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3. Beyond the IOM Report: Identifying and Implementing Additional Strategies
IOM report offered many useful recommendations for improving the
safety of the health care system, additional actions can and should
be taken to reduce errors. Federal agencies have been working on
a variety of projects designed to reduce medical errors and, in
many instances, are the national leaders in experimenting with programs
intended to promote safety. A brief description is provided below
of some of the current activities, as well as recommendations for
additional activities to reduce errors through increased awareness
of medical errors; commitment of substantial resources to further
research; the use of information systems; and the redesign of systems,
procedures, and medical products.
Public Awareness of Medical Errors
patients are key participants in the effort to enhance the quality
and safety of American health care. The right question from a patient
at the right time may be the intervention that averts an error.
As the IOM report recognizes, the public largely believes that it
is protected from errors and safety problems. For instance, the
public assumes that licensure and accreditation confer a "Good
Housekeeping Seal of Approval" on practitioners and institutions
(Institute of Medicine, 1999). Thus,
the public assumes that they can implicitly trust those professionals
and facilities to do the right thing in the right way. Despite health
professionals’ best attempts to make patients’ assumptions a reality,
the available evidence about medical errors suggests that reality
falls short. In that respect, patients’ understanding of the medical
errors situation is not substantially different from their understanding
of other confusing aspects of the health care system. For example,
the Employee Benefit Research Institute (EBRI) reports that only
21 percent of managed care participants know they are in this type
of plan. Instituting a national patient safety electronic bulletin
board, as indicated in "Learning
from Errors" in Chapter 2, will not only enable patients
to report errors that they see or experience, but will also aid
in improving the public’s general understanding of patient safety.
members of the public are aware that the health care environment
itself is less safe than previously assumed, they have made few
demands for improvement of the system. A 1997 survey by the National
Patient Safety Foundation found that many people view errors as
a problem that can be fixed by getting rid of bad providers, rather
than as the consequence of delivering care within a complex delivery
ongoing, aggressive public information and education effort is needed
to increase all Americans' understanding of both how medical errors
occur and what steps they can take to prevent such errors. This
campaign must carefully address the tension between the need for
increasing general awareness with the competing need of ensuring
that patients are not afraid of receiving necessary care.
The QuIC agencies,
working in close collaboration with private-sector organizations,
can develop consistent patient safety messages and themes that can
be used by Federal agencies and private-sector employers, health
care purchasers, and others to disseminate a powerful and consistent
message to individuals about their role in ensuring the quality
of their own health care. The QuIC has established the Enhancing
Patient and Consumer Information working group with the specific
intent of providing the public with clearer and more consistent
information about health care qualityand patient safety is
a key part of that information. The QuIC agencies see this work
group as a foundation for strengthening the effectiveness of the
actions that agencies might have otherwise taken independently.
Federal agencies that provide or purchase health care have a responsibility
to work with their constituencies to increase awareness of patient
safety issues and the role their constituents can play in improving
safety. For instance, part of HCFA’s and OPM’s mission in purchasing
health care is to provide information to enrollees that will help
them choose their health coverage. These agencies are exploring
how to educate enrollees so that they can understand and evaluate
issues related to medical errors and take appropriate actions. HCFA
and OPM also lead the QuIC working group on patient and consumer
information, which provides a natural vehicle for extending the
messages to other Federal beneficiaries and the public.
A number of
other mechanisms exist to extend the work of this work group to
more people. It is possible to use public–private partnerships to
communicate the patient safety message to a variety of audiences
through recently developed mechanisms. These partnerships include
the NPSF, NPSP, and the Quality Forum, and are summarized in the
"Actions" section that follows.
- Through the
QuIC’s Enhancing Patient and Consumer Information Working Group,
led by OPM and HCFA, Federal agencies will develop and coordinate
an information campaign for their constituencies and beneficiaries
to increase their awareness of the problem of medical errors and
- AHRQ will
develop generic material for the public on preventing medical
errors that Federal agencies can disseminate, reprint, or adapt.
This material will enable patients to become more involved in
their care and to be more active participants in the decisionmaking
surrounding their care.
