Improving Patient
Safety And Preventing Medical Errors
http://www.hhs.gov/news/press/2002pres/safety.html
Overview:
The Department of Health and Human Services (HHS) plays a critical
role in promoting safer health care for all Americans and helping
prevent medical errors. Each year, tens of thousands of Americans
suffer injuries and death due to preventable medical errors in
hospitals, doctors' offices, nursing homes, pharmacies and other
places where people receive care. These errors most often result from
systemic problems rather than poor performance by individuals.
Since 1998, HHS agencies have served with other federal agencies on
the Quality Interagency Coordination (QuIC) Task Force to promote a
coordinated effort toward improving the quality of care for patients
in America. In 2000, the QuIC task force issued an action plan
(available at
http://www.quic.gov) to reduce patient injuries due to medical
error, including a series of steps now underway at HHS agencies. In
April 2001, HHS Secretary Tommy G. Thompson established a new Patient
Safety Task Force to coordinate HHS efforts and work with states and
the private sector on one of the most important issues identified in
the QuIC report -- the need to improve the collection of patient
safety data.
HHS' fiscal year 2003 budget proposal includes $84 million for efforts
to improve patient safety and reduce adverse events -- a $10 million
increase above the current year's budget. Overall, HHS agencies
support a wide range of initiatives designed to reduce preventable
medical errors and to improve the quality of care provided to
Americans of all ages. These efforts include: collecting and analyzing
data to measure quality and target improvement efforts; identifying
and promoting best practices to avoid systemic medical errors; and
educating consumers and providers about ways to prevent errors.
Background
Preventable medical errors can occur in any health care setting from a
wide range of causes. Examples of errors include a patient receiving
the wrong medication or a medication to which they have a known
allergy or a patient not receiving appropriate care after an abnormal
test result. Most often, such errors occur as a result of systemic
problems rather than poor performance by individual doctors, nurses or
other providers. For instance, drugs with similar names or appearances
may be easily confused with one another, or abnormal test results may
not be quickly shared with those involved in a patient's care.
In
the early 1990s, the Agency for Healthcare Research and Quality (AHRQ)
funded a series of research studies examining the frequency and causes
of medical errors. Based on these studies, the Institute of Medicine
(IOM), an independent body that is part of the National Academy of
Sciences, estimated that as many as 44,000 to 98,000 Americans die in
hospitals each year as a result of medical errors. The IOM further
estimated that adverse events cost the nation $37.6 billion each year
-- including about $17 billion associated with preventable errors.
In
1998, HHS and other federal agencies formed the QuIC Task Force to
coordinate efforts toward improving the quality of care for patients
in America. The task force provides a mechanism for agencies to work
together to better measure quality of care and to take steps to
improve it. In addition to HHS, the QuIC task force includes the
departments of Labor, Defense, Veterans Affairs and Commerce; the
Office of Personnel Management; the Office of Management and Budget;
the U.S. Coast Guard; the Federal Bureau of Prisons; the National
Highway Administration; and the Federal Trade Commission.
In
November 1999, the IOM issued a comprehensive report, "To Err Is
Human: Building A Safer Health System," that focused public attention
on the need for research, data and reforms to reduce medical errors
and improve patient safety. The report included wide-ranging
recommendations for both the public and private sectors for improving
patient safety in the areas of leadership, improved data collection
and analysis, and development of effective systems at the level of
direct patient care.
Following the report, the QuIC task force issued an action plan in
February 2000 that highlighted a series of steps for HHS and other
federal agencies to take to reduce medical errors. In addition, HHS
continues to expand its efforts to improve patient safety by gathering
and analyzing data, conducting relevant research, and educating
consumers, businesses and health care providers about preventing
medical errors.
Data Collection and the HHS Patient Safety Task Force
Federal and state agencies, accrediting bodies and other organizations
collect data that can provide insights into the causes of medical
errors and strategies to increase patient safety, but these separate
sources of information are difficult to compare and analyze. In April
2001, Secretary Thompson created the HHS Patient Safety Task Force to
coordinate the efforts of these various data-collection sources to
promote more consistent, effective use of the information.
The
secretary directed the task force to identify the data that health
care providers, states, and others need to improve patient safety and
will work to develop a less-burdensome reporting system that avoids
duplication, increases efficiency and allows providers to learn from
others' experiences. This system will provide reliable, valid
information to identify safety risks and to develop solutions. All the
data collected will be de-identified, with references to individual
patients, doctors and facilities eliminated in order to encourage
reporting and to protect individual privacy.
This
system will be built upon data from existing reporting systems, such
as adverse events reported to the Food and Drug Administration (FDA)
and voluntary reports of hospital-related infections to the Centers
for Disease Control and Prevention (CDC). Information about existing
reporting requirements is available at
http://www.ahrq.gov/qual/taskforce/hhsrepor.htm.
The
new system will complement efforts at the Centers for Medicare &
Medicaid Services (CMS), formerly known as the Health Care Financing
Administration, to develop and implement a confidential Medicare
patient safety monitoring system that will describe patterns and
trends of adverse events in hospitals. This monitoring system will
provide information on the causes of errors broadly, but not at the
level of an individual hospital.
Promoting best practices to prevent errors
Since March 1998, the QuIC task force has worked to coordinate the
quality of care activities in federal agencies involved in health
care. In September 2000, the task force sponsored a national summit on
medical errors and patient safety research that included health care
providers, administrators, purchasers, policymakers, oversight groups
and consumers to address future research needs.
