Summary: Panel 5—State Coalitions and Public Policy Advocates

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.

Panel 5: State Coalitions and Public Policy Advocates

The purpose of hearing from this panel was to learn of the common concerns of health care providers, accrediting agencies, professional associations, and other public policy advocates. In an optimal environment for patient safety, all of these bodies will collaborate in order to find solutions to many of the problems they share with regard to patient safety.

Jim Winn, M.D., Federation of State Medical Boards of the United States, Inc.

Dr. Winn's testimony focused on the use of the large amount of data received by State medical boards to contribute to national efforts for reducing medical errors. He suggested that analysis of the aggregate data could identify patterns that contribute to errors and reveal interventions to improve patient safety. Dr. Winn felt that what is needed is:

• Research to determine how information is currently being reported to State medical boards (as well as the sources of that information and State reporting requirements), which can be useful in identifying sources of medical errors.
• Research to determine how physician data collected by State licensing boards (e.g., specialty, site of service, age, use of alcohol/drugs) may be useful in determining the predictability of medical errors being committed by particular physicians.

Paul Schyve, M.S., Joint Commission on the Accreditation of Healthcare Organizations

Mr. Schyve's testimony focused on the importance of creating a culture of safety in health care organizations. This includes proactive safety engineering of health care processes, safety training of staff, and dissemination of errors information to patients. He noted that such information will result from empirical studies on safety and/or the advice of experts in the safety field inside and outside of health care. He suggested that more research is necessary:

• To provide a better understanding of the epidemiology and statistics underlying medical errors.
• To identify the characteristics of organizations that make them more risk-prone (e.g., hierarchical versus flat structures, communication mechanisms, team work, staff morale).
• To examine how technology (e.g., bar coding, computerized physician order entry systems) can be used to reduce risk, and also how technology can introduce new risks (and new prevention strategies).
• To identify the most effective strategies for disseminating information about high-risk situations to individuals who are most likely to respond.

Sharon Martin, Texas Forum on Health Safety

Ms. Martin recommended that research should be conducted in three main areas: data management (and associated culture change), technological and industry-driven solutions, and dissemination of information and implementation of best practices. She suggested the following specific areas of research:

• Research to identify what type of data is most important to collect, which will require a scientific determination of the information needs of various stakeholders. In addition, research is needed to develop standard indicator definitions and reporting units.
• Research to determine what is needed to make physician order entry systems available and affordable to health care institutions nationwide.
• Research to examine how consumers can be valuable partners in achieving patient safety goals. Specifically, research can determine what consumers want to know and how much they are willing to participate.

Randolph Peto, Massachusetts Coalition for the Prevention of Medical Errors

Mr. Peto's testimony focused on two specific goals: identifying best practices to minimize medical errors; and increasing awareness of error prevention strategies through public and professional education. He proposed research be conducted:

• To identify strategies for overcoming barriers to implementing best practices, and lessons learned in various health care settings.
• To establish evaluation systems for determining the impact of existing reporting systems.
• To study the feasibility of building a secure near-miss reporting system, given the differences in State reporting requirements.
• To establish steps for changing the culture in health care institutions, licensing boards, accrediting bodies, and regulators, so that medical errors (and the lessons that can be learned from them) can be discussed in a nonpunitive environment.

Question and Answer Session

The following additional areas for research focus were discussed:

• State organizations have an information-sharing responsibility: to provide training and support to other institutions, and to solicit consumers' needs and involve them in solutions.
• Research is needed to examine what is the right infrastructure to allow organizations to be more involved in the type of research that helps them look at policies that create opportunities for errors to occur.

Current as of September 2000

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