error (75%). The lowest PPRs were for: Staffing (39%), Frequency of Events Reported (59%) and Non-punitive Response to Errors (61%). Nurses exhibited significantly higher PPRs than doctors.

CONCLUSIONS

This small-scale study of staff's attitude towards patient safety in Romanian hospitals suggests that there is room for future improvement, especially within the doctor category. Further research should assess the relationship between patient safety culture and frequency of adverse events.

'Never Events in Surgery': Mere Error or an Avoidable Disaster

Never events in surgery is not an uncommon occurrence. It is difficult to find any surgeon who never had an experience of one or another kind of mistake, committed while delivering the surgical care to the patient. Whatever the reports come out through news media or other sources are just a tip of iceberg. Collectively, its results, not only as a huge suffering and financial burden for the patients but also its impact on the operating surgeon and sometimes to related institute, are very far reaching and extremely negative. In spite of all of this, every one of us thinks this as an individual problem or one of the anecdotal media coverage. The aim of this study is to create an awareness among surgeon's fraternity and bring the attention of associations of surgeon bodies to this serious issue so that collective steps can be initiated to address it. In an attempt to find all the related information, an extensive search of literature in English language was performed using online search engines: PubMed NCBI database, Google search, and other digital sources available online. Error may be in the form of an act of commission, act of omission, error of planning, or error of execution, but whatever the reason, ultimate impacts are not less than disastrous, affecting individuals to global level. In addition to the enforcing authorities, all other stake holders should wake up and must take collective and comprehensive approach to create a safety system inside the health care organisations.

Risk factors for i.v. compounding errors when using an automated workflow management system

PURPOSE

Results of a study to determine the frequency of and risk factors for errors in automated compounding of i.v. medication doses at a pediatric hospital are presented.

METHODS

Data compiled by the hospital's automated i.v. compounding workflow management system over a 12-month period were analyzed. A descriptive analysis was conducted to characterize intercepted errors by frequency and type. Multivariate regression analysis via a backward stepwise procedure was performed to identify notable risk factors for i.v. compounding errors.

RESULTS

Among the 421,730 i.v. doses evaluated, there were 3,101 documented errors (an overall error rate of 0.74%). The automated system intercepted 72.27% of the errors, mainly those containing an incorrect drug or diluent. The remaining 27.73% of i.v. compounding errors, primarily dose preparation in the wrong volume (21.51%) or damage to the final product (0.93%), were identified during final inspection by a pharmacist. The logistic regression model showed that four factors were significantly (p < 0.05) associated with an increased risk of compounding errors: dose preparation during the morning shift (relative risk [RR], 1.84; 95% CI, 1.68-2.02) or on a Sunday (RR, 1.28; 95% CI, 1.11-1.47), preparation of doses for use in critical care units (RR, 1.17; 95% CI, 1.07-1.28), and technician versus pharmacist compounding (RR, 1.17; 95% CI, 1.04-1.32).

CONCLUSION

Analysis of error reports generated by an i.v. compounding workflow management system at a large pediatric hospital over one year found an overall rate of detected errors of 0.74%. Four factors were identified as significant predictors of increased error risk.

Validation of a Novel Cognitive Simulator for Orbital Floor Reconstruction

PURPOSE

The increasing focus on patient safety in current medical practice has promoted the development of surgical simulation technology in the form of virtual reality (VR) training designed largely to improve technical skills and less so for nontechnical aspects of surgery such as decision making and material knowledge. The present study investigated the validity of a novel cognitive VR simulator called Touch Surgery for a core maxillofacial surgical procedure: orbital floor reconstruction (OFR).

MATERIALS AND METHODS

A cross-sectional study was carried out on 2 groups of participants with different experience levels. Novice graduate dental students and expert surgeons were recruited from a local dental school and academic residency programs, respectively. All participants completed the OFR module on Touch Surgery. The primary outcome variable was simulator performance score. Post-module questionnaires rating specific aspects of the simulation experience were completed by the 2 groups and served as the secondary outcome variables. The age and gender of participants were considered additional predictor variables. From these data, conclusions were made regarding 3 types of validity (face, content, and construct) for the Touch Surgery simulator. Dependent-samples t tests were used to explore the consistency in simulation performance scores across phases 1 and 2 by experience level. Two multivariate ordinary least-squares regression models were fit to estimate the relation between experience and phase 1 and 2 scores.