- The CQuIPS
will develop and test patient safety questions for inclusion in
the patient survey now being developed for provider-level assessment
of health care.
- HCFA will
conduct research aimed at shaping programs to educate beneficiaries
about medical errors.
- Within 1
year, FDA will increase collaborative programs with patient and
consumer groups regarding patient safety.
- FDA will
enhance its interactions with the public through meetings with
consumer and patient organizations, and through grass-roots informational
meetings. The meetings will focus on patient needs and the safe
use of medical products, particularly for home use. The meetings
will also discuss how to reach patients with important information
on safe use of medical productsincluding through the use
of local networks, the Internet, and electronic and print media.
This will occur within 1 year.
- Patient safety
and reducing medical errors will be a featured topic at OPM’s
Fall 2000 annual health plan conference.
Purchasers’ Awareness of the Problem
Just as with
Federal purchasers of health care, it is critical that employers
who sponsor group health plans understand that quality, not just
cost, is a factor to be considered in selecting health care providers
for their employees. In 1998, the DOL’s Pension and Welfare Benefits
Administration (PWBA) issued a letter making clear that, where the
selection involves the disposition of employee benefit plan assets,
taking quality into account is part of a plan decisionmaker's responsibility
under the Employee Retirement Income Security Act (ERISA).
To assist employers
in meeting this obligation, the DOL launched the Health Benefits
Education Campaign in December 1998. One of the goals of the Campaign,
a coalition of the DOL with both public- and private-sector partners,
is to inform employees about issues of quality and safety under
their employer-provided health benefits so that they can make informed
health benefits decisions. The Campaign further seeks to inform
employers of the value of providing quality and affordable health
benefits to their employees. It provides a forum for sharing with
the private sector the information learned from other QuIC agencies
on quality care, setting and implementing standards, developing
and implementing data integration techniques, and effectively communicating
A number of
employers and employer health care coalitions are already taking
the initiative of making safe medical practice an important criterion
in selecting the health insurance they provide to their workers.
For example, the National Business Coalition on Health (NBCH), a
Campaign partner, is developing a set of standards that employers
can voluntarily use to evaluate safety and quality in health plans.
The Business Roundtable, another Campaign partner, has allocated
funds for the Leapfrog Group, an organization of eight executives
of some of the Nation’s biggest companies and health care purchasers,
including OPM, to encourage all employers to make safety and quality
in health care a top priority. DOL will, through the Campaign, work
with plans, employers, and participants to advance the provision
of safe, high-quality health benefits. Some of the work that is
being done is summarized in the "Actions" section that
on existing relationships with purchasers and business coalitions,
such as the National Business Coalition on Health, and the Washington
(DC) and Midwest Business Coalitions on Health, DOL, HCFA, OPM,
and AHRQ will spearhead the QuIC’s efforts to promote collaborative
programs with other public- and private-sector partners to increase
purchasers’ and providers’ awareness of medical errors as a health
care problem and of steps that each can take to address this problem,
such as addressing patients’ health literacy skills.
- At the Federal
Benefits Conference (June 2000), OPM will share information about
patient safety with representatives from Federal agencies throughout
With Providers to Improve Patient Safety
to information for patients and purchasers, information is needed
for health professionals, facilities, and systems of care to ensure
that they understand the scope of the medical errors problem and
its impact. Results from surveys and focus groups conducted by VA,
involving both VA and private-sector facilities, have shown that
a substantial portion of doctors, nurses, and others working in
health care facilities do not believe that medical errors present
a significant threat to patients. If they believe that medical errors
and issues of patient safety are isolated, random events, efforts
to reduce the current incidence of preventable errors will not be
perception is that the health professional credentialing and institutional
accreditation processes provide meaningful assurances of the quality
of care. It is crucial that professional societies, accrediting
bodies, and licensure organizations use their roles to promote patient
safety by ensuring that those whom they credential and accredit
are knowledgeable about issues of safety and implement procedural
changes that have been shown to reduce the likelihood of error.
Help by these organizations is paramount in fostering awareness
and understanding of issues about medical errors and patient safety.
