Panel 2: Broad-based Systems Approach
Testimony of Gordon Sprenger, President and Chief Executive Officer, American Hospital Association
The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summitís goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs.
Individuals were selected by the Agency for Healthcare Research and Quality (AHRQ) to testify at the summit as members of the witness panels. Each submitted written statements for the record before the event, documenting key issues that they confront with regard to patient safety as well as questions to be researched. Other applicants were invited to submit written statements.
Disclaimer and Copyright Statements
Mr. Chairman, I am Gordon Sprenger, president and CEO of the Allina Health System in Minneapolis, Minnesota, and former chairman of the board for the American Hospital Association (AHA). I am here today on behalf of the AHA and its nearly 5,000 hospital, health system, network, and other health care provider members. We appreciate this opportunity to present our recommendations for a coordinated research agenda on medical errors and patient safety.
In my role as the head of a large health system and having been a member of the Harvard Executive Session on Medical Errors and Patient Safety for the past three years, I know first hand that addressing medical errors and patient safety issues in health care is a complex task. It requires the commitment and attention of patients, insurers, hospital leaders, and individual providers. It requires aligning the incentives of a complicated health care delivery system, where medicine is practiced in a fast-paced, often stressful, and highly litigious atmosphere.
For thousands of years, healers have lived by the motto "primum non-nocere"—first, do no harm. The nurses, doctors, and others on the patient care team in hospitals strive every day to deliver the safe, compassionate care that patients deserve. But in today's complex, high-tech world of medicine, our best intentions can have unwanted and unintended consequences. The Institute of Medicine (IOM) report, "To Err is Human: Building a Safer Health System," points out that, as good as our systems are for preventing and reducing medical errors of all kinds, we can and must do better.
That's why, some two years ago, the AHA board and many of our hospital leaders attended a national forum on improving patient care. Though we have long been involved in improving the quality of care provided in the nation's hospitals, we came away from that meeting with a strong sense from hospital leaders that, on a national level, we could do more... we needed to address these issues head on.
But the issue of patient safety is very broad. We set our sights specifically on improving medication safety—reducing and preventing medication errors that result from things like different drugs being packaged in similar containers, confusing abbreviations on labels and prescriptions, illegible doctor handwriting, and more.
As part of our initiative, we formed a partnership with a highly respected organization in this field, the Institute for Safe Medication Practices (ISMP), which is also expected to be here today. This non-profit research and education organization is dedicated to reducing the incidence of medication error throughout the health care system, and is providing leadership and technical expertise for the AHA's initiative. We've also worked with the American Organization of Nurse Executives, the American Society for Healthcare Risk Management, the Society for Healthcare Consumer Advocacy, and our state, regional, and metropolitan hospital associations to bring information and resources to hospital leaders throughout the U.S.
A brief list of what we've done so far:
- We distributed the ISMP Medication Safety Self Assessment to all hospital pharmacy directors. This comprehensive tool helps hospitals assess the safety of their medication practices, identify opportunities for improvement, and compare their experience with that of similar hospitals.
- We compiled a list of successful practices for improving medication safety and shared it with every hospital.
- We sent every hospital videotapes to get boards of trustees involved in quality improvement and patient safety. "Beyond Blame" and "Improving Patient Safety" videos were produced by Bridge Medical and the Institute for Healthcare Improvement, respectively, and raise the level of awareness and provide information about opportunities for improving patient safety.
- We created a weekly column, "Prescriptions for Safety," in our AHA News publication. This regular feature shares innovations, success stories and practical advice.
These are just some of the activities we've undertaken to help hospitals improve patient safety. Our objective is to take what we already know about the sources of error and about how to make the medication administration process safe, and put that knowledge to work.
Many of our state associations are also undertaking initiatives to improve patient safety. For example, in my home state, one of the things the Minnesota Hospital and Healthcare Partnership is doing is partnering with state health plans, hospitals and caregivers to change the language used to discuss patient safety issues. The goal: a blameless nomenclature that fosters a culture where errors are discussed openly without fear of retribution.
Hospitals have learned a lot; but there is much more to know.
We applaud the Agency for Healthcare Research and Quality for taking the important step of coordinating a research agenda to study ways to improve patient safety and reduce medical errors.
LEARNING ABOUT PATIENT SAFETY
What do we need to know to make things better? What are some of the key research questions that need to be answered?
Let's begin with what we do know:
- Improving patient safety involves problems and issues that require "system" solutions. Health care is a human experiencepeople caring for people. Individuals, by the very nature of being human, are vulnerable to error. Although individuals are the focus of the error, errors also happen because of the systems in which people work. More often than not, a single error has multiple sources. Reducing errors also will require us to design and implement more error-resistant systems.
- There are few "quick fixes." Part of improving patient safety involves changing behavior over timehow we work, how we communicate, and how we interact with others.
- Improving patient safety involves changing the traditional culture of health care. It requires us to create a culture that is open to discussing errors when they occur... a culture that encourages providers to bring errors to the forefront... a culture that is non-punitive and "blameless"... a culture that encourages us to learn from failure.
