This is part one of a series of National Audio Teleconferences sponsored by the User Liaison Program, Agency for Healthcare Research and Quality, conducted on May 18, 2000.
CINDY DIBIASI: Good afternoon and welcome. My name is Cindy DiBiasi, and I'll be your moderator for today's session.
This the first call of this User Liaison Program teleconference series on medical errors. Today's call will address the issue of "How Safe Is Our Healthcare System? Understanding Medical Error." We'll be examining the nature and severity of medical errors, their causes, and consequences for healthcare quality and costs.
On May 24th, we'll address "How States Can Improve Patient Safety And Reduce Errors." This session will give us insight to the State's initiatives to reduce errors.
Our final teleconference on June 5th will cover "A Systems Approach To Improving Safety: Translating Lessons From The Aviation Industry." In this session, we'll talk about a conceptual framework and systems approach for addressing issues of patient safety. We'll also hear from Dr. John Eisenberg, Director of AHRQ, who will tell us what initiatives the Federal Government is proposing.
We hope you can join us for all of these sessions.
Today, we're going to take a closer look at medical errors—the definition, the prevalence of the problem, its causes, what we can do about them, and why States should be concerned.
Last December, the Institute of Medicine (IOM) released a landmark report and recommendations on the prevalence and challenges of medical errors. The report has captured the public's attention and it was going to be summarized in our call today.
We have a panel of two experts—Janet Corrigan is the Director of the Division of Healthcare Services and Director of The Quality of Healthcare In America Project at the Institute of Medicine. Janet led the committee that wrote the IOM report.
Hi Janet.
JANET CORRIGAN, DIRECTOR OF THE DIVISION OF HEALTHCARE SERVICES AND DIRECTOR OF THE QUALITY OF HEALTHCARE IN AMERICA PROJECT: Hello. Good afternoon.
DIBIASI: And we also have Dr. Lucien Leape. Lucien is an adjunct professor of Health Policy Management in the Harvard School of Public Health. He's studied extensively the prevalence and causes of medical error.
LUCIEN LEAPE, ADJUNCT PROFESSOR OF HEALTH POLICY MANAGEMENT, HARVARD SCHOOL OF PUBLIC HEALTH: Good afternoon.
DIBIASI: Yes, hi. I was just—now before we begin our discussion, I have a few housekeeping items to take care of. And later in the call, our experts will be taking your questions.
There are three ways you can communicate your questions to us today. You could ask your question over the air by pressing the number one key on your keypad to ask the question. And press the pound sign to remove yourself from the queue. Or you can fax us your questions. The fax number is 301-594-0380. You may also E-mail us your questions at info@ahrq.gov. Let me give you that E-mail address again, it's info@ahrq.gov.
If you prefer not to use your name, that's fine. But we'd like to know from what department or organization you're calling. So please indicate that in your E-mail or fax.
We're going to have tapes of this teleconference available for purchase after the series is completed. And I'll give you further details about this at the end of today's show.
But now I think we're ready to turn to the important matter of discussing medical errors.
And Lucien, I'd like to start with you. Your extensive study in this area brought the issue to the forefront of the Public Policy Agenda. You've been studying medical errors for many years. So let's start with some of the basics. First, what is a medical error and can you give some examples of them.
LEAPE: Sure. Well, an error is when you do the wrong thing. People have spent a lot of time giving fancy definitions but I think we all know what it means when we've made a mistake—failure of action or a failure of our thinking.
And in medicine, we see the whole gamut. Technical errors, which a surgeon makes and damages a organ or fails to tie off a blood vessel, or that sort of thing. Slips when a physician writes ten and means—when he really means to write one or when a nurse picks up a medication and reads the vial incorrectly and gives the wrong dose or gives it to the wrong patient. When somebody misreads an x-ray or they fail to get a test. All the kinds of things that can happen.
Some of them are amazingly simple and others are more complicated. But none of them are intentional. Nobody makes an error on purpose. But medicine's so complicated that the opportunities for making errors everyday are literally in the hundreds.
DIBIASI: Are they increasing? Do we know whether or not they're increasing?
LEAPE: We really don't know. We don't have any respectable measure of errors. It's a very difficult thing to do and to do it in any comprehensive way would be quite a challenge. So I don't think we really know. And therefore, we don't have any reason to think that things are any worse or better than they were, say 10 years ago.
