Chicago—While erring is human, writing research papers showing how to avoid such mistakes in health care is, if not quite divine, at least very useful, according to two organizations concerned with the consequences of medical errors. The National Patient Safety Foundation (NPSF) and the Joint Commission on Accreditation of Healthcare Organizations cosponsored an October 6 conference showcasing 30 abstracts explaining ways to reduce medical error and improve safety. The highlight of the conference, which was called "Patient Safety Initiative 2000: Spotlighting Strategies, Sharing Solutions," was the presentation of National Patient Safety Awards to the authors of three abstracts. The NPSF and Joint Commission hope the conference will serve as a starting point for saving lives by translating patient safety research and learning into common practice. This effort follows last year's report by the Institute of Medicine with its claim that between 44,000 and 98,000 people die annually in the United States because of medical errors (To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999). Mistakes are made While the patient death totals continue to be debated (JAMA. 2000;284:93-97), it is acknowledged that mistakes are made. The problem, said Michael R. Cohen, RPh, president of The Institute for Safe Medication Practices and keynote speaker at the conference, arises when those who make an error or witness a mistake fail to view it as a systems problem and focus on the discrete event. "I think it goes back to the culture; we're not supposed to make errors. People say, ‘Those errors don't happen here. Our nurses or physicians would never do that—and yet they will,'" Cohen said. "When things do go wrong, we tend to see only what happens in our own practice and don't get the word out to other practices. That's a big missing link." Cohen is frustrated that those in a position to be that link, public and private regulatory agencies, have been unable to improve safety by alerting others to potential problems and solutions. "We have a tremendous amount of information, and we have experts who have made recommendations, but there doesn't seem to be an oversight organization to put this information to use," Cohen said. That situation may be changing. One intent of the October patient safety conference was to disseminate research-based attempts at reducing medical errors. The NPSF and Joint Commission, in their request for submissions in May, were seeking solutions that were tested, implemented, and proven to reduce errors; scientifically based; practical to implement and administer; creative and innovative; and transferable across organizations and settings. A compendium of the 30 abstracts submitted, plus 10 more, is scheduled for publication later this year. In the meantime, here's what the three award winners did to improve patient safety. Improvement is possible Pharmacists and nurses at Fairview Southdale Hospital in Edina, Minn, created "An Interdisciplinary Model for Reducing Intravenous Heparin Errors." The authors noted that intravenous heparin is a complicated drug to administer and is one of the drugs most commonly associated with serious medication errors. The goal of the program was to reduce errors in administering heparin in cardiac care units by 80%. The primary change in protocol was the creation of a combined heparin order form and documentation tool. Other changes included improved communication with the hospital laboratory, converting all heparin protocols to pharmacy-managed protocols, instituting pretyped heparin orders, double-checking pump programming, and encouraging the use of low-molecular-weight heparin instead of standard heparin. The authors said these steps reduced errors by 66%, with all remaining errors attributed to errors in pump programming, which are undergoing a separate improvement project. Another award winning solution, "What Messages on Patient Safety Should the Federal Government Promote? HCFA Research with Medicare Beneficiaries," was submitted by researchers with the Health Care Financing Administration. This study looked at how receptive Medicare beneficiaries were to patient-safety tips and other error-prevention messages. The researchers concluded that consumer messages about reducing medical errors work best if they advocate a collaborative, rather than challenging, patient-physician relationship, specify actions to be taken instead of offering generalized slogans, and clearly indicate modes of implementation. The third award winner, "Partnering with Families: Disclosure and Trust," was presented by authors from Children's Hospitals and Clinics in Minneapolis. This study looked at how an organization's response to medical errors can advance a culture of safety, especially for pediatric patients. The safety agenda stated by the authors included encouraging families to participate in patient care and ask questions; offering complete, prompt, and truthful disclosure of information and counseling to families when an accident (ie, a medical injury) occurs; fully analyzing each accident to prevent such an event from happening again; and continuing patient safety education through the creation of targeted learning packets for institution leadership, clinical staff, and patients and their families. The NPSF is an independent, nonprofit research and education organization founded in 1997 by the American Medical Association, CNA HealthPro and 3M—with Schering-Plough Corporation a major benefactor. Further details about the awards can be found online at http://www.npsf.org.
JAMA – American Medical Association
Published: Nov 8, 2000
Keywords: patient safety