February 11, 2003 Volume 39 Issue 06
Better measurement needed to stop med errors
As many as 98,000 U.S. patients die annually due to
preventable
errors
By Gillian Wansbrough
TORONTO – To reduce medical errors, efforts must focus on
better
measurement of the problem, finding new tools and strategies for
change, and improving the context in which care is given to
prevent
and intercept errors, according to Dr. Ross Baker (PhD).
Dr. Baker, an associate professor of health policy, management
and evaluation at the University of Toronto, is leading a study
looking at adverse events in Canadian hospitals. He spoke to
delegates at a physician session on patient safety at the recent
Ontario Hospital Association convention.
Evidence of unacceptable levels of adverse events in health
care
has emerged from the U.S., Australia, Britain, France, Denmark
and
New Zealand. The Quality in Australian Health Care Study, one of
the
first to explore the issue, found 16% of admissions were
associated
with adverse events.
The seminal study on medical errors, said Dr. Baker, is the
Harvard Medical Practice Study (published in 1991 in the New
England
Journal of Medicine), which found adverse drug events in 3.7% of
hospitalizations, 28% due to substandard care.
Preventable errors
An Institute of Medicine report published in 2000 (To Err is
Human: Building a Safer Health System), based on the results of
the
Harvard study and the Utah-Colorado Study (1999), suggested at
least
44,000 Americans, and possibly as many as 98,000, were dying
annually to preventable medical error. The report was
instrumental
in bringing attention to the issue.
Health care can look to other high-risk industries and take
its
cue from how they deal with safety problems, said Dr. Baker, in
singling out the aviation industry of the 1970s and 1980s.
High-risk industries learned "you don't improve safety by
blaming
individuals," he said. "It's a property of
systems . . . but having
said that, clearly there are cases of incompetent and negligent
individuals that provide care and we need measures to deal with
that."
He referenced a 2001 study he co-authored that involved a
survey
of health-care development organizations and professional
colleges
and associations about key patient safety issues. Medication
errors
were found to be common to both but there were also many
dissimilar
items, making it clear it's an issue that begs further
exploration.
In health care, Dr. Baker said, the assumption is that all
errors
and adverse events are the result of individual actions, not
complex
systems. Interest by the media, as well as the public and
regulators, seems to serve only to generate blame rather than
insight.
Good news
The good news is the issue is increasingly getting attention
and
other efforts are underway to look for solutions—such as the
Canadian Institutes of Health Research and Canadian Institute for
Health Information study Dr. Baker is leading. It aims to
estimate
the incidence of adverse events in Canadian hospitals.
Much of the knowledge of what to do already exists, he
stressed.
He offered the following potential system solutions:
• simplify processes and reduce handoffs;
• improve access to information;
• automate wisely;
• use constraints and forcing functions;
• involve patients as part of the system;
• determine effective practices and standardize where
appropriate; and
• change product designs to reduce opportunity for failure.
Computerized physician order-entry systems may help but their
effectiveness is not clear and their adoption is not an easy
process. "The issue of handwriting is also on the table big
time,"
he added, noting U.S. insurer Kaiser Permanent offers handwriting
courses for physicians.
To bring about changes, more visible leadership is needed,
along
with the recognition that improving safety is a priority, as is
improving the reporting of errors, increasing the focus on system
changes, and gaining greater knowledge of safer systems, he
said.
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