RESULTS

Thirty-nine novices and 10 experts who were naïve to Touch Surgery were recruited for the study. Experts outperformed novices on phases 1 and 2 of the OFR module (P < .001), which provided the measurement of construct validation. Responses to the questionnaire items used to assess face validity were favorable from the 2 groups. Positive questionnaire responses also were recorded from experts alone on items assessing the content validity for the module. Participant age and gender were not relevant predictors of performance scores.

CONCLUSION

Construct, content, and face validities were observed for the OFR module on a novel cognitive simulator, Touch Surgery. Therefore, OFR simulation on the smart device platform could serve as a useful cognitive training and assessment tool in maxillofacial surgery residency programs.

Analysing 'big picture' policy reform mechanisms: the Australian health service safety and quality accreditation scheme

BACKGROUND

Agencies promoting national health-care accreditation reform to improve the quality of care and safety of patients are largely working without specific blueprints that can increase the likelihood of success.

OBJECTIVE

This study investigated the development and implementation of the Australian Health Service Safety and Quality Accreditation Scheme and National Safety and Quality Health Service Standards (the Scheme), their expected benefits, and challenges and facilitators to implementation.

METHODS

A multimethod study was conducted using document analysis, observation and interviews. Data sources were eight government reports, 25 h of observation and 34 interviews with 197 diverse stakeholders.

RESULTS

Development of the Scheme was achieved through extensive consultation conducted over a prolonged period, that is, from 2000 onwards. Participants, prior to implementation, believed the Scheme would produce benefits at multiple levels of the health system. The Scheme offered a national framework to promote patient-centred care, allowing organizations to engage and coordinate professionals' quality improvement activities. Significant challenges are apparent, including developing and maintaining stakeholder understanding of the Scheme's requirements. Risks must also be addressed. The standardized application of, and reliable assessment against, the standards must be achieved to maintain credibility with the Scheme. Government employment of effective stakeholder engagement strategies, such as structured consultation processes, was viewed as necessary for successful, sustainable implementation.

CONCLUSION

The Australian experience demonstrates that national accreditation reform can engender widespread stakeholder support, but implementation challenges must be overcome. In particular, the fundamental role of continued stakeholder engagement increases the likelihood that such reforms are taken up and spread across health systems.

Patient safety in spine surgery: regarding the wrong-site surgery

Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your site program by the American Academy of Orthopedic Surgeon, the sign, mark and X-ray program by the North American Spine Society, and the Universal Protocol program by the Joint Commission, the incidence of wrong-site surgery has not decreased. To prevent wrong-site surgery in spine surgeries, the spine surgeons must put patient safety first, complying with the hospital policies regarding patient safety. In the operating rooms, the surgeons need to do their best to level the hierarchy, enabling all to speak up if any patient safety concerns are noted. Changing the operating room culture is the essential part of the patient safety concerning spine surgery.

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery

BACKGROUND

The concept of "Sign Your Site" was established in 1997 to prevent wrong-site surgery in the U.S., and this was expanded to the mandated Universal Protocol in 2008. However, the true incidence of wrong-site surgery in the U.S. is not known, nor do we know whether the incidence has changed. The American Board of Orthopaedic Surgery (ABOS) requires that candidates for Board certification provide a list of their cases, including surgical complications, whether wrong-site surgery was performed, and whether they complied with the "Sign Your Site" practice. Each candidate attests to the accuracy of his or her notarized case list. The purpose of this study was to report the incidence and nature of wrong-site surgery self-reported by orthopaedic surgeon candidates for certification between 1999 and 2010 and to assess whether any change was associated with the timeline of implementation of the Universal Protocol.

METHODS

The ABOS database was queried for the number of examinees, cases, and wrong-site surgery cases reported; a description of each wrong-site surgery case; whether the site was signed; and the surgeon's subspecialty.

