An Agenda for Research in Ambulatory Patient Safety
Topic Two—Strategies to Improve Care and Research
- We have little "real data" on ambulatory health care (ambulatory health care) safety and what works to improve safety. How can we use the data and experience of liability insurance companies in research and demonstrations in ambulatory patient safety?
- What kinds of confidentiality protection will be required to establish and maintain near miss reporting systems? Do we have enough now? Is it more a problem of education and demonstration?
- How can existing reporting databanks be better used to understand threats and injuries?
- PROs, Risk Management organizations, national foundations, and voluntary accreditors are already maintaining adverse event and near miss databanks. How many more do we need? What are the best models to disseminate?
- Should a national, "nested" system for near miss reporting be designed, or should it be allowed to develop from the market?
- If fragmentation of care, highly variable structure, and loose linkages are a major source of risk to patient safety in ambulatory care, should we build a national model of integrated ambulatory health care delivery that would reduce risks from these factors? What are the key elements, the first steps?
- We advance the hypothesis that the lack of universal electronic medical record is a critical gap in the fabric of ambulatory health care safety. Are we right to prioritize this as a critical ambulatory health care safety issue? Is it achievable?
- We advance the hypothesis that focusing on the chain of medication prescribing, delivery and use should be an immediate focus of ambulatory health care safety. Are we right in thinking that gains in this area are likely to cascade into others and expedite the formation of a patient safety infrastructure in ambulatory health care?
- How might technology amplify negative consequences? How might the science of technology assessment in health care be developed?
- Will the rapidly growing area of patient-provider email communication affect safety? Will it perversely decrease access to care for those with easy computer access? Will it create an even greater divide between the haves and have-nots?
- Can low volume centers successfully adopt practices of high volume centers? Or is it finally a function of size (critical mass of resources and maintaining expertise)? Will widespread adoption of high volume referral centers paradoxically worsen care in lower volume facilities that must care for the conditions in question?
- How will solo and small group practices cope with increasing trends towards use of expensive information systems, need for more documentation, decreasing reimbursement, etc...? What organizations might fill this niche?
- Hypothesis: Significantly improving health care worker safety will significantly improve patient safety. Do we have good enough baseline data on threats/injuries re: health care workers? What level of evidence is required?
- What level of evidence will be needed to widely support adoption of simulation training in health care? If cost is an issue, what is the cost of training under the current model? If that is not known, how do we get that data?
- How might available research dollars best be leveraged to have the widest and most sustained impact?
Topic Three—The External Environment
- We assert that "leadership" is a key to advance patient safety. How do we build leadership to advance patient safety in ambulatory health care?
- How do we build trust among stakeholders to advance patient safety? Are disclosure and apology necessary steps to earning consumer trust? Is it realistic to think that ambulatory health care facilities will adopt practices of disclosure and apology? Why or why not?
- We advance the hypothesis that accountability for safety in ambulatory health care is distributed among several stakeholders. Is it realistic to think that those stakeholders will accept these responsibilities? What would you recommend as vehicles for growing this understanding of accountability?
- Legislation pending in Massachusetts would establish a patient safety center with the function of coordinating all State regulatory initiatives relating to patient safety, to allocate resources, avoid overlap of reporting requirements, encourage consistency of definitions, measures and language, etc. Is this a good model? Why or why not?
- Coalition efforts in Massachusetts and the Houston area, among others, reflect the phenomenon of stakeholders coming together to create a safe space to discuss safety and forge interventions. Is this a good model? Is it likely that such a structure can effectively coordinate the different roles and responsibilities of stakeholders in advancing patient safety?
- A strong case is being made for developing a national mandatory reporting system structure and process (States>Fed). Why will it work any better than what we have legislated now, subject to severe underreporting and resource constraints?
- Could mandatory reporting enforcement constrain voluntary reporting through fear of what might be disclosed?
- The National Practitioner Data Bank has been the subject of research suggesting the NPDB has caused perverse and unintended incentives to downcode and underreport problems. Is this widely accepted? What does this mean for planned mandatory reporting schemes?
- Given the public and political climate, how will demand for new "strong" Federal confidentiality protection for reporting fare? What about the longstanding practice of public disclosure of adverse event data by State departments of public health?
- What are the obstacles to developing a business case for medication safety in ambulatory health care? What are the key elements of a business case for medication safety?
- Research suggests that patients do not now use public physician and organization profiling data to make decisions about where they choose to receive care. How will proposed public safety indicator data influence consumer behavior? What information and/or incentives will motivate consumers to migrate to safer health care environments?
- How can patient experience with adverse events and near misses be integrated into reporting systems?
- Does a focus on patient safety and the core value "First, do no harm?" have the potential for re-opening the discussion of civil justice system reform?
- Has the patient safety movement made the notions of enterprise liability or no-fault more palatable to clinicians, liability insurers and ambulatory health care organizations? Do you think a no-fault system of compensation would advance patient safety? Increase consumer trust? Would early offer and recovery mechanisms be a better approach?
Appendix Three: Proposed Federal Legislation on Medical Error Introduced in the 106th Congress
|Bill Number||Bill Title||Primary Sponsor||Latest Action||Key Provisions|
|S. 2738.||A bill to amend the Public Health Service Act to reduce medical mistakes and medication-related errors.||Senator James Jeffords (R-VT).||6/15/00: Introduced and referred to the Senate Labor, Health, Education and Pensions Committee.||Amends current law to reduce medical mistakes and medication-related errors by creating a Center for Quality Improvement and Patient Safety to track medical mistakes and best practices.|
|S. 2743.||Voluntary Error Reduction and Improvement in Patient Safety Act.||Senator Edward Kennedy (D-MA).||6/15/00: Introduced and referred to the Senate Labor, Health, Education and Pensions Committee.||Amends current law to develop the Center for Quality Improvement for Patient Safety to direct a national voluntary reporting system, research and dissemination of critical information.|
|S. 2038.||Medical Error Reduction Act of 2000.||Senator Arlen Specter (R-PA).||2/8/00: Referred to Senate Health, Education, Labor, and Pensions Committee.||Provides grants for States to establish reporting systems designed to reduce medical errors. Establishes 15 demonstration projects to be competitively awarded to health care facilities and organizations in geographically diverse locations.|
|S. 2378.||Stop All Frequent Errors in Medicare and Medicaid Act of 2000.||Senator Charles Grassley (R-IA).||4/6/00: Referred to Senate Finance Committee.||Sets a goal of 50 percent medical error reduction over the next five years in Medicare and Medicaid. Requires health institutions to establish medical safety programs; identify medical error causes; take steps to prevent further accidents; and disclose to the public the name and address of facilities that fail to comply.|
|H.R. 4607.||Medicare Prescription Drug Act of 2000.||Representative Anna G. Eshoo (D-CA).||6/19/00: Referred to House Commerce Subcommittee on Health and Environment.||Requires to be in place systems for improving clinical quality, including the prevention of drug-drug interactions, assessment of clinical relevance, monitoring and improving compliance, and adoption of information technologies proven to reduce prescription errors.|
|H.R. 3672.||Medication Error Prevention Act of 2000.||Representative Connie Morella (R-MD).||2/23/00: Referred to House Commerce Subcommittee on Health and Environment.||Provides voluntary reporting by health care providers of medication error information in order to assist public and nonprofit entities in developing and disseminating recommendations and information to prevent medical errors.|
Current as of December 2001
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin, HR. Conference Synthesis: Research Agenda for Ambulatory Patient Safety. December 2001. Grant No. R13-HS10106. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/ptsafety/