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Medical Mistakes, 10 Years Post-Op

From: The Hospitalist, November 2009

HM and renewed emphasis on patient safety grow in tandem

by Larry Beresford

It’s November 1999, and the release of an advance copy of a breakthrough Institute of Medicine (IOM) report on patient safety provokes headlines around the world with its estimate that as many as 98,000 people per year die from medical errors in U.S. hospitals. The report and subsequent book, To Err is Human: Building a Safer Health System, already is labeled a landmark event for modern medicine.1 It launches a nationwide effort to systematically improve patient safety and reduce errors.

Believe it or not, the IOM report celebrates its 10th anniversary this month. Many healthcare leaders point out that the QI and patient-safety revolution birthed by the IOM report has paralleled the simultaneous—and seismic—growth of HM.

The IOM report drew upon data from Harvard Medical Practice Studies and other existing research for its shocking estimates of error-induced deaths. The report, to a large degree, focused on prescribing errors, with less emphasis on hospital-acquired infections and other safety and quality issues that have emerged since its publication. The report also proposed a comprehensive safety strategy for government, industry, consumers, and healthcare providers—a proposal that has been adopted only in pieces.

In commemorating the 10th anniversary of the IOM report, industry leaders agree that HM more than any other medical specialty will continue to play a leading role in pushing the quality and patient-safety agenda in hospitals throughout America.

IOM’s Committee on Quality of Healthcare in America, which was made up of physicians, researchers, and healthcare leaders, authored the breakthrough report on medical errors, and followed up two years later with Crossing the Quality Chasm: A New Health System for the 21st Century (www.iom.edu/?id=12736).2

The Hospitalist caught up with two of the original committee members, Donald Berwick, MD, MPP, FRCP, president and CEO of the Institute for Healthcare Improvement (IHI), and Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM), to discuss how far medicine has come—and how far it has to go—in the areas of hospital quality and patient safety.

Christine Cassel, MD, president, CEO, American Board of Internal Medicine, PhiladelphiaWhen we think about how we train doctors … they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change.
—Christine Cassel, MD, president, CEO, American Board of Internal Medicine, Philadelphia

Question: What is the legacy of the IOM report?
Dr. Berwick: It didn’t launch the patient-safety movement, but it was the most important single contributor to that movement. In one step, it took the focus on safety as a goal in medicine from a relatively fringe concern to a central issue, and a central task for health providers.

Its most important element was the focus on systems improvement, rather than exhortations to individual health professionals to do a better job with patient safety. It is a cultural norm to blame someone when something goes wrong. That hasn’t changed fundamentally. But the IOM report made the point that it’s not people who are to blame for problems in patient safety, and blame won’t get us where we need to go.

HM Jumps into Quality and Patient Safety with Both Feet

Robert Wachter, MD, FHM

An incredible, happy coincidence: That is how Robert Wachter, MD, FHM, explains the paralleled growth of HM and patient-safety awareness in U.S. hospitals. HM had “just emerged in the mid-1990s and was still figuring out what it was about when the IOM report [To Err is Human] was published,” says Dr. Wachter, chief of the hospital medicine division, professor and associate chair of the Department of Medicine, the University of California at San Francisco, former SHM president and author of the blog “Wachter’s World,” noting concerns at the time that HM would be branded as a cost-saving measure for hospitals and health plans.

“I remember vividly when the IOM report came out. A light bulb went off for me—what a spectacular opportunity for our field,” the well-known HM pioneer recalls. “Here was this huge report saying patient safety stinks and needs to be fixed. I was pretty sure other medical specialties would not welcome the findings. I and other hospitalist leaders pushed very hard to say ‘we own this’—we believe the report is true and we believe it requires a new kind of physician who believes in systems thinking, teamwork, and collaboration. I still think it was a good call for hospital medicine to jump with both feet into the quality and safety field.”

The IOM report sparked a patient-safety renaissance, Dr. Wachter says. “We recognized that there is a science here—a core knowledge, a way of thinking and an understanding that we were not going to make much progress on patient safety until we understood that knowledge, learned its science, and did the research. We have since learned that fixing patient safety is tricky, and yet as you scan the landscape, you see all of the important actors are doing something to make patient care safer.”

One of the first steps to fixing the problem is “owning up” to the fact people die because of medical mistakes. Hospitals’ willingness to adopt transparency, from the first floor to the C-suite, has changed in the past decade, Dr. Wachter says.