RESULTS

From 1999 through 2010, 9255 orthopaedic surgeons submitted 1,291,396 cases, and sixty-one of these surgeons reported performing seventy-six wrong-site surgical procedures. Spine surgeons were the most likely to report wrong-site surgery, most commonly single-level lumbar laminotomy. The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate was not significantly different. Eighteen of the twenty wrong-site surgical procedures performed since ABOS data collection for "Sign Your Site" began had been signed preoperatively.

CONCLUSIONS

Keeping patients safe remains an essential goal worthy of enormous effort. This study suggests that additional layers of precautions may yield diminishing returns and that attention should be focused on methods to prevent wrong-level spine surgery. Improving communication among the health-care team and shared responsibility may bring us closer to eliminating wrong-site surgery.

Analysis of Australian newspaper coverage of medication errors

OBJECTIVE

To investigate the frequency, style and reliability of newspaper reporting of medication errors.

DESIGN

Content analysis of articles discussing medication errors that were published in the 10 most widely read Australian daily newspapers between January 2005 and January 2010. Main outcome measure(s) Newspaper source, article type, article topic, leading news actors, identified causes and solutions of medication errors and cited references.

RESULTS

Ninety-two articles included discussion of medication errors, with the one national newspaper, The Australian, the main source of articles (n = 24). News items were the most frequent type of articles (n = 73), with the majority (n = 55) primarily focused on broader hospital problems. Government representatives, advocacy groups, researchers, health service staff and private industry groups were prominent news actors. A shortage of hospital resources was identified as the central cause of medication errors (n = 38), with efficient error reporting systems most frequently identified as a solution (n = 25). Government reports were cited on 39 occasions, with peer-reviewed publications infrequently cited (n = 4).

CONCLUSION

Australian newspaper reporting of medication errors was relatively limited. Given the high prevalence of errors and the potential role consumers can play in identifying and preventing errors, there is a clear argument for increasing public awareness and understanding of issues relating to medication safety. Existing coverage of this issue is unrelated to research evidence. This suggests the need for patient safety researchers and advocacy groups to engage more strongly with the media as a strategy to increase the productive public discourse concerning medication errors and gain support for evidence-based interventions.

Risky Business: How Professionals and Professional Fields (Must) Deal with Organizational Issues

As professionals belong to occupational systems but also increasingly work inside organizations, new linkages between occupational and organizational domains are required, but they are difficult to develop. Occupational principles and professional standards are usually considered to be at odds with managerial and organizational control principles. This generates academic and practical dualisms. Either a return to professionalism is advocated in order to protect occupational spaces and ‘rescue’ professional work, or there is a move beyond professionalism in order to restrict autonomies and discipline professional work. This article argues that both stances are unsatisfactory and that new forms of organized professionalism are called for. Changing circumstances force professional services to respond to external changes that call for organizational capacities, also inside professional domains: (a) professionals develop new work preferences and seek organized work conditions; (b) professionals face new cases, which are difficult to categorize and call for well-organized multi-professional acts; (c) due to critical attention for case treatment and incidents, professionals face new risks that have to be managed. The article shows how these realities are incorporated in professional practices – albeit slowly – and it draws normative conclusions. Professionals must take organizing and managing more seriously and will have to develop organizational capacities. In addition, connective organizational standards must be established in order to strengthen the viability and legitimacy of professional services in demanding times.

Use of benchmarking and public reporting for infection control in four high-income countries

Benchmarking of surveillance data for health-care-associated infection (HCAI) has been used for more than three decades to inform prevention strategies and improve patients' safety. In recent years, public reporting of HCAI indicators has been mandated in several countries because of an increasing demand for transparency, although many methodological issues surrounding benchmarking remain unresolved and are highly debated. In this Review, we describe developments in benchmarking and public reporting of HCAI indicators in England, France, Germany, and the USA. Although benchmarking networks in these countries are derived from a common model and use similar methods, approaches to public reporting have been more diverse. The USA and England have predominantly focused on reporting of infection rates, whereas France has put emphasis on process and structure indicators. In Germany, HCAI indicators of individual institutions are treated confidentially and are not disseminated publicly. Although evidence for a direct effect of public reporting of indicators alone on incidence of HCAIs is weak at present, it has been associated with substantial organisational change. An opportunity now exists to learn from the different strategies that have been adopted.

