“Eventually we will all have our health information stored electronically for easy retrieval,” says Rodney W. Hicks, PhD, ARNP, manager, patient safety research and practice for the USP and first author on its most recent report. The beginning of regional networks for EMR is taking hold.
“Even before the IOM report, the USP was familiar with intensivists,” says Dr. Hicks. “We recognize hospitalists as experts who bring efficiency and effectiveness to the healthcare system.”
The USP maintains perhaps the largest database of medication errors in the world.1 Each year the USP issues a report that focuses on one topic and builds its knowledge base.
This year’s report focuses exclusively on the perioperative continuum of care. Last year’s covered ICU- and radiology-related errors. Two years ago the report was a five-year data summary of errors occurring primarily in hospitals.
“The area of errors due to breakdowns in handoffs remains a huge problem for diagnosis and the continuity of care,” says Shawn C. Becker, MS, BSN, RN, director of patient safety initiatives for the USP.
In general, errors are divided into those that stem from individual factors and those that are system-related, which include environmental and organizational factors.
Environmental risks are often related to human factors. Dr. Nagamine offers an aviation analogy to demonstrate the many pulls on caregivers’ attention.
“What happens in a cockpit at take off is that you are not allowed to talk about anything other than the take-off checklist,” she says. “In medicine, we have nurses’ stations or medication carts in the middle of the hallway, so nurses are preparing meds and people are tugging on their shoulder and interrupting them during a critical task.”
Organizational factors involve culture and priorities. If your organization says it values quality and safety but doesn’t put in place policies and processes to support it, that affects diagnostics and error-free performance.
“The discussion about quality is driven by medical error,” says Evan Falchuk, president of Best Doctors Inc., based in Boston. “But the issue is more interesting than simply looking for mistakes.”
Best Doctors partners with employers and health plans to help members with serious illnesses make sure they have the right diagnosis and treatment. Members can consult with specialists who assess diagnoses and can recommend treatment. The firm believes this is the best way to measure quality, and consumers around the world increasingly agree: The company serves more than 10 million people in 30 countries.
Best Doctors was founded in 1989 by two internists: Falchuk’s father, Kenneth H. Falchuk, MD, a professor of medicine at Harvard University Medical School, and Jose Halperin, MD, an associate professor of medicine at Harvard. The service they created is one in which doctors review a patient’s medical information, identify the important issues, and consult with leading experts from their peer-reviewed database. The company then has clinicians work with the patient and his or her doctor to ensure that the patient is getting appropriate care. The process has identified incorrect diagnosis or treatment in more than half of reviewed cases.