“We have created an environment where we’re on the path to getting safer,” he says. “We’re much more open and honest about errors. We attack them with root-cause analysis and find better ways to fix the problem. For me, that’s all healthy. It leaves me with great confidence that things are safer in American hospitals than they were 10 years ago—although certainly not as safe as they need to be.”—LB

Q: How do you rate the impact of To Err is Human on the medical industry as a whole?
Dr. Cassel: The Agency for Healthcare Research and Quality, five years after the IOM report, said we hadn’t made enough progress. We have, most importantly, been able to talk about it and understand some of the approaches to safety and quality. But that’s not nearly enough, in my opinion.

Dr. Berwick: I’d give it a C-minus. There has been a change in awareness of medical safety. Before the IOM report, you just didn’t hear about it. A scientific basis for the statement of the problem was created, and we can never go back. Prototypes of what could be achieved have started to emerge, not just in this country but worldwide. The problem is that the success is just in pockets—not fundamental change in the nature of the American healthcare industry. That level of execution just is not there yet. Now it’s game time—time to take safety and quality mainstream.

Q: In retrospect, what was missed in the report?
Dr. Berwick: If we missed any boat in our analysis, the idea of “no blame” is not meant to relieve everyone of responsibility for medical errors, but to relocate responsibility for safety in the offices and work of leaders of healthcare institutions. The finger points to the executive suite. There’s more and more evidence that safety does not improve without the clear commitment of leaders.

Dr. Cassel: When we think about how we train doctors, which I spend a lot of time doing, they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change. ABIM’s new pathway for hospitalists, which will be rolled out in another year or so (see “A-Plus Achievement,” p. 1), treats questions of how … to identify patient-safety issues as core knowledge.

Q: What is the relationship of the patient-safety movement to the hospitalist movement?
Dr. Cassel: The development and growth of patient safety has paralleled the growth of hospital medicine, and I think that’s a good thing. Most of the literature on available errors focuses on the hospital because that’s the easiest place to find numbers of patients and shine a light on safety. Specialists in hospital medicine have a unique opportunity and responsibility to be leaders in continuing to advance the cause of patient safety.

Q: What should HM’s patient-safety agenda look like going forward?
Dr. Berwick: No. 1, aim for zero. There are types of injuries and infections that can be nearly eliminated in the hospital. When you look at safety-oriented efforts in other industries, they strive to get to the point where they’re no longer talking about ratios, only numerators (how many actual incidents).

Second is to broaden the focus from safety to all the other dimensions of quality. Think about reliability, processes and performance across the board.

Third is to be authentic about teamwork across professions. In the medical culture at large, there still is too much focus on turf issues between doctors and nurses. I believe in the long run new safety initiatives will be fostered by teams working at unprecedented levels of collaboration, reaching across traditional boundaries.

Dr. Cassel: The issue of diagnostic error is also emerging as another kind of medical error.

In order for patients to get the right treatment, they need to get the right diagnosis. That’s where all of your medical training, knowledge, and judgment come into play. For ABIM, that’s how we evaluate physicians’ judgment.

To hear more of what HM leaders think about patient-safety and QI progress in U.S. hospitals, visit the-hospitalist.org and click on the audio buttons.

The next frontier in patient safety is the handoff, from ambulatory to hospital and back, but also with long-term care, which is a black box. An enlightened and energetic hospitalist movement could decide to take that issue on.

Where it would happen is at the community level, although some of the healthcare reform legislation includes ideas about innovation zones and how to create payment mechanisms to support continuity of care. TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

  1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
  2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press, 2001.
  3. Moser R. Diseases of Medical Progress: A Contemporary Analysis of Illnesses Produced by Drugs and Other Therapeutic Procedures. Springfield, Ill.: Charles C. Thomas, 1959.
  4. Reason, J. Human Error. Cambridge, England: Cambridge University Press, 1990.
  5. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
  6. United Kingdom Department of Health. An Organisation with a Memory. 2000.
  7. Jerrard J. No fee for errors. The Hospitalist. 2008;(5):18.
  8. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-221.

The Evolution of Patient Safety

Key milestones in the patient-safety and medical QI movement:

200 B.C. - Hippocrates, the Greek scholar and father of modern medicine, promulgates the concept primum non nocere, which translates to “first, do no harm.”