It is time to talk about people: a human-centered healthcare system

Examining vulnerabilities within our current healthcare system we propose borrowing two tools from the fields of engineering and design: a) Reason's system approach [1] and b) User-centered design [2,3]. Both approaches are human-centered in that they consider common patterns of human behavior when analyzing systems to identify problems and generate solutions. This paper examines these two human-centered approaches in the context of healthcare. We argue that maintaining a human-centered orientation in clinical care, research, training, and governance is critical to the evolution of an effective and sustainable healthcare system.

Multiple accountabilities in incident reporting and management

In this article, we examine the current and increasing emphasis on accountability and patient safety in health care, focusing on practices of incident reporting and management in New South Wales, Australia. We describe the frames of accountability associated with an incident reporting system, and explore how this system manifests in practice. In contrast to literature that situates incident reporting and local practices as oppositional, we used ethnographic methods to observe the incident management practices of clinical staff in a hospital, and found evidence to characterize this relationship differently. We found that accountability has multiple conceptualizations, and we present three findings that demonstrate how the reporting system and incident management policy are interwoven with local enactments of accountability. We suggest that systematic efforts toward improvement cannot be divorced from the local context, and emphasize the importance of local ecologies of practice in facilitating the meaningful utilization of such incident reporting systems.

Challenges in delivering safe patient care: a commentary on a quality improvement initiative

The specific aim of this commentary is to identify the challenges identified by nurses in the delivery of safe patient care. In reporting, some of the messages emanating from the research and policy literature, the paper highlights the importance of taking a system approach to the investigation of patient safety failures, the conflicting evidence relating to patient deaths as a result of failures in safety, and the underlying importance of culture. The paper outlines the reasons why patient safety has become so prominent, and provides a brief description of some of the definitions and terminology in current use. The commentary articulates a number of challenges in the delivery of safe care as identified by nurses during a recent quality improvement initiative, and these are organized under the themes of organizational context, working environment, and the organization and management of care. In conclusion, the paper describes the implications arising from the quality improvement initiative and the need for further research exploring the nature of safety culture in health-care organizations.

Trust in the context of patient safety problems

PURPOSE

This paper considers some implications of recent developments relating to patient safety for understandings of trust in health care contexts.

DESIGN/METHODOLOGY/APPROACH

Conceptual analysis focusing on patients' trust in health care providers and health care providers' trust in patients.

FINDINGS

Growing awareness of the scale of the problem of iatrogenic harm has prompted concerns that patients' trust in health care providers may be threatened and/or become inappropriate or dysfunctional. In principle, however, patients' trust may be both well placed and compatible with current understandings of safety problems and efforts to address these. Contemporary understandings of patient safety suggest that, to be deemed trustworthy, health care providers should make vigorous efforts to improve patient safety, be honest about safety issues, enable patients to contribute effectively to their own safety, and provide appropriate care and support after safety incidents. Patients who trust health care providers need not be ignorant of patient safety problems and may be vigilant in the course of their care. Iatrogenic harms do not necessarily reflect breeches of trust (not all such harms are yet preventable), and patients who are harmed might in some circumstances appropriately forgive and resume trusting. Health care providers may feel vulnerable to patients in several respects. From their perspective, trustworthy patients will act competently to optimise the outcomes of their health care efforts and to preserve health care providers' good reputations where those are justified. Providers' trust in patients may strengthen patients' trust in them and facilitate safety improvement work.

ORIGINALITY/VALUE

Shows how, in principle, trust can be compatible with current understandings of patient safety issues and may enhance efforts to improve patient safety.