DIBIASI: So you're saying there are potentially hundreds of errors each day. Is that right?
LEAPE: Well, every action or every step you take in the course of treating patients, whether you're a nurse or a doctor, or pharmacist, or whatever. Every—each one is an opportunity to make a mistake. And you do a surgical operation, you have hundreds of maneuvers. So in a sense, each of those are possibilities. That doesn't—I think what's impressive is that we make so few.
DIBIASI: What are the most common errors that are made based on your research?
LEAPE: Well, there really isn't—there isn't just sort of one area which is a particular problem. I mean it's the kind of thing that's throughout. I mean people make errors in diagnosis, obviously. They make errors in administering the treatments. Failure to—one of the common things is just failing to get information that you need. Forgetting or not following up on a test, and that kind of thing. But there's incredible range.
DIBIASI: OK. And have you found that the errors are usually the faults of individuals? Or is it a broader system's failure?
LEAPE: Well, I think that there have been a lot of study of errors in the last 50 years. Much of it outside of medicine. And the common theme is that errors are by definition, human errors. But the person involved, as I said, never makes an error on purpose.
And so the question is why do they make mistakes? And there's been a lot of study of that. And the bottom line is that people make mistakes because they are in doing jobs, doing—carrying out responsibilities that are not properly designed. You are, in effect, sort of set up to make a mistake. For example, two medications that have names that sound alike—Celebrex and Cerabix, for example. Now that's an error waiting to happen.
Handwriting prescriptions. Everybody makes a joke about that. But the fact of the matter is that a certain percentage of the time, physicians will make an error when they write a prescription. Just like you and I will write 1999 on a check in January, when it's 2000. And you can predict that a certain number of those kinds of mistakes will be made.
So that the industries that have been successful at reducing errors have focused not on individual performance but on the design of their work. And they pay attention to how the work is designed and how you can make it, in effect, hard to make a mistake and easy to do it right.
DIBIASI: Now medical errors, obviously, have been a—around for a long time. It's not like doctor and healthcare providers are just starting to make mistakes. But why all of sudden has it become such a hot issue?
LEAPE: Well, I think there are two reasons. One is that a few years back, we had a series of celebrated cases—really major tragedies that got public attention. And at about the same time, information became available in healthcare about this different way of looking at errors.
We have traditionally put all of our emphasis on individual performance. We've said the way you keep people from making mistakes is to try to train them very highly and then insist that they don't make mistakes and punish them when they do. And that just hasn't worked.
And what's happened is we have, if you will, awakened up to the fact that safe industries have looked at this systems approach. And when these accidents and serious situations developed a few years ago, people began to look at what we could do and found well, here is a better way. This is something that's much more likely to be successful. Is to —medicine took this information and published this report last fall. And that suddenly got people's attention and recognition that there's a serious problem. But also the clear delineation of what we can do to do something about it. So for the first time we had recommendations about what changes that need to be made. And I think that's gotten movement really going.
DIBIASI: We're going to go to Janet in just one minute about the IOM study. But first, just to put it in some perspective, what are the implications of these medical errors? And how important are they? And should this be a major concern to the public?
LEAPE: Well, I think the question's important. I mean, we estimate that over a million people a year have an injury of some sort. And maybe as many as 100,000 of those result in a death. So it's clearly a serious problem.
On the other hand, the risk in the individual is not very great. I think we all are concerned. I think, on the other hand, safety is now on the agenda. And healthcare is going—I'm absolutely convinced healthcare's going to get much safer over the next few years as people begin to focus on it. So I'm very optimistic about the potential in the near future.
DIBIASI: Well, good. Let me get back to you in just a minute. But Jan, you directed and staffed the Medical Errors Study Committee for the Institute of Medicine. Why did IOM conduct that study?
CORRIGAN: Well, I think it's important to put it in a little bit in a broader context. Over the last 3 or 4 years, there have been really two major efforts to try to draw attention to the quality of care shortcomings in the healthcare system. One of them was an earlier effort by IOM, a national round table on quality. And the second was the Advisory Commission On Consumer Protection And Quality that was co-chaired by Secretary Schalala and Secretary Herman.
