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National Summit on Medical Errors and Patient Safety Research

Summary: First 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.

First Public Comment Session

Adam Scheffler, M.A., L.S.W., Health Policy Consultant, Chicago, IL

Mr. Scheffler suggested that research literature in the area of risk perception/communication is worthy of examination and testing in the health care industry to see how well it translates. He emphasized that this should be part of a broader effort to begin to create a culture of communication and data-sharing that involves patients in their own care.

John Wilson

Mr. Wilson noted that with regard to medication dosing errors, a "gold standard" drug delivery system has already been established but abandoned due to costs. He proposed going back to the "gold standard" and using it as the prototype when doing drug delivery research, and comparing other methodologies against it.

Gregory Apelian, Tender Loving Care Ministries, Rio Ranch, NM

Mr. Apelian raised the need for better systems management, and in particular, a more comprehensive data collection method so harmful drug dispensing errors can be readily identified and appropriate interventions made.

Stephen Gleason, D.O., Ph.D., Iowa Department of Public Health

Dr. Gleason noted that it may be too early to begin inserting patient safety standards into contractual relationships because several issues have not been fully examined. For example, there has not been an examination of how to link provider behaviors to incentives (both regulatory and financial), nor an examination of the combined regulatory burdens on providers (from government and private payers). He also stressed the need for greater investment in computer technology.

Paul Barish, M.D.

Dr. Barish suggested that a system of education and training of future providers is the most lasting way to change the health care system. Education should begin at the undergraduate level and continue through the graduate and CME continuum. He proposed research questions to focus on how to create opportunities for education, to study the impact of curricula aimed at enhancing patient safety, and to study the interaction between education and ultimate performance.

Mary Cooper, M.D., New York Presbyterian Hospital

Dr. Cooper highlighted the issue of adopting a culture of safety, and suggested research to study how to engage direct care providers in the area of patient safety so they feel a need to provide such care to their patients.

Harvey Kaufman, M.D., Quest Diagnostics, Teterboro, NJ

Dr. Kaufman suggested that the research also focus on the following areas: comparing organizations that have value missions and those that do not in terms of driving safety and quality; examining processes in addition to outcomes; and studying successful approaches to quality, and how they impact on quality and safety.

Greg Pawlson, M.D., M.P.H., National Committee for Quality Assurance

Dr. Pawlson emphasized the need for Federal agencies and foundations to jointly fund research to pull together different groups such as accrediting agencies, employers, insurers, hospitals, and practitioner groups.

Joshua Rising, M.P.H., American Medical Student Association, Reston, VA

Mr. Rising stressed the importance of examining different curriculum models that enable future practitioners to work together to address the issue of patient safety. He also suggested research to look at international models that have recognized the negative impact of overworking health care professionals on patient safety and what efforts have been made to address the problem.

Current as of September 2000

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National Summit on Medical Errors and Patient Safety Research
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