The "To Err is Human" report and the patient safety literature

BACKGROUND

The "To Err is Human" report published by the Institute of Medicine (IOM) in 1999 called for a national effort to make health care safer. Although the report has been widely credited with spawning efforts to study and improve safety in health care, there has been limited objective assessment of its impact. We evaluated the effects of the IOM report on patient safety publications and research awards.

METHODS

We searched MEDLINE to identify English language articles on patient safety and medical errors published between 1 November 1994 and 1 November 2004. Using interrupted time series analyses, changes in the number, type, and subject matter of patient safety publications were measured. We also examined federal (US only) funding of patient safety research awards for the fiscal years 1995-2004.

RESULTS

A total of 5514 articles on patient safety and medical errors were published during the 10 year study period. The rate of patient safety publications increased from 59 to 164 articles per 100,000 MEDLINE publications (p<0.001) following the release of the IOM report. Increased rates of publication were observed for all types of patient safety articles. Publications of original research increased from an average of 24 to 41 articles per 100,000 MEDLINE publications after the release of the report (p<0.001), while patient safety research awards increased from 5 to 141 awards per 100,000 federally funded biomedical research awards (p<0.001). The most frequent subject of patient safety publications before the IOM report was malpractice (6% v 2%, p<0.001) while organizational culture was the most frequent subject (1% v 5%, p<0.001) after publication of the report.

CONCLUSIONS

Publication of the report "To Err is Human" was associated with an increased number of patient safety publications and research awards. The report appears to have stimulated research and discussion about patient safety issues, but whether this will translate into safer patient care remains unknown.

Patient safety perceptions: a survey of Iowa physicians, pharmacists, and nurses

BACKGROUND

Patient safety is of concern to consumers, health professionals, policymakers, insurers, and researchers.

OBJECTIVE

Assess the perceptions of health care providers regarding the impact of parts of the health care system on patient safety, barriers to patient safety, and strategies to improve patient safety.

METHODS

Statewide survey mailed in May 2001. Participants rated the impact of 10 parts of the health care system on patient safety, selected barriers to patient safety that they thought should be priorities, and selected the best strategies for improving patient safety.

RESULTS

Of random samples of 1310 physicians, 1310 pharmacists, and 2620 nurses licensed by the state of Iowa, 5075 providers were eligible and 2388 responded (47%). Provider education, norms and values, patient and family characteristics, and continuity of care were rated as having a major impact on patient safety by at least 70% of each provider group. A general lack of consensus exists among providers about which barriers to patient safety should be priorities and which strategies would best improve the system. However, a majority of providers agreed that educating patients about their role in health care and sharing information between providers and across settings of care are important strategies for improving patient safety.

CONCLUSION

In areas in which providers agree on the best strategies, broader, system-wide interventions that include physicians, pharmacists, and nurses in multiple settings may be implemented to improve patient safety. Health care organizations and providers must get patients more involved in their care by asking them to help define roles, design educational materials, and develop useful methods of sharing information across settings.

Medical errors and clinical risk management: state of the art

Medical errors represent a serious public health problem and pose a threat to patient safety. All patients are potentially vulnerable, therefore medical errors are costly from a human, economic, and social viewpoint. The present report aims not only to provide an overview of the problem on the basis of the published literature, but also to stress the importance of adopting standard terminology and classifications, fundamental tools for researchers to obtain valid and reliable methods for error identification and reporting. In fact, agreement on standard definitions allows comparison of data in different contexts. Errors can be classified according to their outcome, the setting where they take place (inpatient, outpatient), the kind of procedure involved (medication, surgery, etc.) or the probability of occurring (high, low). Error categories are analysed taking into consideration their prevalence, avoidance and associated factors as well as the different strategies for detecting medical errors. Incident reporting and documentation of near-misses are described as useful sources of information, and Healthcare Failure Mode Effect Analysis (HFMEA) and Root Cause Analysis (RCA) are seen as powerful methods for process analysis. Furthermore, means to increase patient safety are considered in the broader context of clinical risk management. New approaches in the field of medical errors are aimed at minimizing the recurrence of avoidable patterns associated with higher error rate. A system approach and a blame-free environment, aimed at better organizational performances, lead to much better results than focusing on individuals. Furthermore, use of technology, information accessibility, communication, patient collaboration and multi-professional team-work are successful strategies to reach the goal of patient safety within healthcare organizations.

