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National Summit on Medical Errors and Patient Safety Research

Summary: Second Public Comment Session

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.

Other Summit information includes: Written Statements of panel testimony, Additional Statements, and Streaming Video.

Second Public Comment Session

Bruce Bagley, M.D., American Academy of Family Physicians, Latham, NY

Dr. Bagley suggested that research needs to be directed at outpatient care, where the majority of patients receive medical care, in addition to inpatient care. He noted the importance of integrating computerized medical records, decision support systems, and prescription alert systems in order to reduce errors in outpatient settings.

Jeffrey Cooper, Ph.D., Anesthesia Patient Safety Foundation, Boston, MA

Dr. Cooper proposed research to: look at what approaches have been successful in anesthesia's patient safety agenda; develop tools to document and analyze hazardous events associated with moving hospital-based procedures to unregulated facilities; gain an understanding of the optimal uses of simulation modalities for preventing and recovering from critical events.

Gregory Alexander, M.H.A., R.N., Freeman Health System, Joplin, MO

Mr. Alexander raised the issue of communication, both within and among systems, and encouraged research to focus on the education of providers as well as the interaction between providers and patients. He also called for the inclusion of rural health care providers in some research initiatives.

Jeffrey Newman, M.D., M.P.H., California Medical Review, Inc., San Francisco, CA

Dr. Newman focused on patient complaints as a source of information about medical errors, noting that the root cause is often miscommunication between providers and patients. He suggested research to do qualitative work on defining errors, identifying incentives and counterincentives to patients to complain, and establishing a better mechanism for reviewing complaints.

Claire Sharda, Washington Business Group on Health

Ms. Sharda reemphasized the need to make a business case for employers to be interested in patient safety issues.

Ilene Corina, Pulse of New York, Wantagh, NY

Ms. Corina suggested that a research agenda should identify ways of bringing together health care providers to discuss where errors are most often made.

Kristen Hellquist, M.S., National Council of State Boards of Nursing

Ms. Hellquist suggested that professional regulatory bodies should collaborate together and with other stakeholders to identify causes of errors and how to reduce them, thus avoiding duplication. She also emphasized the importance of using research to identify what type of reporting system will best serve the patient safety agenda.

Thomas Obst, Ph.D., C.R.N.A., State University of New York, Buffalo

Dr. Obst focused on high-fidelity simulation in training programs for physicians and nurses, noting that such simulations can allow trainees to develop a better appreciation for the systemic etiologies of error that they will have to contend with as practitioners. Research should focus on: what types of mechanisms can be put in place to make this training more widely available; how to link patient outcomes to the training; and what role such training should play in the development of credentialing and competency assessments of practitioners.

Carol Haraden, Ph.D., Institute for Healthcare Improvement, Boston, MA

Dr. Haraden suggested pursuing an agenda to take advantage of what is already known about patient safety. She also emphasized the need to think of entire systems of safety, including recruiting for safety, training for safety, technology assessment, reporting, and best practices.

Sam Ho, M.D., Pacificare Health Plan, Santa Ana, CA

Dr. Ho raised a question for policymakers and funders to produce risk-adjusted hospital mortality rates related to different medical procedures, as a way of identifying best practices.

David Meyers, Frisbie Memorial Hospital, Rochester, NH

Mr. Meyers' suggestions for research included: studying the communication between providers and patients; studying facility designs that enhance error reduction; and studying approaches taken by other countries for no-fault reporting systems.

Robert Leitch, Uniformed Services University of the Health Services

Mr. Leitch raised the concern that while technology has huge merits, it is also the cause of many new problems that must be recognized.

Current as of September 2000

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National Summit on Medical Errors and Patient Safety Research
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