- Most importantly, improving patient safety is about creating significant change.
A COORDINATED RESEARCH AGENDA
Against that backdrop, the AHA is pleased to offer the following suggestions as potential areas for research from the hospital field's perspective, that iswhat we don't know and the answers we need to further improve patient safety.
Changing the Culture of Health Care
Safety experts repeatedly cite the importance of creating an environment in which we encourage people to learn from failure. In health care, this will require a fundamental cultural shift from today's environment—no easy task. Our current legal environment tends to promote quick finger-pointing solutions. Our medical education system tends to emphasize individual autonomy over team care. And our traditional health care system has focused on individual accountability and independent achievement. Questions to consider:
- What are the critical factors that make for a more open, learning environment?
- What are the critical success factors in creating this kind of cultural transformation?
- Are there examples from other fields that have undertaken similar transformations, and lessons to be learned?
Learning from Other High-Risk Fields
While patient care is not widget making, there are likely to be models in other fields that offer lessons to be learned about safety improvement. For example, we can learn much from the aviation field, but those strategies must be specifically tailored to the health care environment. Aviation leaders indicate that the success of their incident reporting system is largely attributed to its ability to shield from punitive action anyone who reports errors and adverse incidents. The system is also touted for its ability to share information about close calls and errors with others. We need to investigate how the health care field might adopt a similar approach. Additional potential lessons to be learned from other fields include strategies for avoiding over-reliance on memory, standardizing work processes, promoting teamwork and redesigning systems. We should examine:
- What has worked to improve safety in other fields?
- How were those changes adopted?
- What other risk management techniques have been tried?
- What is and isn't transferable to health care?
- What modifications would be needed for the health care environment?
Current Safety Practices
The health care field today employs numerous techniques for ensuring patient safety. Laws, regulations, public and private oversight, risk management, internal and external quality improvement methods and other techniques are all part of today's system of care. We recommend studying:
- Which of these practices are working well?
- Which practices yield little benefit?
- How can existing practices be improved?
Safety in Non-hospital Settings
Nearly 90 percent of patient care is delivered outside the hospital, whether in a nursing home, physician's office, pharmacy, ambulatory surgery center or the patient's home. Yet, we know little about medical error or patient safety in these non-hospital settings, in part, because there is no system for capturing or tracking performance in these settings. More research is needed to evaluate patient safety in these non-hospital settings and to develop systems to prevent errors. This is particularly important for health care systems like mine that offer many services outside the hospital. Areas to research:
- What is the extent of error in non-hospital settings?
- How can systems solutions to prevent error be adapted for settings that are smaller and have less organizational structure?
Closing the Gap between Knowledge and Practice
Another area of improvement involves closing the gap between what is known in the medical literature and on the cutting edge of "best practice," and how medicine is most often practiced. Some variation in care is appropriate and inevitable. But perhaps patient care and safety could be improved by closing this gap. This challenge is great, especially in an increasingly complex and rapidly changing field that involves new techniques, pharmaceuticals and technology. It is made more difficult because the technologies and research that can bring safety and "value" to the health care system are expensive. At a time when many providers are financially squeezed, we need more information that will help providers make the right decisions about expensive technologies. Areas to study:
- How is new learning and training best disseminated?
- How can knowledge and appropriate use of new technologies be better shared?
- How can accepted standards of care be better accessed and communicated?
With respect to new technology that can specifically help to reduce errors (such as computerized physician order entry, bar coding, and automated drug dispensing systems):
- What works and what doesn't?
- What degree of improvement do these technologies provide?
- What are critical factors in the diffusion of these technologies to ensure they are actually and properly used?
- What private sector research agenda might be suggested for technology vendors, device manufacturers and the pharmaceutical industry?
Creating Early Warning Systems
Today, our awareness of specific medical errors is triggered by a serious and sometimes tragic event. Appropriately structured error reporting systems can be an important tool in reducing and preventing errors, but what other approaches are available?
- How can we make better use of precursor events to predict the occurrence of medical error?
Human Factors Research
While problem reporting is important, we are seeking systematic solutions—solutions that can help to create an error-resistant environment. Many of the answers lie in a better understanding of human beings, our limitations, and how to work around these limitations. Human factors research is key to understanding the triggers and sources of errors and to creating systematic solutions. Questions to research:
- How can we advance our understanding of why humans err?
- How can we better design work environments to minimize the occurrence of errors?
- How can we involve the patient in helping to identify potential errors?
Reducing and preventing medical errors, and improving the overall safety of the health care system, will demand the thoughtful collaboration and participation of all stakeholders—hospital leaders, pharmacists, drug manufacturers, doctors, nurses, government agencies, other organizations, and consumers. The efforts of the Agency for Healthcare Research and Quality to develop a coordinated research agenda on medical errors and patient safety are an important step in improving our health care system. The AHA appreciates the opportunity to contribute to this dialogue.
Current as of September 2000
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