National Summit on Medical Errors and Patient Safety Research
Summary: Panel 2Broad-Based System Approaches
On September 11, 2000, as part of the Government's response
to the Institute of Medicine's landmark November 1999 report,
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.
Other Summit information includes: Written Statements of panel testimony, Additional Statements, and Streaming Video.
Panel 2: Broad-Based System Approaches
Recognizing that medical errors are the fault of systems and not of individuals, the purpose of
hearing from this panel was to identify how improving patient safety can be a health care
system-wide endeavor. It was generally accepted that reducing and preventing medical errors
and improving the overall safety of the health care system will demand the collaboration and
participation of all stakeholders. Some of the common themes raised by this panel were:
confidentiality and protection, human factors, organizational/cultural issues, reporting systems,
use of technology, and training of providers.
Gordon Sprenger, American Hospital Association
Mr. Sprenger emphasized that efforts to improve patient safety will be most effective if they
are implemented across the entire health care system and in all clinical settings, including
hospitals, nursing homes, and physicians' offices. He recognized that reducing errors will
require the design and implementation of error-resistant systems, and proposed that there be:
- Research to study how to change the traditional culture of health care to one that
encourages learning from failures. Research can identify what critical factors
make for a more open learning environment and what regulatory and legislative
changes are necessary for creating such an environment.
- Research to examine effective risk management strategies and safety practices
from other high-risk fields, with a special focus on how to tailor these models to
the health care environment.
- Research to build an evidence base for current safety practices in health care,
with a focus on how they can yield safer systems.
- Research on human factors issues to help explain why errors occur and how
systems should be organized to minimize errors.
- Research to identify the most useful technology for reducing medical errors, and
to identify areas in which the industry should make an investment in such
- Research to close the gap between knowledge and practice, with a special focus
on communication in health care settings.
Research to study medical errors and patient safety in ambulatory care settings.
Saul Weingart, M.D., Ph.D., Harvard Executive Session on Medical Error and Patient Safety
Dr. Weingart outlined a research agenda calling for the study of patient safety innovation at the
organizational level. He emphasized that medical errors must be studied at the level of
deficiencies in the organizational process in order to arrive at solutions. In view of that, he
proposed six research focal points:
- Collecting case studies of cutting-edge innovators in patient safety and
identifying what factors allow for their success (e.g., organizational context,
leader attributes, market conditions).
- Exploring new models for the dissemination of innovation designed to promote
improvements in patient safety.
- Examining the cost and effectiveness for technological solutions to the medical
errors problem, and also the limits of such solutions.
- Studying the impact of fiscal austerity on safety, with a special focus on the
effect of high patient-to-nurse ratios on error, the relationship between
competing markets for health care and hospitals' safety concerns, and whether
safe organizations also deliver better (and more cost-effective) care.
- Examining the feasibility of establishing multi-site research laboratories for
testing novel drug-delivery systems, reporting systems, order-entry systems, and
other processes designed to improve patient safety.
- Developing a standardized instrument for measuring the effect of patient safety
improvements, for the purpose of reporting to the public.
Robert Crane, Kaiser Permanente Institute for Health Care Policy
Mr. Crane proposed research that would combine both qualitative and quantitative approaches
and would look across institutions and aggregations of data, providing opportunities for
interdisciplinary collaboration to improve patient safety (which, he noted, will require
assurances of confidentiality). He identified five areas of potential research and recognized
their inter-relatedness, providing an opportunity to integrate them into broader studies:
- Research to synthesize current knowledge of best clinical practices and to
evaluate those practices in order to facilitate the subsequent creation and
implementation of successful practices. Such research could employ large
integrated data systems (currently in place in many health care organizations) to
find and study antecedent conditions of errors and high-risk situations that
would signal a greater than usual rate of errors or adverse events in a specific
- Research to study human factors and incorporate the information into
reengineering specific processes for improving patient safety. Human factors
issues include: what human factors lead to error, how knowledge of human
factors can improve the effectiveness of error prevention strategies, and what
the impact of training and team factors is on safety in hospital settings.
