Case for Change

Background
Modern health care is a highly complex, high-risk, and error-prone activity. Not surprisingly, adverse health care events are a leading cause of death and injury. Despite remarkable advances in health care technology and delivery, too many patients die or are disabled as a result of adverse health care events. Adverse health care events occur in all health care settings: hospitals, clinics, nursing homes, urgent care centers and surgery centers.

The Institute of Medicine's report, To Err is Human, projected between 44,000 and 98,000 deaths annually secondary to preventable medical errors in our hospitals. The higher estimate of 98,000 deaths ranks medical errors as the fifth leading cause of death in the United States – higher than motor vehicle accidents (43,458), breast cancer (42,397), or AIDS (16,516).

Preventable injury resulting from medical errors cost the economy from $17 billion to $29 billion annually, half of which are health care costs.

One in five Americans (22%) reported that they or a family member has experienced a medical error of some kind. Nationally, this translates to an estimated 22.8 million people with at least one family member who experienced a mistake in a doctor's office or hospital.

Of those experiencing a medical error, 10% reported that they or a family member had gotten sicker, and about half of those said the problem was serious. Nationally, this means that an estimated 8.1 million households reported a medical mistake that was very serious.

Patient Safety
Patient safety is simply defined as "the prevention of harm to patients." Patient safety is an integral part of the delivery of quality of care and a fundamental right of all Americans. Although simple in definition, the road to ensuring patient safety in health care facilities is complex and replete with obstacles.

Health care organizations should make patient safety a declared and serious aim by establishing comprehensive patient safety programs with defined executive responsibility, operated by trained personnel and in a culture of safety.

Patient safety programs should:

• Provide strong, clear and visible attention to safety.
• Implement a just system for reporting and analyzing errors within their organizations.
• Incorporate well-understood safety principles (such as best practices).
• Establish interdisciplinary team training programs for providers that incorporate proven methods of team training such as simulation.
• Identify and analyze system failures such as medical errors and near misses.
• Provide proactive evaluation and redesign of systems to improve care processes to prevent future errors.
• Involve participation of patients and their families and be responsive to their inquiries.
• Communicate findings throughout the organization in a consistent manner.
• Provide education related to patient safety science.

The information presented should be treated as a gateway and a toolkit. Each element provides basic information which is then followed by resources (books, journal articles and websites) for further review or investigation. There is no one right way in the development or evaluation of a patient safety program. Therefore, take what is useful and applicable and leave what is not.

The information contained is provided as advisory and is not meant as an endorsement of any particular methodology or website, but only as a collection of resources for consideration and use.

Sources:

• Safe Practices for Better Healthcare, Kizer K. National Quality Forum (NQF) 2003.
• Quality of Health Care in the United States: A Chartbook, Sheila Leatherman, Ph.D. and Douglas McCarthy, The Commonwealth Fund, April 2002.
• Institute of Medicine (US). To Err is Human: Building a Safer Health System. Washington (DC): National Academy Press; 2000.
• The Commonwealth Fund 2002
• Institute of Medicine (US). Patient Safety Achieving a New Standard for Care. Washington (DC): National Academy Press; 2004.