Residency work-hours reform. A cost analysis including preventable adverse events

BACKGROUND

In response to proposed federal legislation, the Accreditation Council for Graduate Medical Education limited resident work-hours in July 2003. The cost may be substantial but, if successful, the reform might lower preventable adverse event costs in hospital and after discharge.

OBJECTIVES

This study sought to estimate the reform's net cost in 2001 dollars, and to determine the reduction in preventable adverse events needed to make reform cost neutral from teaching hospital and societal perspectives.

DESIGN

Cost analysis using published literature and data. Net costs were determined for 4 reform strategies and over a range of potential effects on preventable adverse events.

RESULTS

Nationwide, transferring excess work to task-tailored substitutes (the lowest-level providers appropriate for noneducational tasks) would cost 673 million dollars; mid-level providers would cost 1.1 billion dollars. Reform strategies promoting adverse events would increase net teaching hospital and societal costs as well as mortality. If task-tailored substitutes decrease events by 5.1% or mid-level providers decrease them by 8.5%, reform would be cost neutral for society. Events must fall by 18.5% and 30.9%, respectively, to be cost neutral for teaching hospitals.

CONCLUSIONS

Because most preventable adverse event costs occur after discharge, a modest decline (5.1% to 8.5%) in them might make residency work-hours reform cost neutral for society but only a much larger drop (18.5% to 30.9%) would make it cost neutral for teaching hospitals, unless additional funds are allocated. Future research should evaluate which reform approaches prevent adverse events and at what cost.

Sins of omission: getting too little medical care may be the greatest threat to patient safety

BACKGROUND

Little is known about the relative incidence of serious errors of omission versus errors of commission.

OBJECTIVE

To identify the most common substantive medical errors identified by medical record review.

DESIGN

Retrospective cohort study.

SETTING

Twelve Veterans Affairs health care systems in 2 regions.

PARTICIPANTS

Stratified random sample of 621 patients receiving care over a 2-year period.

MAIN OUTCOME MEASURE

Classification of reported quality problems.

METHODS

Trained physicians reviewed the full inpatient and outpatient record and described quality problems, which were then classified as errors of omission versus commission.

RESULTS

Eighty-two percent of patients had at least 1 error reported over a 13-month period. The average number of errors reported per case was 4.7 (95% confidence intervals [CI]: 4.4, 5.0). Overall, 95.7% (95% CI: 94.9%, 96.4%) of errors were identified as being problems with underuse. Inadequate care for people with chronic illnesses was particularly common. Among errors of omission, obtaining insufficient information from histories and physicals (25.3%), inadequacies in diagnostic testing (33.9%), and patients not receiving needed medications (20.7%) were all common. Out of the 2,917 errors identified, only 27 were rated as being highly serious, and 26 (96%) of these were errors of omission.

CONCLUSIONS

While preventing iatrogenic injury resulting from medical errors is a critically important part of quality improvement, we found that the overwhelming majority of substantive medical errors identifiable from the medical record were related to people getting too little medical care, especially for those with chronic medical conditions.

Perceptions of Medical Errors by Internal Medicine Residents

Efforts to identify the underlying structure of 40 survey items dealing with perceptions of medical errors are reported on the basis of responses from 195 medical residents. Factor analysis revealed that the medical errors perceptions were represented by a 10-factor solution. The external validity of these factors was examined relative to perceptions about the cost of medical errors, the cost of errors to health care, and the need for education and interventions to address errors. Results indicated that 13.9% of the variation in the perceived cost of medical errors and 17.1% of the variation in the perceived need for additional physician education was explained by the factor structure.

