An Agenda for Research in Ambulatory Patient Safety
21 The risk is not absolutely zero. If medical records document that particular threats to safety were known but no effective action taken over a substantial period of time, this information could be used against the organization during determination of fault and cause in a liability action.
22 Heinrich (1941) is cited in a report (analogous to the Institute of Medicine's report To Err is Human) from the United Kingdom, An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the National Health Service, Department of Health. London: The Stationery Office Limited, 2000.
23 The body of knowledge that has developed to explain these multifactorial interactions is called "complexity science." A concise explanation of complexity science is provided in Appendix B (Plsek 2001) of the Institute of Medicine report (Institute of Medicine 2001) Crossing the Quality Chasm: A New Health System for the 21st Century. Additional sources include a four part series of recent articles in the British Medical Journal (Plsek and Greenhalgh 2001, Wilson and Holt 2001, Plsek and Wilson 2001, Fraser and Greenhalgh 2001).
24 The extent to which the VA experience can be generalized is not clear. The VA system is different from other health care systems with respect to both individual liability and the structure of accountability. Patients must sue the Federal Government under the Torts Claims Act. In the event of a settlement or judgment, a peer review panel recommends whether or not individual practitioner(s) should be reported to the National Practitioner Data Bank.
26 To inform and provide a context for designing research, what we know about ambulatory care should be assembled into a conceptual model that includes all the elements of ambulatory care. A complete and accurate conceptual model of ambulatory care would capture the many people and tasks, the key processes and systems, and their interactions, interdependencies and complexity.
27 James and colleagues found that 62 of more than 600 identifiable clinical conditions (and associated clinical processes) accounted for over 90% of hospital-based care delivery. They have also identified about 40 key clinical support processes that account for about 80% of the resource use in support operations such as the clinical laboratory, pharmacy, a nursing unit, an ICU, a procedure suite, a therapy group, etc. (Brent C. James, M.D., M.Stat., personal communication, June 2001).
28 Technology can bring its own risks. Inadequate operator training and equipment maintenance may lead to misuse and malfunction. If a clinician or other person believes that a device or machine essentially eliminates risk, they may be less vigilant and less likely to detect errors as they are happening (Senders 1994, Macklis et al. 1998, Bates et al. 2001).
29 Redistributing responsibilities and tasks among several clinicians working together would also be expected to reduce costs as less costly people do some tasks that physicians would have done—and do them as well or better.
30 A change in this mental model may be quite difficult to achieve so long as the influence of the tort liability system in medicine is so strong. At the least, it will be necessary to erect protective barriers to enable learning from adverse events.
31 Of course, standardized processes must be built to accommodate differences among patients.
32 Analysis of data from MGMA's annual Cost Surveys (1995 ff) and annual Physician Compensation and Production Surveys (1995 ff) for the years 1995-2000; David Gans, personal communication, April 2001; and Gans 2001.
33 Pursuing Perfection: Raising the Bar for Health Care Performance, is a recently launched program of the Robert Wood Johnson Foundation. It is one example of an approach to large scale, sustained, multifaceted research and demonstration projects (see http://www.rwjf.org).
34 Five of Minnesota's largest health plans (Blue Cross Blue Shield of Minnesota, Medica, Preferred One, UCare MN, and HealthPartners) recently agreed to work together as sponsors of the Institute for Clinical Systems Integration to promote and support the use of medical practice guidelines and protocols developed at the Institute (Quality Letter 2001).
35 Information on Virginians Improving Patient Care and Safety is available at www.vipcs.org. The National Patient Safety Foundation (www.npsf.org) incubates regional patient safety coalitions through its Education Program.
36 Betsy Lehman died in 1996 after an overdose of chemotherapy in a Boston Hospital in 1995. Willie King suffered amputation of the "wrong leg" in a Florida Hospital in 1996, after giving informed consent to amputation of his other leg.
37 105 Code of Massachusetts General Laws, ch. 111, sec. 203; ch. 112, sec. 5, ch. 112, sec. 52 (1999).
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