The QuIC agencies
will work collaboratively with professional societies to promote
awareness of the medical errors problems and to identify ways to
improve the education, credentialing and accrediting processes to
rigorously examine safety knowledge and practices. AHRQ will work
with private-sector groups, such as NPSF, NPSP, and the Quality
Forum to educate providers and purchasers about improving patient
- Through the
QuIC, Federal agencies will take advantage of existing resources
to promote collaborative patient safety programs involving agency
constituents, the health professions community, the public, academia,
and other stakeholders, such as the American Medical Association,
the American Nurses Association, NPSF, NPSP, and the Quality Forum.
- VA will develop
and run pilot patient safety education programs for medical residents
Systems and Information Technologies
Government has played a pivotal role in the application of information
technology to health care. The predecessor of AHRQ funded some of
the earliest research on computerized patient records, studies evaluating
the impact of computer reminder systems on laboratory testing errors,
and research on the effect of computers on drug ordering. VA and
DoD are recognized national leaders in the implementation of electronic
medical records and decision-support tools. They have recently joined
in partnership with the Indian Health Service (IHS) to develop a
prototype for a computerized medical record system. In addition,
many private-sector leaders in health care informatics, such as
Intermountain Healthcare and the Brigham and Women’s Hospital, have
used Federal grants to develop and test their systems. The President
has also requested $20 million in the FY 2001 Budget for the Health
Informatics Initiative, which includes support for strategies to
address the problem of medical errors through enhanced information
success of health care informatics models is well documented and
their applicability to patient safety is clear, they have not been
widely adopted. A Federal effort to further knowledge about the
application and effectiveness of these technologies to patient safety
improvement and to promote the appropriate adoption of these tools
would build on a strong foundation of prior work and put health
care technologies to use in improving the quality of care for Americans.
of where the QuIC could have an impact through its participants’
activities is in the area of electronic records and order entry.
Most health care providers currently work with handwritten patient
notes, which are often difficult to read, not readily available,
incomplete, and prone to alteration, destruction, and loss. Electronic
medical records and interactive decision-support tools have the
potential to allow health care providers timely knowledge of a patient’s
health history and improve clinical care. Electronic access to a
patient's chart removes uncertainties regarding the patient's health
history. Further, well-designed electronic systems can give physicians,
nurses, and other providers essential access to the most current
results of consultations, laboratory tests, x-rays and other studies,
and to previous test results. Structured, electronic order entry
systems that require complete data entry remove ambiguities that
arise from incomplete information or illegible writing.
decision support constitutes a powerful technology that can help
address the significant problem of medication errors. Decision-support
systems can intercept errors, such as interactions between incompatible
medications and the prescription of drugs to which the patient's
electronic medical record notes an allergy. Patient factors relevant
to the dosing of particular medications can also be evaluated electronically;
drug overdosing or underdosing can be corrected by accounting for
a patient’s age, weight, and kidney function. Taken further, better
choices of medications for a particular condition can be recommended,
such as the most diagnosis-appropriate antibiotic. Finally, bar-coding
of medications and use of robotics in dispensing medications can
ensure that the appropriate medication is provided to the appropriate
patient at the appropriate time.
organizations can more easily and reliably aggregate their electronic
records to look for trends and provide data for research on patient
safety issues without relying on costly chart reviews. Provider
profiles can be used to provide helpful feedback to clinicians and
to identify needs for training and system changes. Health care organization
profiles can be developed for any level of the organization to look
for systemic problems and evaluate interventions.
is a real need to involve clinicians and other users in the design
of systems at an early stage to optimize usability. Increased emphasis
on design controls for manufacturers is needed to ensure that usability
testing occurs throughout development, especially in the premarket
design phase of medical device development. Continued development,
taking into account knowledge of human factors and results of usability
testing, is needed. Use of human factors standards, such as nationally
or internationally accepted standards for products and the human
factors standards used by NASA and DoD, could aid in that process.
technology has tremendous potential to reduce errors in health care
by providing information when it is needed, providing clinical feedback,
and alerting providers to potential problems. But, as noted earlier,
information technology also has the potential to cause errors. Therefore,
attention to human factors and other aspects of system design is
vital. Additional research is needed to explore the safety and effectiveness
of, for example, decision-support systems embedded in software and
other technical aspects of medical products.
