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Written Statement


National Summit on Medical Errors and Patient Safety Research

Panel 5: State Coalitions and Public Policy Advocates

Testimony of Sharon Martin, Texas Forum for Health Safety

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

Agency for Healthcare Research and Quality members, committee members and panelists, Iím Sharon Martin, Associate Vice President for Quality Management at the University of Texas, M. D. Anderson Cancer Center, in Houston, Texas. I also Chair the Texas Forum on Health Safety, a coalition of healthcare providers, consumer advocates, regulators, and others committed to the task of promoting the agenda of patient safety in Texas. It is in this role that I testify today.

The Texas Forum for Health Safety was formally established in 1999 with representation from fifteen entities. The majority of the participating institutions reside in the Texas Medical Center (TMC), the worldís largest medical center, seeing more than 100,000 patients and visitors each day. Texas forum members are, therefore, in a unique position to lead the patient safety effort in Texas through collaborative efforts. This testimony is intended to capture the spirit and content of discussions with Texas Forum members, but does not necessarily represent the consensus of the group or the endorsements of the organizations we represent.

We recommend that research be conducted in three main areas:

  • Data management and associated culture change.
  • Technological and industry driven solutions.
  • Dissemination of information and implementation of accepted best practices.

Data Management and Associated Culture Change

There is widespread agreement than enhancing safety in healthcare depends upon obtaining better information about errors that happened or almost happened. Good information, then, is the basis for a learning system to support improvements. There is also widespread agreement that a major barrier to collection of information about errors is fear that the information will be used to the detriment of the person or institution reporting it.

Several participating institutions in the Texas Forum enthusiastically collaborated to develop a medication error reporting database. However, this reporting effort was thwarted because of lack of protection for the participants in the study. We learned from this effort that changing the culture cannot be done without changes to the current legal and regulatory systems.

Radical changes to the legal system are unlikely in the short-term. One step forward would be to enact a federal law protecting quality improvement activities and not simply peer review activities. Such a law would specify that these activities are confidential and would not be admissible as evidence or discoverable in any civil or criminal action or proceeding. The vast majority of physicians, nurses and pharmacists are strongly in favor of efforts to prevent errors, improve systems and identify and eliminate "bad apples", however, few are willing to jeopardize their own careers to do so. Without very strong protective measures, the likelihood of successful reporting programs is severely limited.

Because the privileges that protect health care organizations in their quality improvement analysis of medical error are state law privileges, it is also necessary to develop a federal ruling stating that providing information to reporting organizations does not constitute a waiver of existing state laws covering peer review and attorney-client privileges.

Although some legal protections of this nature are already in place, there is considerable variation in the scope of the protections. An evaluation of the existing laws with the intent to determine the fundamental requirements to encourage error reporting is a worthwhile research topic.

Building a "learning system" should go hand-in-hand with a firm "accountability system". When a physician, nurse or pharmacist witnesses something that is truly negligent go unpunished, it undermines the entire system. We must have effective systems in place to hold practitioners and institutions that pose risks to patients accountable.

Individual health care providers (physicians, nurses, pharmacists) are licensed at the state level. Licensure is intended to protect the public by assuring the competence of licensees. Legislative "practice acts", in each state generally include mechanisms for mandatory reporting of actions by an individual practitioner which harmed or may have harmed a public member. The ensuing investigation of the event is focussed solely on the actions of the individual practitioner, not on the systems and processes surrounding the incident. Therefore, licensure boards are typically seen by practitioners as the adversary, with mandatory reporting perceived as a punitive mechanism. In addition, employers view licensure boards as having no role to play in addressing the internal systems issues which contribute to practice variances and errors made by individual practitioners.

We need to develop a model plan that identifies why practitioners may not be reporting errors and determines changes needed in the practice acts to encourage reporting within the healthcare institution while maintaining practitioner accountability.

