Summary: Final Comments

On September 11, 2000, as part of the Government's response to the Institute of Medicine's landmark November 1999 report, To Err is Human: Building a Safer Health System, the Federal Quality Interagency Coordination (QuIC) Task Force sponsored a national summit to help set a research agenda on medical errors and patient safety. A summary of part of that Summit follows.

Final Comments

John Eisenberg, M.D., M.B.A., Agency for Healthcare Research and Quality

Dr. Eisenberg reflected on the magnitude of the problem and once again likened it to a public health epidemic. He emphasized that assessment of the effectiveness and outcomes of interventions is critical to moving out of the present analytic stage and into the therapeutic stage.

Gregg Meyer, M.D., M.Sc., Agency for Healthcare Research and Quality

Dr. Meyer reviewed three main areas of research that were discussed throughout the summit:

1. Striking a balance between fundamental research (i.e., human factors, cultural issues) and applied research (i.e., training and evaluation programs).
2. Looking outside the traditional foci of hospital settings to rural settings, outpatient settings, and on vulnerable populations with special safety needs.
3. Developing partnerships not only among Federal agencies but between the public and private sector, between researchers and providers, and between the U.S. and its international partners.

Steven Solomon, Centers for Disease Control and Prevention

Mr. Solomon observed that since there has been a general agreement about viewing medical errors as a public health problem, the same techniques for addressing epidemics should be applied to medical errors and adverse events: assessment (e.g., surveillance); policy development (e.g., standards, guidelines, recommendations); and assurance (i.e., making sure that everyone has access to health care services). Mr. Solomon also reiterated the general agreement on the need for better data, more constructive use of the data, and the development of research activities to allow local-level users to use the data in targeted ways so that intervention strategies can be developed and applied immediately to begin controlling this epidemic of medical errors.

Joanne Turnbull, Ph.D., National Patient Safety Foundation

Dr. Turnbull emphasized that in order to reduce the fragmentation in today's health care system and to move the patient safety agenda forward, partnerships and collaborations are essential.

John Kelly, M.D., Ph.D., Aetna U.S. Healthcare

Dr. Kelly also noted the tremendous partnership opportunities for moving forward on this issue, and encouraged future research to take advantage of knowledge that is currently available.

Lauren LeRoy, Ph.D., Grantmakers in Health

Dr. LeRoy noted that while there has been a lot of talk about taking a systems approach to this problem, there has not been much discussion of how exactly such integration can be accomplished. She also raised the concern that increased visibility of the issue may lead some organizations to rush to respond without fully considering the implications of their response and the systemic roots of the problem. Dr. LeRoy reviewed two important points from the discussion: (1) The importance of communication, which encompasses communication within organizations and between providers and patients; and (2) The importance of moving forward without forgetting to learn from what has already been accomplished. Finally, she posed the question: What are the appropriate expectations of the roles to be played by all the parties discussed at this summit?

Steven Clauser, Ph.D., Health Care Financing Administration

Dr. Clauser made two observations: (1) There has been a consensus on the need for a basic foundation of data and data systems; and (2) There has been a continual reference to a system problem, yet simultaneous allusion to the lack of a "system" in place. This provides the opportunity for Federal agencies to focus on how to bring together partnerships to create systems to make programs work.

Jim Bagian, M.D., U.S. Department of Veterans Affairs

Dr. Bagian noted that with a problem as complex as medical errors, there are several important points to consider: (1) The final goal is not research or reporting systems, but best patient outcomes; (2) There needs to be more thought about reporting systems, which are just one possible tool; and (3) Effecting cultural change is a long-term process which must first begin with changes in behavior and attitudes.

Lewis Sandy, M.D., The Robert Wood Johnson Foundation

Dr. Sandy observed that there are at least two components of the patient safety issue that need to be equally considered for progress to occur: (1) A process change for improvements in care directed at the patient and family; and (2) Leadership for a cultural change among health care professionals, employers, and patients. He also noted that the most difficult problem will not be a technical one, but a cultural problem. Therefore, cultural issues must be incorporated into the research agenda. Finally, he observed that while the task of reducing medical errors is a complex one, it is not hopeless: there have been many effective strategies developed in other industries, and so the health care industry should look into implementation and policy research to learn how to translate those strategies to a new area.

Marsha Lille-Blanton, Dr.P.H., The Henry J. Kaiser Foundation

Dr. Lillie-Blanton raised two issues she felt did not receive full attention. She observed that the tensions between learning and public accountability that were discussed actually both reflect issues of trust. Accordingly, the research agenda must consider how much trust providers have in reporting systems, and how much trust consumers have in the system. She also observed that a great deal is already known about how organizational systems can give incentives to providers and the impact of those incentives on better care, so this area can immediately be examined.

Karen Davis, M.D., The Commonwealth Fund

Dr. Davis proposed two additional areas for research that were not discussed at the summit: (1) Improving the quality of care for underserved populations such as minorities, low-income, and uninsured; and (2) Studying the effectiveness of patient education strategies to prevent medical errors.

Liam Donaldson, M.D., U.K. National Health Service

Dr. Donaldson underscored that the path to change will be difficult, but an international collaboration can be useful in changing the way the world of health care is viewed and changing the way providers work together.

Ross Wilson, Australian Council on Safety and Quality of Health Care

Mr. Wilson highlighted several important issues that surfaced during the discussion:

1. The solution will not be an easy one, and will require time and a management of expectations.
2. Careful attention to priority-setting in the research agenda is crucial.
3. The research agenda must be future-based, and not intended to fix the current system.
4. The agenda must revolve around patients, who are most impacted by systems of care that are now too complex.

Collin Feek, M.D., New Zealand Ministry of Health

Dr. Feek reiterated that the problem will take time to solve, and highlighted a few important points from the day's discussion. Firstly, he emphasized that while there is indeed a tension between accountability and learning, these are very different issues that must be dealt with in different ways, and so should not be confused. The need to promote service-level systems was also raised, as well as the role of central agencies to facilitate such systems. Finally, there is a need to share information at the local level, in terms of what works best to improve quality, costs, and priorities.

Charles Jacobson, Premier Health Care Systems

Mr. Jacobson made several observations about research priorities: (1) Understanding human factors, culture, and work environments; (2) Focusing on education of new professionals and staff; (3) Learning from the experiences of anesthesia and other fields that have made efforts in patient safety; and (4) Involving the consumer in the research agenda. Finally, he raised a concern about reporting systems, stressing that technology is important but it must absolutely be built around the local culture to be most useful.

Frances Stewart, U.S. Department of Defense

Captain Stewart emphasized the additional issue of unintended consequences: any new intervention (e.g., education, technology) can lead to new types of errors. Therefore, she urged that research be done to carefully assess how to safely implement new interventions and how to monitor them for unintended consequences.

Karen Wolk Feinstein. Ph.D., Jewish Healthcare Foundation

Dr. Feinstein underscored the following areas for future research: (1) Aligning systems around patients; (2) Establishing new professions such as medical safety engineering; (3) Learning more about legal protection for institutions; (4) Communicating with trustees; (5) Learning how to put existing research into practice; and (6) Assembling a more formal vehicle for public and private funders to share their agendas and collaborate their efforts toward a common goal of enhancing patient safety.

Current as of September 2000

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