- AHRQ and
CDC will expand research efforts in the area of informatics to
include initiatives aimed at developing and evaluating electronic
systems to identify, track, and address patient safety concerns.
- CQuIPS at
AHRQ, along with VA, DoD, FDA and other QuIC member agencies,
will evaluate the effectiveness of automated physician order-entry
systems in hospitals.
- DoD, VA,
and IHS will introduce electronic patient records to offer structured
documentation and a common clinical lexicon for practitioners
working throughout those systems. The QuIC will encourage other
potential Federal participants to do likewise.
Procedures, Checklists, and the Results of Human Factors Research
and standardized procedures in medical devices (as has been done
with anesthesia gas machines) needs to be expanded to many more
medical devices to protect patient safety. The American National
Standards Institute (ANSI) is leading an effort to develop U.S.
national standards for medical device alarms and human factors-based
engineering designs of medical devices. The Association for the
Advancement of Medical Instrumentation is developing human factors
standards for medical devices. The development of standard operating
procedures can also help. For example, the Occupational Safety and
Health Administration’s (OSHA’s) Bloodborne Pathogens Standard requiring
proper disposal of contaminated sharps and needles ensures a safer
environment for both workers and patients. The DHHS Advisory Committee
on Blood Safety and Availability has issued recommendations to prevent
errors and accidents in the collection and administration of blood.
Systems Regulation, which governs the design process for medical
devices, provides manufacturers with guidance on human factors design
principles and information on how to conduct a risk assessment to
qualify their design, and serves as a model for other programs.
The internationally recognized expertise in human factors research
of NASA, DoD, and FAA could be applied to the improvement of patient
safety with the establishment of appropriate links to the QuIC participants.
recognizing that many problems are not detected until after a product
has been marketed, FDA believes that strengthening its premarket
activities, including those related to human factors, will aid in
reducing problems that users may encounter with medical products
in clinical use. For example, premarket testing of standardized
procedures for operation and maintenance of products, user instructions,
and labels would aid in detecting and preventing errors associated
with the use of medical products. FDA proposes to encourage manufacturers
to explore human factors issues through the use of premarket focus
groups as well as through user testing of the product in its intended
organizations need to develop staff awareness of the need for continuous
improvement of quality, processes, and performance as another critical
component of error reduction. The Federal health care delivery systems
have been providing meaningful quality improvement training to personnel
at their delivery sites for several years. Error reduction has been
a strong focus for some programs, such as those at VA. For example,
quality improvement training led to concentrated potassium chloride
containers being removed from patient care settings. This kind of
information can be shared broadly with other health care providers
to emulate VA’s success.
- CDC and FDA
will work with the DHHS Advisory Committee on Blood Safety and
Availability to help ensure that the highest quality standards
are met in blood collection and transfusion.
- Within 1
year, FDA will begin working with manufacturers of medical products
to explore incorporating standards, including human factors standards,
into guidance to ensure that medical products are designed to
minimize the chance of errors.
- NASA will
be invited to become a participant in QuIC activities and bring
its understanding and experience in redesigning processes and
procedures to enhance safety. Linkages between NASA and the CQuIPS
will be established through the NASA Medical Policy Board.
- The QuIC
will sponsor an educational program, noted in the section on research
above, to increase the awareness of Federal regulators and policymakers
regarding patient safety, human factors, and systems-based improvement.
- VA will continue
to work with private-sector organizations (e. g., the American
Hospital Association and JCAHO) to explore the utility of its
comprehensive error analysis and corrective action system.