It is then, important to implement both types of reporting systems—one for "accountability" and one for "learning." Both systems are necessary and to be effective must be administered separately. There are viable methods of operating both systems in other high-risk industries. A worthy research project would be to determine the elements of those systems that are effective and subsequently to develop a model that will be effective in healthcare.

Much attention has been given to the issue of mandatory versus voluntary reporting systems. It is our observation that healthcare providers, in practice, treat all reporting systems as "voluntary" and something to be avoided given the current legal and regulatory systems design. If the systems are modified to protect the individuals and institutions from heightened risk of litigation and narrowly focussed scrutiny from licensing boards, then the mandatory versus voluntary issue becomes less critical and the system designers will be able to focus on the human factor research and the operational design efforts that will enable us to establish both types of reporting systems.

Collecting data is only the beginning of the learning quest. To make improvements, we must be able to analyze and interpret the data and develop solutions to prevent these errors from recurring. Few, if any, states have the funding and expertise to manage the data in this way. Simultaneous demonstration projects in several states are needed to determine the best way to collect and analyze data and engage in effective problem solving techniques. Since matching funds have been an effective way to encourage states to meet federal objectives, one of the research projects might evaluate that funding option.

Technological and Industry Driven Solutions

Fortunately most errors are caught before causing patient harm. To catch these errors, healthcare institutions have implemented very complicated checks and balance systems, which are expensive. In an industry confronting severe workforce shortages, we need systems designed to be error-free or, at least, error-resistant.

This technology is available. In fact, robotics, automated distribution units, bar-coding processes and computer order entry systems are in sporadic use across the nation. However, there is no coordinated effort to study the effectiveness of these systems and make data available to providers to prioritize efforts and establish budgets to meet their goals.

Machine-readable devices, such as bar code scanners, used at the point of administration would greatly lesson the possibility for error. First, however, we need a universal bar coding system for drug identification. Additionally, drug manufacturers, interested in name recognition, frequently package drugs with the logo prominently displayed and the name of the drug less prominently displayed. This results in dangerous look-alike products. So, pharmacists repackage and/or relabel drugs at the pharmacy. Research should be conducted to determine the most appropriate and cost effective manner of approving names and packages for new drugs.

Perhaps the technology that would most dramatically reduce errors, and simultaneously help the understaffed nurses and pharmacists, is the availability of an effective computerized physician order entry system with decision support capability. An electronic record would support the users by providing accessibility to complete and accurate data, alerts, reminders and clinical decision support. Most information systems experts agree that for physician order entry to be successful, it must be designed in such a way to have minimal disruption to the workflow and be fairly intuitive to use. Research must be conducted to determine what is needed to make physician order entry systems available and affordable to healthcare institutions. An evaluation of the effectiveness and transferability of systems in use is a good place to start. We need to determine the most appropriate incentives for encouraging industry experts to partner with healthcare institutions to design effective systems with decision support capability that meets the needs of the health care providers.

Dissemination of Information and Implementation of Accepted Best Practices

As we consider data collection and analysis systems, me must also evaluate the best means of disseminating this information to the providers. Many hospitals do not have experts in quality improvement techniques on site nor do most nursing homes or rehabilitation centers. And yet these facilities need to have the same processes in place to improve patient safety. It may be necessary for the healthcare institutions that have these systems to provide the skills necessary for institutions with lesser resources.

Research should be conducted to determine the level of quality improvement awareness in all types of healthcare settings. Then curriculum content and delivery process necessary to provide QI training can be developed. Research also is needed on the incentives needed to develop a core group of specialists to deliver the training, and the funding required to make it happen.


Texas Forum members represent some of the nationís largest, highly specialized healthcare institutions. Yet we regularly experience the frustration associated with the daily potential for errors. We felt that by joining forces and sharing information, we would be able to significantly reduce this error potential. We now realize that we need changes beyond our immediate control to make significant progress. Thanks to the IOM report and initiatives such as this AHRQ Summit, we have the potential to work together to make a good healthcare system great. The opportunity is here! The time is now! Thank you for your consideration!

Current as of September 2000

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