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Improving Patient Safety - Five years after the IOM Report
Improving Patient Safety - Five years after the IOM Report
Improving Patient Safety - Five years after the IOM Report
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Improving Patient Safety - Five years after the IOM Report

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  • 1. PERSPECTIVE Improving Patient Safety — Five Years after the IOM ReportImproving Patient Safety — Five Years after the IOM ReportDrew E. Altman, Ph.D., Carolyn Clancy, M.D., and Robert J. Blendon, Sc.D. A 1999 report from the Institute of Medicine (IOM) ed patient-safety goals as part of the accreditation featured a now-familiar statistic: 44,000 to 98,000 process, and nearly all eligible hospitals are report- people die in hospitals each year because of prevent- ing data on the quality of care through the Center able medical errors, making hospital-based errors for Medicare and Medicaid Services. Most hospitals alone the eighth leading cause of death in the Unit- now have a written policy for informing patients or ed States, ahead of breast cancer, AIDS, and motor their families of a preventable medical error. And vehicle accidents. Regardless of debate about these the American Board of Medical Specialties has ex- estimates, they remain the standard for describing panded the requirements for maintenance of board the scope of the nation’s problem with medical certification to include demonstrated competence errors. in providing safe, high-quality care. Furthermore, When the report, titled To Err Is Human: Building recently published studies document the effective- a Safer Health System, was released, these numbers ness of system-based changes, such as reducing the caught the public’s attention as few other health work hours of medical personnel, in reducing the policy issues have done. A 1999 survey showed that rate of errors.3 the report was the most closely followed health pol- Congress has also joined the effort. The House icy story of the year.1 The subject also grabbed the of Representatives passed legislation in 2003, and attention of public and private organizations that the Senate passed related legislation in August 2004; were in a position to address the quality of U.S. these bills are intended to increase the reporting of health care. On December 7, 1999, President Bill medical errors and problems with patient safety. If Clinton signed an executive order requiring federal the bills are reconciled, the legislation will establish agencies and departments to develop, within 90 greater protections for providers that report such in- days, a list of activities to make patient care safer. formation, as well as creating patient-safety organi- As a result, new programs were initiated at numer- zations in the states to help analyze safety data and ous agencies. implement improvements. In the private sector, health care purchasers, in- The ultimate purpose of all these efforts, of dustry trade organizations, accrediting and stan- course, is to protect the public. In our 2004 nation- dards-setting bodies, and others embarked on pro- al survey, one third of respondents reported person- grams of their own. One of the more ambitious was al or family experience with medical errors, many of that of the Leapfrog Group, a coalition represent- them causing serious health consequences.4 Un- ing large health care purchasers that has advocated fortunately, despite five years of focused attention, “safety leaps” through the use of computerized or- people do not seem to feel safer. More than half (55 der entry, evidence-based hospital referrals, and percent) of the respondents in our survey said that physician staffing in the intensive care unit. There they are currently dissatisfied with the quality of is some evidence that these recommendations are health care in this country4 — as compared with 44 being adopted: in surveys, 24 percent of responding percent four years ago.5 In fact, 40 percent believe hospitals said they had intensive care units staffed that the quality of health care has “gotten worse” in by intensivists in 2003, as compared with 12 percent the past five years, whereas only 17 percent think it in 2001, and the use of computerized physician or- is better. And half are worried about the safety of der entry had increased from 2 percent to 5 percent.2 their medical care.4 Among other organizations, the National Qual- How can we increase confidence in health care, ity Forum has endorsed a range of patient-safety as we continue to address safety and quality? A ma- measures through its consensus process, the New jor obstacle is the absence of a consensus on what York and Georgia hospital associations are using the specific efforts should be the focus of safety im- patient-safety indicators developed by the Agency provement, including how best to collect and report for Healthcare Research and Quality in their im- information on the quality and safety of hospitals provement efforts, the Joint Commission on Ac- and health care providers. Reaching that consensus creditation of Healthcare Organizations has adopt- will be difficult for many reasons. Perhaps mostn engl j med 351;20 www.nejm.org november 11, 2004 2041 Downloaded from www.nejm.org on December 30, 2004 . This article is being provided free of charge for use in Argentina. Copyright © 2004 Massachusetts Medical Society. All rights reserved.
