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About this book Advances in Patient Safety: From Research to Implementation Volume 1. Research Findings Sections and articles in Advances in Patient Safety volume 1: Five Years LaterAre We Any Safer? Can We Talk? Priorities for Patient Care Differed Among Health Care Providers Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors Do Transient Working Conditions Trigger Medical Errors? Organizational Climate, Stress, and Error in Primary Care: The MEMO Study Seamless Care: Safe Patient Transitions from Hospital to Home Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician's Office Quantitative and Qualitative Analysis of Medication Errors: The New York Experience Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System Prescribing Safety in Ambulatory Care: Physician Perspectives Impact of Pharmacy-led Dyslipidemia Interventions on Medication Safety and Therapeutic Failure in Patients Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM Code Classifications Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event Hospitalizations A Study of Adverse Occurrences and Major Functional Impairment Following Surgery Measuring Safety: A New Perspective on Outcomes of a Long-term Intensive Case Management Program The Impact of a Patient Safety Program on Medical Error Reporting Making Information Technology a Team Player in Safety: The Case of Infusion Devices Post-fielding Surveillance of a Guideline-based Decision Support System The Role of Patient Safety in the Device Purchasing Process Learning from Errors in Ambulatory Pediatrics Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings Comparing Patient Safety in Rural Hospitals by Bed Count Regulation of Health Policy: Patient Safety and the States What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare Financial and Demographic Influences on Medicare Patient Safety Events Peer ReviewersVolume 1

Advances in Patient Safety: From Research to Implementation Advances in Patient Safety: From Research to Implementation Volume 1. Research Findings

Five Years LaterAre We Any Safer?

Brent C. James

The Institute of Medicine (IOM) released To Err Is Human: Building a Safer Health System, ¹ its seminal summary of preventable patient injuries suffered within American hospitals, on November 29, 1999. This report was unique in one important way: it was the first IOM report directed as much to the general American public as at the U.S. government, the health care industry, members of the healing professions, and health policy experts. While evidence documenting high rates of treatment-associated injury and mortality have appeared in the peer-reviewed medical literature since the 1950s, neither the health professions nor the health care industry have ever prioritized patient safety as a critical imperative. The IOM's Committee on the Quality of Health Care in America, which produced To Err Is Human, soughtthrough its new public relations directionto force patient safety to the pinnacle of the policy and care delivery improvement agendas. The committee set a goal of reducing fatalities associated with hospital-based care delivery by 50 percent within 5 years.

Five years have passed. A few institutions have reached the initial IOM goal for some injury sources (for example, Brigham & Women's Hospital in Boston for adverse drug events [ADEs]; Intermountain Health Care's LDS Hospital in Salt Lake City for ADEs and for postoperative wound infections; and Johns Hopkins University Hospital in Baltimore and Vanderbilt Hospital in Nashville for central venous catheter-associated infections). However, as a country, progress has fallen far short of the IOM's ambitious goal. Some members of the original IOM committee have publicly decried the lack of substantial progress, ^{2, 3} citing a continuing inability by the United States to hold patient safety at the center of a national health care reform agenda. For example, even though more than 30 percent of a random sample of physicians responding to a survey reported that they or a member of their immediate family had experienced significant injuries when receiving care, physicians still see patient safety as a low priority. ⁴

Donald M. Berwick summarized efforts to improve patient safety in terms of will, ideas, and execution. ⁵ He focused on the execution of patient safety efforts, and catalogued four major barriers at that level:

Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality (AHRQ), has put forward a much more positive view. ³ She points to growing interest in patient safety within the healing professions and health care delivery organizations, representing the will to change. The contents of this volume, summarizing AHRQ- and other government-sponsored patient safety research over the past 5 years, demonstrates solid, broad, and rapid progress in the other key element upon which successful execution will rest: ideas. Here you will find every dimension of safe patient care delivery, ranging from state-of-the-art detection and tracking systems (concurrent and retrospective clinical trigger systems), to successful interventions that addressed specific, single injury sources (e.g., adverse drug events), to organizational structures (e.g., building a culture of safety; nursing roles; teamwork), to safety features within and among care delivery locales (e.g., rural versus urban care; ambulatory versus inpatient care; patient transitions), to core theory (e.g., human factors; cognitive factors; work load; transitory work assignments), to the role of technology (decision-support systems for safe care; methods to safely deploy new technologies), to the role of national and State-level policy.

We all hold the future of patient safety in our hands. The problems are urgent, yet the pursuit is lifelong. Indeed, it is difficult to overemphasize the complexity of the problem, given the fragmented nature of health care in the United States. We are learning that safety is an emergent property of systems, not a problem that can be easily and uniformly reduced by a certain percentage in a fixed period of time. While impressive in its own right, the contents of the present volume is but a down paymentthe first few steps of a lifelong journeyfor new levels of understanding and effective execution. Building on this foundation, the next 5 years should be even more challenging and productive than the past 5 years have been.

References

1. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.

2. Berwick DM. Invisible injuries. (Op-ed column) The Washington Post 2003 July 29; p. A17.

3. Morrissey J. Patient safety proves elusive. Mod Healthc 2004 Nov 1;pp. 6 7, 24 5, 30, 32.

4. Blendon RJ. Views of practicing physicians and the public on medical errors. NEJM 2002;347(24):1,933 40.

5. Berwick DM. Errors today and errors tomorrow. NEJM 2003;348(25):2,570 2.