1910 - Ernest Codman, a Boston surgeon who loses his privileges at Massachusetts General Hospital for pushing his end-results system (known today as medical outcomes), establishes the “End Result Hospital” and helps found the American College of Surgeons’ Hospital Standardization Program. This program evolves into the Joint Commission.

1959 - Diseases of Medical Progress by Robert Moser argues that iatrogenic disease is both common and preventable.2

1980s-1990s - Various medical errors result in high-profile patient deaths, including that of Libby Zion at New York Hospital in 1984 and Betsy Lehman at the Dana-Farber Cancer Institute in Boston in 1994. The deaths keep medical errors in the headlines.

1985 - The Anesthesia Patient Safety Foundation is established; anesthesiology is the first specialty to dedicate resources to preventing medical error.

1990 - James Reason’s Human Error describes his theory of error as systems failure.3 It is undiscovered by healthcare until …

1994 -Lucien Leape’s article “Error in Medicine” is published in the Journal of the American Medical Association, drawing upon advances in error prevention from fields other than medicine.4

1999- The Institute of Medicine releases its landmark patient safety report, To Err Is Human.

2000 - The National Health Service in the United Kingdom releases another major medical safety report, An Organisation with a Memory.5

2001 - Congress establishes the Agency for Healthcare Research and Quality (AHRQ) to begin an aggressive patient-safety research and improvement program.

2001 - IOM releases a follow-up safety and quality report, Crossing the Quality Chasm.2

2002 - The Joint Commission releases its first National Patient Safety Goals.

2004 - The federal government creates the Office of the National Coordinator for Healthcare Information Technology to promote systems improvements in the medical industry.

2005 - The Institute for Healthcare Improvement’s 100,000 Lives campaign begins; it encourages hospitals to adopt basic steps to reduce harm and deaths.

2006 - The National Quality Forum issues its list of “never events,” 28 medical errors that should never occur in hospitals.6

2007 - Medical checklist research spearheaded by Peter Pronovost, MD, of Johns Hopkins University, including a patient- safety project involving all ICUs in the state of Michigan, is highlighted in a widely noted New Yorker profile and elsewhere.

2009 - The American Recovery and Reinvestment Act passes Congress and is signed by President Obama. It contains $19 billion for advancing healthcare information technology.

Source: Adapted from Wachter, R. Understanding Patient Safety (Lang Clinical Medicine), McGraw-Hill: 2007, Appendix III, Selected Milestones in the Field of Patient Safety, p. 280-281, which was adapted from sources including Vincent C. Patient Safety. London; Elsevier, 2006; and Sharpe VA, Faden AI. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic illness. New York: Cambridge University Press, 1998.

Image Sources: DNY59, ZEFFSS1, AYZEK, DON BAYLEY, BECKY REED/ISTOCKPHOTO.COM

 

HM Leaders Weigh In

Question 1: What was hospital medicine’s contribution and role in the patient-safety movement that ensued following the IOM report?

Time Capsule: Hospitalists Ahead of the Curve

By Larry Beresford

The following are excerpts from the “President’s Column” that appeared in the January 2000 edition of The Hospitalist:

“The problem of medical mistakes presents at once a major opportunity and challenge for hospitalists, both individually and collectively. Hospitalists are well suited for leadership in systems and process improvements within the hospital setting. By being ‘good citizens’ of the hospital, hospitalists have the chance to make lasting improvements in processes of care, thereby reducing medical errors. …

“The challenge for the National Association of Inpatient Physicians [later renamed SHM] is to offer educational programs and other resources for process and quality improvement, so hospitalists have the skills to take back to their institutions to apply toward better quality of care. Skills such as multidisciplinary team building, outcomes measurement, implementation of evidence-based medicine, and identification of root cause were not imparted to most of us during medical training, yet are vitally important to bringing about the kind of systemic change that is required. …

“While attention to the individual patient is of paramount importance, the ability to address broader, systemic problems may be the greatest legacy of hospitalists.”