The Faces of Errors: A Case-Based Approach to Educating Providers, Policymakers, and the Public About Patient Safety

BACKGROUND

When patient safety became a subject of policy and research, the question was how to engage clinicians-perhaps they would respond more to case studies of dramatic adverse events than to statistics. THE CHRONOLOGY: In 2001, we launched a case-based series in the Annals of Medicine which focused on diagnosing what ailed the system rather than the patient. For example, in "The Wrong Patient," 17 discrete errors resulted in a woman's receiving a cardiac electrophysiology procedure intended for another patient with a similar last name. The Web-based Agency for Healthcare Research and Quality (AHRQ) WebM&M was then developed as a forum that was part-reporting system and part-journal. Finally, we then applied this approach to writing a book for a popular audience.

LESSONS LEARNED

We found that clinicians were willing to submit cases, assuming that anonymity was protected. Cases of errors that led to harm were generally more compelling than near misses. As in real life, many cases lacked complete information, but sufficient information was usually available to highlight the key lessons. All three vehicles generated substantial readerships and critical praise, indicating that there is a "market" for case-based education about patient safety.

CONCLUSION

Presenting de-identified cases of medical mistakes in a variety of public venues is an effective way to educate patients and providers about safety.

The silence

Despite several well-crafted Institute of Medicine (IOM) reports, there remains within health care a persistent refusal to confront providers' responsibility for severe quality problems. There is a silence of deed--failing to take corrective actions--and of word--failing to discuss openly the true consequences of that inertia. These silences distort public policy, delay change, and, by leading (albeit inadvertently) to thousands of patient deaths, undermine professionalism. The IOM quality committee, to retain its moral authority, should forgo issuing more reports and instead lead an emergency corrective-action campaign comparable to Flexner's crusade against charlatan medical schools.

A fragmented patient safety concept: the structure and culture of safety management in healthcare

Safety in healthcare organizations is often an ownerless process with responsibility falling under a myriad of departments that individually are coordinating initiatives to improve aspects of safety. In contrast, other high-hazard industries seek to institutionalize safety management as a key characteristic of organizational culture. Healthcare seeks to model its approach to patient safety on other high-hazard industry models, but without an understanding of the impact of creating a uniform approach to safety management, healthcare organizations will not implement a similar organization-wide safety culture.

Patient safety and health policy: a history and review

Policy initiatives on many fronts have converged to improve patient safety. A major tension that characterizes this process is the attempt to achieve a balance between learning and control in complex systems with technical, social, and organizational components. Efforts to improve learning are marked by better information flow, discovery, flexibility in thinking, embracing of failures as learning opportunities, and core incentives to promote voluntary participation of all stakeholders in the process. Efforts to improve accountability are traditionally marked by public disclosure, meeting of certain widely disseminated standards, availability of performance measures, exposure to legal liability, and compliance with mandated directives (statutes, regulations, accreditation requirements). In some sense, these directions are mutually exclusive. Although a more collaborative regulatory-improvement model would be helpful in creating an industrywide safety culture, it is likely that learning and accountability functions will follow separate tracks. An exception would be policy that stimulates organizations to comply with regulation by showing how well and by what methods they are learning and how others can profit from these experiences. Any approach to improving patient safety should, at a minimum, include a nonpunitive in-depth mechanism for reporting incidents, postincident evaluations for identification of system changes to prevent subsequent occurrences, and state-guaranteed legislative protection from discovery for all aspects of information gathered to improve patient safety. Nonpunitive approaches have yielded useful results in other industries [43]. State and federal courts, state licensing boards, and accrediting bodies such as JCAHO all function to maintain accountability and standards; however, the very fear of existing legal liability or its misapplication are the greatest hurdles to pioneering patient-safety efforts. The health care system needs to transform the existing culture of blame and punishment that suppresses information about errors and adverse events into a culture of safety that focuses on openness and information sharing to improve health care and prevent adverse outcomes. Education and leadership will be most important to creating and sustaining a strong safety culture and arguably the most important defense against preventable harms. Safety culture cannot be legislated, just as the old adage states that it is easier to pull rather than push a piece of spaghetti. Given the imbalances and inefficiencies of market forces in health care, perverse incentives that have strengthened resistance to change, and secrecy when it comes to adverse event information, however, it is likely that policy initiatives will continue to play an important role in the transformation of the industry to more highly reliable, safer levels of care.