Both of those groups were made up of the best and the brightest experts in the area of quality and healthcare delivery and medicine from around the country. And they both reached very similar conclusions when they released their reports almost 2 years ago—that we have a very wide quality gap. The kind of healthcare that people should be receiving, given the current state of medical knowledge and technology, is unfortunately not what many people experience when they go into the healthcare system.
So the Quality of Healthcare In America Project—which is the project that I direct—was set up about a year and a half ago by IOM. And the purpose of that project—its objective, is to lay out a plan to try to produce a threshold improvement in quality over the next 10 years. So we think incremental efforts are not enough. We need to take a big step here in order to really improve healthcare quality in a major way.
And the Committee is chaired by William Richardson, whose the President and CEO of the WK Kellogg Foundation and just has a tremendous group of people and expertise around the table like Lucien Leape and Don Berwick and others. And that group decided that medical errors was a very good starting point for several reasons and in part—because as Lucien just said, there is a great deal of evidence out there, a strong evidence base to support the seriousness of the problem.
In fact, we found that there were, in looking at the literature over the last 10 years, about 30 articles in leading peer review journals all pointing in the same direction—that we have a serious medical errors problem.
But there are a couple of other reasons. Errors are the kind of thing that I think everybody agrees—they just shouldn't happen. They're understandable to both the lay public and to providers. And there's a strong sense that we should be doing better in this area.
And in addition to that, there's a good deal of knowledge and technology available to do something about the problem. And much of that has been applied successfully in other industries. It'll have to be adapted for healthcare. But there are interventions that are readily available and can be put in place to try to address the issue.
DIBIASI: And Jan, let's talk about some of the key points that the IOM report made.
CORRIGAN: OK. Well, I think one of the points that the IOM report really tried to make was that this is an issue where it has really been surrounded by silence for a very long time. As Lucien noted, we've known about the errors issue for 10 years or more with the work that he published about 10-12 years ago—landmark contribution to the field.
And for a variety of reasons, a lot hasn't happened during that time. So what the IOM report tried to do was to put out a strong call that we really need to make this a national priority. And we need to involve many different stakeholders and constituencies in trying to improve the situation if we're going to be successful. And we think we can be.
There's a four-point strategy that the IOM Committee laid out in its report. The first is that we need a National Center For Patient Safety and that should be housed within AHRQ, the Agency for Healthcare Research and Quality.
And that center needs to provide leadership, very strong leadership in this area. They need to keep national attention focused on the patient safety issue. And they should have sizeable funds available to them. Our committee recommended upwards of $25-30 million a year starting out, and moving on up to $100 million a year to conduct applied research and provide technical assistance, build prototypes systems that could be readily used by many healthcare institutions and provider groups.
The second part of the four-point strategy was for reporting systems. It's hard to fix what you don't know about. So we really think we need to have better error reporting systems. And more specifically, there's a sense that we need two types of error reporting systems.
We need voluntary systems that focus on errors that are what they call "near misses"—they didn't produce any harm, or they produced only very minimal harm. And that kind of information can really be extremely useful for quality improvement purposes. And our committee recommended that Congress extend peer review protections to voluntary reporting systems for errors that result in minimal or no harm.
But we also think it's absolutely critical to have mandatory error reporting systems, and that those systems should focus on a very narrow band of reporting—a narrow band of errors—only those that resulted in death or serious, permanent injuries. And in that instance, those really should be put in place by States. But it was strongly recommended that there be some uniformity and standardization of the type of information that would be reported into those systems so we can all learn from each other.
And on the third part of the strategy is that purchasers or creditors, licensers, professional associations and groups, that all of those areas of constituencies put much greater emphasis on patient safety, whether it's—if you're a group purchaser, it's in your contracting arrangements and purchasing decisions. If you're a creditor or a licenser, then you need to be beefing up your standards that apply to the development of internal patient safety systems within hospitals and other healthcare organizations.
And then last, the fourth part of the strategy, is that our healthcare institutions, in particular, hospitals need to really create a better culture that encourages improvements in safety and really make a commitment from the board of directors and the CEO, all the way down through the organization, to investing appropriately to have safer systems.
DIBIASI: Now, you were talking a little bit about the States' role in terms of the mandatory error report and also the role of purchasers and what they can do. But what do you think States' major role would be regarding patient safety?