4. Working With the Private Sector and State Governments
that constitute the QuIC have longstanding relationships with
the private sector, including professional organizations,
purchasers and purchaser coalitions, business groups, independent
accrediting entities, quality measurement and consumer information
experts, researchers, medical product manufacturers, hospitals,
group practices, health systems and health plans. Working
collaboratively, the QuIC agencies can make use of these relationships
to help reduce medical errors and increase patient safety,
thereby improving the quality of care for all Americans.
agencies working with the private sector can use a systems
approach to help bring a level of organization to the Nation’s
systems of health care. They can:
articulate, and encourage clear lines of accountability
through measures and standards.
reporting and identification of errors through data integration.
clear, consistent information and educate patients to be
more responsible for their own care and safety.
out to others in the health care industry and increase support
for efforts to reduce medical errors and improve patient
Federal agencies and the private sector can bring patient
safety to the forefront of the national agenda and help the
Nation achieve greater safety and quality in its health care
member agencies represent health care purchasers, providers,
policymakers, regulators, researchers, and patient advocates.
These agenciesworking together with their private-sector
counterpartscan define, demand, recognize, and reward
quality. Specifically, they can capitalize on the current
consensus for action in the areas of standards and data integration,
improve the knowledge base about errors, learn from errors,
and encourage the dissemination of information on patient
safety to the publicissues that were addressed earlier
in this report.
government plays a critical role in a number of patient-safety
related activities, such as the authority for licensure of
health care providers. Importantly, over 20 States have existing
mandatory reporting programs related to patient safety. State
and local governments can also have a significant impact on
patient safety in their roles as health care purchasers, providers,
and regulators. These activities could be enhanced by partnership
with both Federal agencies and the private sector. For example,
the collection of protected State reporting datathat
has also been stripped of identifying informationthrough
the coordination of the CQuIPS at AHRQ will provide a national
resource for learning more about the occurrence of errors
and developing strategies to reduce them. The CDC has programs,
including the Epidemic Intelligence Service, that could serve
as a model for coordinated Federal-State efforts to improve
patient safety. The Department of Labor’s PWBA has also developed
a valuable collaborative relationship with the National Association
of Insurance Commissioners (NAIC) and individual State insurance
regulators to foster a better understanding of ERISA's health
benefits provisions among the public and the regulated community.
Many of the actions proposed by the QuIC will benefit from
building upon existing Federal-State Government partnerships.
these encouraging and productive collaborations between the
Federal Government’s agencies involved in health care quality
and both the private sector and State governments, the IOM
report emphasizes how much more can be done to reduce the
rate of medical errors and to enhance patient safety. The
QuIC and its member agencies are committed to implementing
additional cooperative and collaborative programs, especially
in the areas of standards and data integration.
health care industry, standards, broadly defined, are reflected
in two areas: accreditation programs and performance measures
(or measurement sets). Accreditation programs for health plans
offer a powerful vehicle to enhance quality and safety. Such
programs not only assess the structural capacity of organizations
to meet critical standards, but also increasingly incorporate
performance measures into the accreditation process. By working
with independent accrediting organizations, such as JCAHO,
the American Accreditation Health Care Commission/URAC, and
the National Committee for Quality Assurance (NCQA), and by
encouraging or requiring accreditation of health plans, QuIC
agencies that purchase or provide health care can raise the
bar for quality across the industry.
will send a clear and consistent message about the desirability
of appropriate measures and standards by encouraging its member
agencies to participate in development efforts, disseminate
information, adopt or encourage adoption of measures and standards
related to patient safety, and require reports and performance
improvement, as appropriate. The QuIC will assure that individual
agency efforts are communicated, coordinated, and cohesive
in terms of what is being asked of the health care industry
and its providers. By doing so, the QuIC will directly impact
the quality of care available to Americans.
under HCFA’s leadership, a group of public- and private-sector
partners developed the DQIP measurement set. The measures
were developed based on research sponsored by QuIC agencies
and translated into performance measures by collaborating
Federal agencies. QuIC agencies have endorsed and will use
the DQIP measurement set. Similarly, NCQA, one of the DQIP
partners, has adopted the measurement set for testing in 2000.
