Treatment Goal #4: Protect Patient Safety

All physicians pledge to "do no harm" and are dedicated to the proposition that even one medical error is one too many. A commitment to a culture of patient safety involves all members of the health care team: physicians, hospitals, nurses, other practitioners, even patients themselves and their families. Health care today involves so many interdependent, moving parts, especially for the sickest and most severely injured patients. We must continue to devise systems that prevent small, unintentional mistakes from quietly and rapidly turning into irreversible, destructive forces. We must ensure that all members of the team possess the knowledge, skills, training, and experience to carry out their assigned tasks. We must do all we can to ensure that our patients, whenever possible, leave the health care system healthier than when they came in.

Texas health care professionals must support an environment conducive to reporting preventable errors and developing strategies to prevent and correct them.

There is, and always has existed, a strong consensus in the medical community on how to continuously minimize the potential for human error in our vast and complex medical delivery systems. The rigors of the scientific method hold the key to identifying and correcting the circumstances that erode patient safety. All members of the numerous interdisciplinary health care teams - physicians, nurses, hospital administrators, and other professionals - must collaborate in this process.

Media coverage of the 1999 Institute of Medicine (IOM) report, "To Err is Human: Building a Safer Health System" implied 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. Despite the report's methodological flaws, medicine can be thankful that it brought new resources to the battle. Physicians and hospitals have been addressing this challenge for decades and have made tremendous progress in improving patient safety. It is remarkable that they have been able to reduce medical errors at all of late, in the face of the cost-cutting onslaught of government and managed care.

Modeled after the aviation industry's nonpunitive reporting of error, physician-led teams have systematically identified the root causes of unintentional errors, devised and implemented system changes that correct these problems, and shared their results with their peers. All of this has taken place, and must take place, in a no-fault environment in which the goal is to fix the problem, not fix the blame. Confidentiality protections for patients, health care professionals, and health care organizations are essential if we are to learn about errors and effect change. Information developed in connection with reporting systems should be privileged for purposes of federal and state civil matters and administrative proceedings.

Errors of omission - such as not prescribing certain medications for patients with certain conditions - are less visible, 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 lies in developing and promoting evidence-based guidelines for patient care and discouraging their colleagues from using those practices that do not comply with these guidelines.

TMA President Robert T. Gunby Jr., MD, appointed a Select Committee on Patient Safety to develop recommendations regarding patient safety legislation and to lead TMA's participation in the Institute of Health Care Improvement's 100,000 Lives Campaign. The select committee is focusing on concrete ideas to reduce adverse outcomes and decrease risks to patients. These include efforts to reduce surgical infections and adverse drug reactions, and to improve the use of proven practices, such as administering aspirin and beta blockers to heart attack patients. Best practices need to be disseminated among physicians and other health providers.

Since 2003, hospitals, ambulatory surgical centers, and mental hospitals in Texas have been required to report certain "sentinel events" to the Texas Department of State Health Services (DSHS) annually. The agency is responsible for aggregating data for public release, but the hospital names remain confidential. Facilities must perform a root cause analysis and develop a corrective action plan within 45 days of any event.

A new federal law, Patient Safety and Quality Improvement Act of 2005, has created a voluntary and confidential system for medical error reporting and is a major step forward in improving patient care. TMA is evaluating whether additions or changes at the state level would allow information to be gathered without the threat of liability so that systemic patient safety problems can be identified and corrected.

To enhance efforts to improve safety, TMA recommends:

  1. Encouraging all Texas hospitals, physicians, health care facilities, and other practitioners to endorse the principles of the Institute of Health Care Improvement's 100,000 Lives Campaign and to implement them wherever possible.

  2. Creating patient safety organizations under the Patient Safety and Quality Improvement Act of 2005 to collect voluntarily reported medical errors, incidents of "near misses," and enhanced health care quality practices.

  3. Developing a non-punitive, confidential culture for reporting health care errors that focuses on preventing and correcting systems failures and not on individual or organization culpability.

  4. Enhancing patient safety education in medical school and residency training.

A strong and fair Texas Medical Board must protect the public safety while it brings new Texas physicians into clinics, exam rooms, and hospitals as quickly as possible. Limited-license health care practitioners must practice within the arena safely defined by their knowledge, skills, training, and experience.

•  The Texas Medical Board (TMB) continues to expand and improve its operations after the 2005 sunset review and the extensive changes to the Medical Practice Act the legislature adopted with TMA's strong support in 2003. Those changes further protect the public health from physicians who practice below the standard of care, and provide due process protections for physicians under investigation. The board received new legal tools and additional financing to hire more and better staff. The legislature must continue to monitor how well the board has instituted those changes.

All Texans must be confident that their physicians are qualified, competent, and uphold the highest ethical and professional standards. All Texas physicians must be confident that their fellow physicians are qualified, competent, and uphold the highest ethical and professional standards.

To protect the public safety, TMA recommends:

  1. Ensuring a strong and well-funded TMB and extensive evaluation of the physician disciplinary process. This includes expediently and accurately processing licensure applications as well as affording due process to both complainants and physicians.

  2. Subjecting physician testimony in health care liability cases to TMB scrutiny because that testimony constitutes the practice of medicine.

•  The scope of practice of health care professionals must be limited by their education, training, and skills. This is a patient safety issue. In virtually every legislative session, one or more groups of nonphysician health care professionals seek to expand their scope of practice, oftentimes under the guise of increasing access to care. Nonphysician health practitioners are highly valued by the medical profession; physicians and allied practitioners care for patients on a daily basis working as a team. However, only physicians should exercise independent medical judgment, serving as the trusted leader of the health care team.

To protect patients, TMA recommends:

  1. Stopping any efforts to expand scope of practice beyond that safely permitted by an allied health practitioner's education, training, and skills.

Next:   Goal 5: Humane and Cost-Effective End-of-Life Care