By Pat Hezmall, MD, Chair, TMA Ad Hoc Committee on Medical Errors
On Nov. 30, 1999, the Institute of Medicine (IOM) of the National Academy of Sciences released its report, "To Err is Human: Building a Safer Health System" on health care quality in the United States. Subsequent media coverage of and responses to the report suggested that patient safety is not a priority concern of physicians and other health care professionals and that the report raised new issues for the medical profession. Nothing could be further from the truth. In fact, medical professionals have long been the strongest proponents of improvements in patient care.
The report does, however, provide significant impetus to enhance ongoing efforts to improve patient safety, spur new efforts, educate physicians and other health care professionals on how they can replicate these activities, and educate the public on what has been and is currently being done.
There is, and always has been, a strong consensus in the medical community on the need to continue to minimize the potential for human error in our vast and complex medical delivery systems - and we know how to do it. It is important to remember that all physicians pledge to "do no harm" and are dedicated to the proposition that even one medical error is one too many. As scientists and professionals, we recognize that the rigors of the scientific method hold the key to our identifying and correcting the circumstances that erode patient safety. As members of numerous interdisciplinary health care teams, we recognize that physicians, nurses, hospital administrators, pharmacists, and other professionals must collaborate in this process.
Although we might question the details and statistical extrapolations, we appreciate the IOM report because it will likely bring new resources to the battle. We have been addressing this challenge for decades. Contrary to the impression that some news media conveyed in the wake of the IOM report, physicians and other health care professionals have made tremendous progress in improving patient safety. It is also important to note that even the research cited in the IOM report documented considerable improvement in the medical error injury rate. However, our ability to sustain ongoing improvements is threatened by the budget constraints of government and managed care.
Significant physician-led advances in patient safety - in Texas and around the nation - include:
- As acknowledged by the IOM report, the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists have championed system reforms that have reduced anesthesia-related deaths 50-fold since the late 1970s.
- From the Veterans Administration health care system to St. Luke's Episcopal Hospital in Houston, bar-coded patient wristbands are reducing medication errors and improving the accuracy of patients' charts.
- Texas Medical Foundation found that using patient record flowsheets in a primary care outpatient setting among diabetic Medicare patients increased performance for the recording of HbA1c's from 9.2 percent to 79.2 percent.
- Memorial Hermann Hospital was able to reduce by half the number of infants suffering the tragedy of blood stream- and ventilator-associated pneumonia in its neonatal intensive care unit. Memorial Hermann also has been able to decrease adverse drug events by 50 percent over a three-year period.
- Scott and White has embarked on a plan of systematic measurement and formalized multifunctional teams to improve quality and patient safety. Using a data-driven approach, clinicians can understand variation within the various health care units, and improve patient care.
There are numerous other projects similar to these underway in the state, and TMA continues to serve as a clearinghouse of important patient safety initiatives in Texas.
These examples illustrate a proper, scientifically valid, effective approach to improving patient safety: Physician-led teams have systematically identified the root causes of unintentional, potentially preventable errors; devised and implemented system changes that prevent these problems; and shared results with their peers. All of this takes place in a no-fault environment in which the goal is to fix the problem, not fix the blame.
Errors of omission - such as not prescribing certain medications for patients with certain conditions - are less visible but potentially easier to correct and have a greater long-term impact on patients' health than errors of commission - such as operating on the wrong limb. The most important work for physicians, then, lies in developing and promoting evidence-based guidelines for patient care.
If Congress or the Texas Legislature feels compelled to take any action in response to the IOM report, they would best serve the public by promoting tort reforms that can lead to enhanced discussions, information-sharing, and improvements in patient safety, and by providing much-needed funding to foster and support expansions of these activities.