The result of these DQIP-related activities will be better
care for Americans with diabetes. QuIC agencies, in partnership
with accreditation organizations and others, will undertake
similar collaborative efforts in other areas to improve standards
and measures related to patient safety and the reduction of
effort, Federal agencies have launched a public-private sector
initiative with over 50 participating organizations or agencies
to reduce medication errors in the outpatient setting. The
Study of Clinically Relevant Indicators for Pharmacologic
Therapy (SCRIPT) project will result in development and field
testing of performance measures for medication management
and error reduction in several common and costly diseases
or conditions (diabetes, coronary artery disease, congestive
heart failure, hypertension, hyperlipidemia, and atrial fibrillation)
and should be completed this year.
care purchasers, either private or Federal, deal directly
with providers. However, purchasers can encourage their health
plans to endorse and facilitate sound provider practices.
They can require that health plans encourage their networks
to implement accountability systems and ensure that sound
practices are noted and rewarded. For instance, Federal agencies,
such as HCFA, that contract with health plans will provide
oversight of health plan arrangements for hospital and practitioner
services to help create a patient-safe hospital environment
(i.e., requirements for medical error reduction systems, including
approaches to producing appropriate results over a specified
period of time). In addition, health plans can encourage their
network providers to participate in nonpunitive error reporting
that facilitates the identification and correction of systemic
problems. Health plans can make a major contribution to patient
safety and quality of care in response to clearly articulated
and achievable purchaser expectations.
agencies also can work with other health care purchasers to
support the development and implementation of provider-level
programs for accrediting organizations and encourage the incorporation
of more rigorous safety standards into existing programs.
While much good work has already been completed, much more
needs to be done to establish and enforce adequate credentialing
standards for physicians, hospitals, and preferred provider
organizations. Under the auspices of the QuIC, VA is leading
an effort to identify a core set of credentialing elements
across different agencies and departments. This effort will
establish a model for interorganizational collaboration that
the private sector may choose to adopt. As part of its research
effort on medical errors, the QuIC will collaborate with certifying
boards for health care professionals to develop measures of
patient safety appropriate for inclusion in certification
and recertification programs.
earlier, the health care industry has much to learn from other
industries that have more impressive safety records. The CQuIPS
in AHRQ will identify successful safety programs, assessing
the evidence that they are, indeed, "best practices,"
and sharing information on their techniques and their adaptability
to health care. QuIC agencies can use their influence to incorporate
those strategies and encourage private-sector purchasers to
do likewise. For example, there is considerable potential
for error reduction through the use of automated systems to
enter and process prescription orders and to monitor for risks
of adverse drug events. The use of and advocacy for such systems
by Federal purchasers and providers could accelerate their
use. Similarly, Federal agencies could create demand for the
use of electronic prescription ordering systems at physicians’
offices by encouraging their colleagues in the pharmaceutical
industry, including pharmacy benefits managers and others,
to support and facilitate the use of such systems by health
care providers. Adherence to recommended protocols (e.g.,
beta-blockers following heart attack) is another aspect of
care that can be monitored to reduce errors. QuIC agencies
and their partners should institute programs of quality assurance
and quality improvement focused on error reduction.
Federal agencies have been involved in the creation of performance
standards used in development of medical products for many
years. The FDA plays a central role in collaborating with
the private sector by helping to develop industry standards
for medical products. For example, FDA works with representatives
from the medical industry, health and technical professionals,
and consumer and patient organizations to identify and develop
new standards for medical products that use emerging and complex
technologies. In addition, the QuIC recommends that Federal
agencies should, in partnership with the Quality Forum, establish
a consortium of private-sector organizations, industry representatives,
academic institutions, and scientific and health care professionals
to examine issues related to medical product standards, such
as addressing human factors early in the development of new
QuIC and its member agencies will ask independent accrediting
organizations to demonstrate how they are coordinating and
strengthening their patient safety standards.
CQuIPS, through the research agenda articulated above, will
develop evidence-based measures that integrate human factors
and lessons from other industries.
with the DQIP measurement set, the QuIC will solicit formal
adoption and use by member agencies of common, validated,
and standardized performance measures in the area of error
reduction. The QuIC will work with certifying boards for
health care professionals to incorporate these measures
into certification and recertification programs where appropriate.
agencies will encourage their private-sector partner organizations
to support the implementation of more rigorous safety standards
and will act to facilitate the ability of private-sector
partners to do so.
