Improving Patient Safety
In the wake of the Institute of Medicine
report about medical errors,
Congress, accreditors, and health-care providers are taking actions
to improve patient safety.
Congress, accreditors, and health-care providers are taking actions
to improve patient safety.
Nearly six years have passed since the
Institute of Medicine issued its influential report “To
Err is Human—Building a Safer Health Care System.”
The institute said that at least 44,000 and perhaps as many as
98,000 patients die each year as a result of medical errors.
(The report is available on line through the National Academy
Press, Washington, DC at: www.nap.edu/catalog/9728.html)
In addition, a study
published in the 1990s found that the average ICU patient
experienced 1.7 errors per day and that one-third of those
errors were potentially life-threatening. (Y. Donchin et al, Critical Care Medicine, 23, no. 2 (1995):
294-300).
Drawing lessons from the
aviation industry, the institute called for a more vigorous
system of reporting and analyzing dangerous incidents including
“near misses.” From 1976 to the 1990s, the aviation
industry reduced the risk of dying on a domestic airline jet
flight by three-quarters, from 1 in 2 million to 1 in 8
million. Similarly, in the 26 years following creation of the
federal Occupational Health and Safety Administration (OSHA) in 1970, workplace deaths were reduced by
one-half.
Since the
institute’s report was issued in November 1999,
health-care safety issues have received increased attention,
particularly from Congress, accrediting organizations, and
health-care institutions.
Congressional action
This July, Congress passed and President
Bush signed the “Patient Safety and Quality Improvement Act of
2005.” (Public Law
109-41; S 544). The act seeks to promote a learning
environment, rather than a punitive environment, in order to
improve patient safety. To that end, the act provides that
“patient safety work product” is privileged and
cannot be subject to discovery or use at trial in civil,
criminal, or administration legal actions.
“Patient safety
work product” is defined as written or oral statements
collected or reported to a health-care provider’s
patient-safety organization for the purpose of improving
patient safety or quality of care. The term does not include a
patient’s medical record or other data that is kept
separate from the patient-safety data. Under the act, almost
all health-care providers are protected, including hospitals,
ambulatory surgical centers, and physicians’ offices.
The act also protects
whistle-blowers who make reports in good faith about safety
issues to their employers or to a public or private safety
organization listed by the Secretary of Health and Human
Services. An employer could not take an “adverse
employment action,” including firing or failing to
promote an employee, because the employee made a good-faith
report about a safety issue.
The Patient Safety and
Quality Improvement Act has similarities to another federal
law, the Health Care Quality Improvement Act of 1986, which provides immunity for persons who engage
in peer review activity, provided certain conditions are met.
The Patient Safety and Quality Improvement Act, however, does
not grant immunity from monetary damages for persons who serve
with patient safety organizations, although the act does
provide other protections for efforts to improve patient
safety.
New JCAHO goals
The leading accrediting organization also
is taking steps to promote patient safety. Each year for
the last four years, the Joint Commission on Accreditation of
Health Care Organizations (JCAHO), which accredits more than
15,000 health-care organizations in the United States, has
issued new goals for patient safety. For 2006, the new goals include implementation
of a “standardized approach to ‘hand off’
communications, including an opportunity to ask and respond to
questions.” For example, under this approach, when a
hospital resident is turning over care of a patient to another
resident, procedures need to be in place to pass on current
information about the patient and give the incoming resident an
opportunity to ask questions. Other JCAHO standards for 2006
include labeling all medications and medication containers
(including syringes and cups) in perioperative and other
procedural settings.
The Joint Commission
also has reaffirmed its official “Do Not Use List,”
a list of abbreviations that can have more than one meaning and
can lead to dangers to patient safety when misinterpreted. For
example, “IU” should not be used to refer to
International Units since “IU” could be mistaken
for “IV” or the number “10.” Instead,
when referring to International Units, the words should be
written out. Use of improper abbreviations is one of the most
frequent non-compliance items on commission surveys with 27
percent of institutions being cited for non-compliance. For the
full list of “Do Not Use” terms and for more
information about JCAHO safety goals, see the sidebars.