— Winfield F. Whitcomb, MD, and John R. Nelson, MD

Mark Williams, MD, FHM

“I believe that hospitalists have been integral to improving patient safety and reducing medical errors in those hospitals. Patients are safer and better off if there is a physician in the house ready to respond should patients have a change in health status. Hospitalists see the hospital as their office, if you will, and they focus not only on treating the patient in the bed, but treating the hospital itself by becoming engaged with quality improvement and patient-safety initiatives that improve the system of care.”—Mark Williams, MD, FHM, chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago; SHM past president; editor of the Journal of Hospital Medicine

Winfield Whitcomb, MD, FHM

“The role hospital medicine has filled has been as a major supplier of physicians to quality-improvement teams and other hospital teams at the front lines, prior to which physicians were conspicuously absent. If you look, for example, at nurses and other healthcare professionals, they came to the party much earlier than we did. Physicians have only recently on a broad scale become involved on these teams, and I think the major contributors have been hospitalists.”—Winthrop Whitcomb, MD, FHM, director of performance improvement, Mercy Medical Center, Springfield, Mass.; SHM co-founder

Russ Cucina, MD

“There was a tremendous kind of synergy where hospital medicine was defining itself by its focus on systems of care, safety culture, error reporting, collaboration, interdisciplinary teams and so forth. The IOM report did a beautiful job of taking the knowledge and literature, not just from within medicine but more importantly from outside, and showing how a lot of those concepts that had been implemented successfully elsewhere were lacking in medicine in general. That really just teed it up for hospital medicine to take the impetus and framework IOM supplied and use it as a rubric for what hospital medicine could do for its part of the health system.”—Russ Cucina, MD, assistant professor of medicine and associate medical director for information technology, University of California at San Francisco

Question 2: What is the most important unfinished business for hospitalists regarding the patient-safety movement?

“I think we have made tremendous strides but there is much more to do. Although we have pockets of success, what we need to do is make those successes more uniform, so they happen in every hospital, not just some hospitals that have the right hospitalist leader or the right skill set or the right culture. We want to create the right culture and skill set and team in every hospital, and one of our challenges at SHM is to work on a mentoring program for hospitalists. That means using those who have been successful to mentor other sites and bring them on board to reproduce and replicate the good work.”—Janet Nagamine, MD, FHM, hospitalist, Kaiser Permanente Medical Center, Santa Clara, Calif.; SHM Hospital Quality/Patient Safety Committee chairwoman

Scott Flanders, MD, FHM

“The patients who enter hospitals today are incredibly sick, with multiple organ failures and other complications. Taking care of these patients is incredibly challenging, and there are always going to be things that do not go well. Hospitalists have begun to uncover and tackle a lot of these problems, but even as they eliminate one problem, new treatments, devices, procedures and strategies for caring for patients—all designed to improve care—may have unintended consequences. It is hospitalists’ job to try to mitigate those consequences and redesign the strategies to continue to improve outcomes. But this is a long road—a marathon, not a sprint.”—Scott Flanders, MD, FHM, director of the hospitalist division, University of Michigan Health System, Ann Arbor; president of SHM

Vineet Arora, MD, MA, FHM

“The greatest area of unfinished business I see is preserving continuity of care for our patients as they transition in and out of the hospital. So much is happening, and there is a great need to get information quickly and communicate between the inpatient and community-based practitioner. I should say we’ve come a long way, but there’s a lot more to do in this area, and that’s why six medical societies, including SHM, came together to produce the recent Transitions of Care Consensus Statement, acknowledging that this is a crucial part of patient safety and describing what are effective transitions of care in and out of the hospital.”—Vineet Arora, MD, MA, FHM, assistant professor, Department of Medicine, University of Chicago

—LB

Campaign to Rid Hospitals of Errors

By Larry Beresford

The Cambridge, Mass.-based Institute for Healthcare Improvement and its partners developed the 100,000 Lives Campaign in 2005 to encourage hospitals and healthcare providers to eliminate preventable medical mistakes. The campaign goal expanded to 5 million lives in 2006, but still recommends the following steps:

  • Deploy Rapid Response Teams (RRTs) … at the first sign of patient decline;
  • Deliver reliable, evidence-based care for acute myocardial infarction … to prevent deaths from heart attack; 
  • Prevent adverse drug events (ADEs) … by implementing medication reconciliation protocols;
  • Prevent central-line infections … by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle”;
  • Prevent surgical-site infections … by reliably delivering the correct perioperative antibiotics at the proper time; and
  • Prevent ventilator-associated pneumonia … by implementing a series of interdependent, scientifically grounded steps including the “Ventilator Bundle.”

When reliably implemented, these interventions greatly reduce morbidity and mortality. For more information, visit www.ihi.org/IHI/Programs/Campaign.


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