AHRQ
included the input from the summit in developing a research agenda to
guide funding decisions of public- and private-sector organizations
that support patient safety research. The agenda includes efforts to
design and test "best practices" for reducing errors, develop the
science base to inform these efforts, improve provider education to
reduce errors, capitalize on advances in information technology, and
build the capacity to further reduce errors.
Based on the research agenda, AHRQ awarded $50 million in fiscal year
2001 to support 94 new research grants, contracts, and other projects
to reduce errors and improve patient safety. This initiative
represents the federal government's single largest investment to
address patient safety issues. The 94 projects are being carried out
at state agencies, major universities, hospitals, outpatient clinics,
physicians' offices, and other settings across the country. More
information on these projects is available at
http://www.ahrq.gov/qual/newgrants/index.html.
HHS
agencies are also involved in a number of other projects to promote
patient safety:
Improving drug labeling.
The FDA in December 2000 proposed a new, user-friendly format for
prescription drug labeling designed to reduce the chances of making
medication errors, such as giving the wrong dose or causing adverse
interactions between drugs. The system would include a bulleted
"highlights" section with information that clinicians are likely to
need and review frequently.
Reducing "high-hazard" risks.
The QuIC task force is working with the Institute for Healthcare
Improvement to test strategies for reducing the number of errors
committed, particularly in emergency rooms, operating rooms, intensive
care units and on-site rescue operations. This is the first such
initiative targeted at error reduction in these "high-hazard"
environments.
Developing quality measures.
In 2001, CMS launched a quality initiative to help people who rely on
Medicare and Medicaid programs and their family members find the best
nursing homes for their needs. Initially, CMS will identify, collect
and publish nursing home quality information in Colorado, Florida,
Maryland, Ohio, Rhode Island and Washington, and then will work to
expand the demonstration nationally. Over the next several years, CMS
will work to develop and publish similar, meaningful consumer
information for home health agencies, and eventually hospitals and
other types of providers. This information will give beneficiaries,
their families and their physicians the information they need to make
informed choices of their providers. CMS and AHRQ continue to work
with the National Quality Forum, a private group of major employers
and other purchasers of health care, to identify and evaluate quality
measures.
Medicare Quality Improvement Organizations (QUIs).
Through State Quality Improvement Organizations (QIOs), formerly known
as Medicare's Peer Review Organizations (PROs), CMS is conducting 14
local pilot projects aimed at improving patient safety. Successful
efforts will be expanded in order to improve quality of care across
larger groups of patients. CMS already has established a number of
national priorities for PROs to improve patient safety, including
reducing the use of contra-indicated treatments and eliminating
unnecessary treatment delays.
Educating patients and health care providers
Well-informed patients and health care providers can play a critical
role in preventing medical errors. HHS devotes a wide array of
resources to education materials targeted at consumers and providers
alike. These efforts include:
Consumer guides.
HHS has numerous pamphlets and guides on preventing medical errors for
consumers in both English and Spanish, including "20 Tips to Help
Prevent Medical Errors," a practical guide with research-based
recommendations involving potential safety risks related to
medications, hospital stays and surgery, and "Five Steps to Safer
Health Care," highlighting ways that patients and their families can
take more control over the quality of their health care. These and
other consumer publications are available at
http://www.ahrq.gov/qual/errorsix.htm.
Research-based information for providers.
AHRQ shares evidence-based information from research about best
practices to avoid medical errors in easy-to-use formats for doctors,
other clinicians and health care providers. "Making Health Care Safer:
A Critical Analysis of Patient Safety Practices," an AHRQ evidence
report, is a review of 79 patient safety practices with a list of 73
that are likely to improve patient safety and a description of 11 that
the researchers considered highly proven to work but are not performed
routinely in the nation's hospitals and nursing homes. HHS agencies
also hold interactive workshops and satellite broadcasts to share
important research findings and other information about patient
safety. Other efforts include summaries of best practices, including a
general guide to promote patient safety, as well as other documents
geared to specific topics, such as reducing adverse drug events in
hospitals. AHRQ's evidence report on patient safety practices and many
other reports are available at
http://www.ahrq.gov/qual/errorsix.htm.
Outreach to states.
AHRQ has partially funded a series of reports to educate state
policymakers, including legislators and state health officials, to
highlight steps that states can take in order to improve patient
safety and reduce medical errors. The reports, prepared by the
National Academy of State Health Policy, deal with topics such as
state-mandated reporting of medical errors and working with the
private sector to improve patient safety. The reports are available at
http://www.nashp.org.
Medication errors information.
The FDA provides updated information about medication errors,
including specific drugs that have been confused with one another. The
information reflects analysis of voluntary reports from consumers,
doctors and other clinicians, as well as mandatory reports from
manufacturers. Details are at
http://www.fda.gov/cder/drug/MedErrors/. FDA also runs
the "Take Time to Care" awareness campaign to educate women and
families about taking medications correctly. The effort includes
consumer literature, as well as local, interactive educational
sessions led by pharmacists and other health professionals. More
information is available at
http://www.fda.gov/womens/tttc.html.
National health information infrastructure.
In
2001, the National Committee on Vital and Health Statistics, which
advises HHS on health information policy, issued a report outlining a
strategy for developing a comprehensive national health information
infrastructure that would help reduce medical errors. The committee's
report is available at
http://www.ncvhs.hhs.gov/nhiilayo.pdf. |