  • 2. PERSPECTIVE Improving Patient Safety — Five Years after the IOM Report very effective in reducing errors, and 7 in 10 per- sons say that such reports would tell them “a lot” about the quality of a hospital or a health plan.4 Although these challenges are real, the issue of patient safety may be less difficult to resolve than many health care issues — such as covering the un- insured or providing prescription-drug coverage — since it does not involve the sort of ideological and partisan differences that stall action. And al- though it will take an investment of resources to tackle, we do not think it will require hundreds of billions of dollars, as these other issues do. Moreover, there has already been some move- ment on a key front — the greater use of informa- tion technology. Although they offer no panacea, such technological solutions as computerized or- der-entry systems, bar coding of medications, elec- Courtesy of the National Academies Press. tronic prescribing, and strategies for sharing infor- mation have the potential to make care safer. Also, the interest expressed in the Health Information Technology Framework recently released by the De- partment of Health and Human Services could gal- vanize further action, leading to greater safety im- provements and more information for patients and providers to use in deciding on the services patients receive. However, the 2003 IOM report on data standards challenging is the gap between the steps identified for patient safety (Patient Safety: Achieving a New Stan- as important by patient-safety experts and the views dard of Care) makes clear that what is really needed of health care providers. For example, according to is a culture that encourages the sharing rather than a 2002 survey, a majority of practicing physicians the hiding of errors and near misses. The principal see just two approaches as very effective in reduc- obstacle to broader action is therefore not Congress ing errors: “requiring hospitals to develop systems or money but a lack of consensus among policy to avoid medical errors” (55 percent) and “increas- makers and the public, and especially among health ing the number of hospital nurses” (51 percent). professionals themselves, on which events should Fewer physicians agree that other proposed mea- be publicly reported and what systemwide steps are sures would be very effective: limiting certain high- needed to prevent avoidable harm. Reaching con- risk procedures to high-volume centers (40 percent), sensus will require a national dialogue and the rec- using only physicians trained in intensive care med- ognition by physicians that business as usual will icine in hospital intensive care units (34 percent), not improve patient safety. increasing the use of computerized ordering sys- In the past five years, many promising efforts tems (23 percent), and computerizing medical rec- have been launched, but the task is far from com- ords (19 percent).1 plete. If we do not expand and accelerate current ef- Physicians also strongly oppose public report- forts, we can expect future surveys to reveal a persis- ing of information on medical errors — perhaps be- tent lack of confidence in the safety and quality of cause of worries about malpractice lawsuits, which the nation’s health care system. physicians name as the top concern facing health From the Kaiser Family Foundation, Menlo Park, Calif. (D.E.A.); care and medicine today.1 In stark contrast, 71 per- the Agency for Healthcare Research and Quality, Rockville, Md. cent of the public believes that public reporting of (C.C.); and the Department of Health Policy and Management, medical errors by government agencies would be Harvard School of Public Health, Boston (R.J.B.).2042 n engl j med 351;20 www.nejm.org november 11, 2004 Downloaded from www.nejm.org on December 30, 2004 . This article is being provided free of charge for use in Argentina. Copyright © 2004 Massachusetts Medical Society. All rights reserved.
  • 3. PERSPECTIVE Improving Patient Safety — Five Years after the IOM Report 1. Blendon RJ, DesRoches CM, Brodie M, et al. Views of prac- 2004;351:1838-48. ticing physicians and the public on medical errors. N Engl J Med 4. Kaiser Family Foundation, Agency for Healthcare Research 2002;347:1933-9. and Quality, Harvard School of Public Health. National survey 2. The Leapfrog Group Hospital Patient Safety Survey, April on consumers’ experiences with patient safety and quality infor- 2003–March 2004. Washington, D.C.: Leapfrog Group, 2004. mation. Menlo Park, Calif.: Kaiser Family Foundation, July 5, 3. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of elim- 2004. inating extended work shifts and reducing weekly work hours on 5. Gallup poll. Storrs, Conn.: Roper Center for Public Opinion serious medical errors in intensive care units. N Engl J Med Research, September 11, 2000.d o c t o r s a n d p at i e n t sA Great CaseJerome Groopman, M.D. “It’s a really great case,” the neurology resident take. I recall a middle-aged woman with months of said. “Gerstmann’s syndrome.” I was a third-year headaches supposedly due to “sinusitis” who turned medical student, and neurology was my first clini- out to have histiocytosis. The resident beamed as he cal rotation. The resident listed the four findings described the multiple and subtle presentations of associated with the disorder: agraphia, right–left the proliferating Langerhans’ cells that eroded bone disorientation, finger agnosia, and acalculia. “Due and invaded the brain. to a tumor in the parietal lobe,” he explained. Other cases were great because of the muscular We entered the patient’s room. A disheveled man drama they brought. In surgery, these were called in a hospital gown looked at us uncertainly. The “womps.” A man with a gunshot wound to the gut resident had the man attempt a series of tasks and was rushed into the emergency room. All hands maneuvers demonstrating all the elements of the were on deck, elbow deep in blood, putting in cath- syndrome’s tetrad. eters, inserting an endotracheal tube, palpating the “What a great case,” I said as we left. The resi- lacerated organs. A woman with a retroperitoneal dent smiled. sarcoma that had snaked up her abdomen, penetrat- Internal medicine followed neurology. A cachec- ed the diaphragm, and gripped her heart underwent tic drug user was admitted in the middle of the an 11-hour dissection requiring teams from surgi- night with spiking fevers. “Listen to his heart,” cal oncology, thoracic surgery, and cardiac surgery. the intern instructed. I placed my stethoscope over Such cases were great because they afforded a live the shrunken chest. Cacophony flooded my ears. tour of human anatomy. “His valves are chewed to nothing,” the intern said. As our clinical rotations came to an end, we dis- It was acute bacterial endocarditis, and the intern cussed where to intern. Choosing well involved con- recited some of its devastating complications: sidering not only the location of the hospital and its brain abscess, heart block, endarteritis. No doubt, staff ’s commitment to teaching, but also whether I thought, it was a great case. there was “amazing pathology,” a range of disease Over the course of the year, I learned that there wide and deep enough to yield “great cases” along were subsets of great cases. Some were great puz- with the regular fare of internal medicine: peptic zles. On rounds, master clinicians with encyclope- ulcer disease, adult-onset diabetes, alcoholic cir- dic knowledge would weave together seemingly rhosis. loose ends of information — threads from the his- As a house officer, I was drawn to the specialty tory, the physical examination, and laboratory tests of hematology because it seemed to be filled with — and form a whole cloth of diagnosis. The very great cases that came cloaked in a special beauty. best of these great cases were called “fascinomas” Under the microscope, blood and marrow from — arcane diseases that tested your acumen and patients with acute promyelocytic leukemia or the evoked awe at the strange forms maladies could Sézary syndrome or thalassemia looked like won-n engl j med 351;20 www.nejm.org november 11, 2004 2043 Downloaded from www.nejm.org on December 30, 2004 . This article is being provided free of charge for use in Argentina. Copyright © 2004 Massachusetts Medical Society. All rights reserved.

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