QuIC will work through the Quality Forum, the NPSF, and
the NPSP to collaborate with private-sector organizations,
industry representatives, academic institutions, and scientific
and health care professionals to examine issues related
to standards, to test standards of performance measurement,
and to establish a set of core standards.
will build on an existing collaboration with the National
Association of Insurance Commissioners to exchange information
between DOL, the States, employers, plans, and individual
patients on medical errors and safe, high-quality health
will participate with private-sector organizations in the
development of standards and measures, share QuIC-adopted
standards and measures with its health plans, and advocate
the use of such standards and measures throughout plan networks.
will also begin collecting performance measurement data
from its participating plans and will make performance information
available to beneficiaries of the Federal Employees Health
safety and reducing medical errors will be a featured topic
at OPM’s Fall 2000 annual health plan conference.
the challenge of improving patient safety with an inadequate
evidence base is compounded by the fragmentation of information
regarding errors. The QuIC can play an important role in bringing
together information from disparate sources to create comprehensive
information resources that could further the development of
research and practice related to patient safety. For example,
FDA could use the databases developed by pharmaceutical benefits
managers to learn about frequent errors and near misses. QuIC
members can play an important role by insisting on data integration
among providers such as pharmacy benefits managers, physicians,
hospitals, and laboratories.
working with the QuIC and its member agencies (e.g., CDC,
DoD, FDA, OPM, VA), State and local governments, providers,
and health plans, should develop and maintain a national program
to collect information abstracted from reports on errors and
incidents, to share the lessons learned from these error-reporting
systems, and to promote action to reduce errors and near misses.
AHRQ's existing Healthcare Cost and Utilization Project (HCUP)
provides a relevant model for this task. HCUP pools hospital
discharge data (that has been stripped of identifying patient
information) from the States, and integrates that data into
a single resource for researchers and decisionmakers. The
HCUP database thus provides an opportunity for States to compare
themselves to other States. The CDC also has relevant experience
in integrating data from the States for learning purposes
that will help guide this effort.
opportunity for QuIC agencies (especially HCFA, FDA, and AHRQ)
to work together through data integration would be provided
by the development of an expanded drug benefit program for
Medicare beneficiaries. Combining data stripped of patient
identifiers from the PBMs (pharmaceutical benefits managers)
into a single resource could provide a valuable tool for enhancing
patient safety. This could build on work being done by AHRQ’s
CERTs and the work of the FDA, as well as on models already
being used by VA and DoD. Through collaborations with the
private sector, the QuIC agencies could develop a plan for
reducing medication errors in an expanded Medicare drug benefit
program. OPM can also use its relationship with health plans
and preferred provider organizations to encourage the adoption
of data integration by those providers as well.
as envisioned by the IOM, requires that a coordinated set
of core information on errors be collected across all of the
participating reporting systems. The IOM suggested that the
Quality Forum be given the task of identifying that core set
of information. Given the mission of the Quality Forum and
its existence as a public-private partnership, the QuIC believes
that this recommendation is entirely appropriate, and QuIC
agencies are committed to working with the Quality Forum on
the development of this set of data requirements. Methods
for integrating, analyzing, and disseminating patient safety
data will also be developed as part of the National Healthcare
Quality Report effort being led by AHRQ and the CDC.
QuIC members will work with and support the Quality Forum
in its identification of a core set of errors reporting
working with its QuIC partners, will identify existing data
sets (such as the State mandatory errors reporting data)
that can be brought together to enhance the Nation’s knowledge
and understanding of errors. Based upon experience with
the HCUP and the CDC’s data integration efforts, AHRQ will
work with those entities that have the data to determine
the feasibility of pooling the data and using this resource
to learn about opportunities to reduce errors and enhance
will discuss with health plans and preferred provider organizations
the development of strategies for focusing disease management
programs and integrated data systems on the goal of avoiding
medical errors and improving patient outcomes.
in collaboration with FDA and AHRQ, will develop a strategy
for incorporating initiatives to increase patient safety
into the pharmaceutical benefits managers program under
an expanded Medicare drug benefit.
Proceed to Next Section