- Research to evaluate and validate the efficacy and cost-effectiveness of new
technology designed to improve health care quality and safety, in order to help
organizations prioritize their investments in such technology. In addition,
research is needed to study how technology actually creates opportunities for
new types of errors to occur.
- Research to evaluate existing medical errors reporting systems (e.g., State
mandatory reporting systems) to determine their impact on the improvement of
patient safety. Research is also needed to identify factors that underlie the
success of such systems, with an emphasis on how causes of errors were
translated into system changes for safety improvement.
- Research to identify the cultural factors at the health care team level that are
needed to transform the current culture of blame. A standardized set of patient
safety-oriented questions or a survey instrument could be developed for this
purpose to allow for comparison across institutions.
Dale Bratzler, D.O., American Health Quality Association
Dr. Bratzler emphasized that a research agenda on patient safety must include studies
identifying the most effective methods for facilitating changes in caregiving processes. To that
end, he proposed two broad areas of research:
- Research to examine the best methods for identifying opportunities for clinical
quality improvement. Specifically, the research needs to determine how much
data is necessary to identify meaningful opportunities for improvement, and to
examine the effect of mandatory reporting on successful identification of such
- Research to examine the best methods for facilitating quality improvement
efforts by practitioners and providers. Specifically, the research needs to
identify best strategies for disseminating information about quality improvement
to providers and practitioners. The effectiveness of error reduction efforts as
they relate to facility attributes (e.g., size, location, affiliation with a larger
organization) also needs to be examined. Finally, the research should study the
ability of existing Peer Review Organizations (PROs) to serve as catalysts for
quality improvement with health care providers and practitioners.
David Woods, Ph.D., Human Factors and Ergonomics Society
Dr. Woods' testimony placed a heavy emphasis on the need to create a useful partnership
between the health care industry and the field of human factors engineering. Research in the
human factors field, with a focus on underlying mechanisms and behavioral patterns, can
provide a convincing basis for changing the system. He asserted that research must be done:
- To consider building a research agenda as an interdisciplinary partnership
between the human performance specialties and various medical specialties.
The health care industry can benefit from studying the formal and informal
organizational basis of the successes of the safety program of the National Aviation and Space Administration (NASA).
- To develop and test interventions for reducing problems arising from
breakdowns in human performance.
- To identify the sources of complexity that contribute to human performance
problems in operating complex systems, to understand the strategies used for
coping with complexity, and to devise better ways of helping people cope with
- To study the user-centered design of computer systems in other high-risk
industries, and to create demonstration projects for user-centered design of
information technology to ensure that benefits are gained while error-inducing
designs are avoided.
- To understand the impact of new advances in the technology of "connectivity"
(i.e., Internet, telecommunications) on the practice of medicine, and to direct
these new advances to enhance patient safety.
- To examine how new technologies will affect roles, judgement, and
coordination, which will reveal side effects that could create new systemic
Robert Wears, M.D., M.S., MedTeams Consortium
Recently, there has been a successful demonstration of the effectiveness of teamwork in
emergency medicine and a growing availability of health care simulators. As a result of this,
Dr. Wears proposed that further research should be conducted in four specific areas:
- Research to expand the use of patient simulators from a single practitioner focus
to a team focus.
- Research to use simulators to identify appropriate team structures best suited to
different settings of care.
- Research to investigate the use of simulation to reinforce, retrain, and refresh
technical skills together with teamwork skills.
- Research to study the establishment of medical simulation centers of excellence.
Question and Answer Session
The following additional areas for research focus were discussed:
- Examining strategies for disseminating information across a health care
"system" that is actually very fragmented.
- Identifying effective ways to translate what is already known into practice.
Understanding how new technology will affect the current concept of teamwork
(i.e., "computer-supported cooperative work").
- International examination of confidentiality protections given to health care
providers, and whether such protections make a difference in error
- Hospitals and medical associations should work with their members to develop
the need for research. Associations have the ability to bring together various
parties and to engage them in the research process, so they remain vested in the
- Using large data sets to study errors in omission and commission. This
endeavor will be greatly enhanced by the development of an electronic medical
record by a number of organizations.
Current as of September 2000
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