CORRIGAN: Well, States wear multiple hats, I think. As a regulator, States have a responsibility to maintain certain minimum standards and protect the public, and also keep the public informed. So in that sense, States can do several things. First and foremost, we think it's important that States, if they don't already have one, put in place a mandatory error reporting system for those most egregious errors that result in death or very serious harm.
And the purpose of that system isn't to be punitive to organizations because such an error was made, but rather to respond by making sure that healthcare organizations—once the serious error has occurred, that they take appropriate action—that they put in place those internal safety systems so that it doesn't happen again. And that's one of the very important roles that they play.
But in addition to that, I mean, States are also purchasers of healthcare services, whether it's the State government on behalf of its own employees, or it's the State Medicaid program. And purchasers can provide positive incentives and encouragement to healthcare institutions, plans, hospitals, and others that they contract with to make sure that they're taking steps to improve patient safety.
DIBIASI: Well, Lucien, let me ask you like a lot of reports always debate about the methodology that's been used and basis of the findings. What are the criticisms then and how would you respond to them regarding the IOM findings?
LEAPE: Well, I think the major concern has been these numbers. You know 98,000 just sounds like a large number of people and it is. And it's kind of interesting because those numbers have been out there for 9 years. But they're now—now that they've got public attention, I think people are beginning to take them more seriously.
And I think doctors in particular find that very hard to except. Most physicians feel very personally responsible for any mistakes. That's the way we're trained. And I — you know, that's good. But the bad side of that is not recognizing that it isn't all your fault and that there are many other things that need to be done. We've put all our eggs in the individual training basket, as I mentioned before.
But people had trouble with those numbers. They really don't want to believe them. And so they've attacked them and said that they're exaggerated, particularly the deaths. One of the things people say is, "Well, many of these people would have died anyway." Turns out that's really not true.
In the medical practice study, which is the study I was involved in and that we — and that generated the big numbers, very few of the deaths were people who were going to die anyway. These were—these were the result of problems in management.
But beyond that, the—even if you discount these numbers some, I think you have to say, "Wait a minute, this is a study that's based on review of medical records." Anybody that works in a hospital and—most of us—most people who even don't work in a hospital can understand, but there's an awful lot that happens that never makes its way in the medical record.
Any time people have done detailed studies in which they make observations or get data any other way, they find many more events than are recorded in the medical record. So anything based on a medical record, we know is probably only capturing half of the events.
And in addition, of course, the studies were focused entirely on injuries in hospitals. Well, as we know, more than half of the errors takes place outside of hospitals—more than half of surgery takes place outside of hospitals now.
We have no measurement of problems in the ambulatory sector—probably not as bad as in hospitals, because people in hospitals are sicker and have more complicated treatment. But who would ever suggest that we make no mistakes in our offices and in our clinics?
So I think any way you look at it, the numbers are, if anything, an underestimate. They're certainly bad enough. We don't need to make them worse. But we don't believe that they're misrepresenting—and the Institute of Medicine doesn't either, for some additional reasons that Janet's already mentioned. It wasn't the Institute of Medicine's conclusion that this was a serious problem—wasn't just based on one or two studies. It was based on a review of an extensive amount of literature over the last 20 or 30 years.
So I think the numbers are pretty solid, and we should move ahead and try to do something about it and not worry about the numbers themselves.
DIBIASI: OK. We're going to get to the audience questions in just a minute. We're going to open the lines up. But before we do that, recall that you can ask your question over the air by pressing the one key on your keypad to ask a question, and press the pound key if your question's already been asked and you want to remove yourself from the queue. You may also send us questions via fax at 301-594-0380. Or you can E-mail us at info@ahrq.gov.
Before going to the questions, however, I want to say a few words about AHRQ and the User Liaison Program.
The mission of AHRQ is to develop and disseminate research-based information that will help clinicians and other healthcare stakeholders make decisions to improve healthcare quality and promote efficiency in the way that healthcare is delivered.
The ULP program serves as a bridge between researchers and State and local policymakers. We not only take research information to policymakers for their better reforms, we take the policymakers' questions back to researchers so they're aware of the priorities. And hundreds of State and local officials participate in ULP workshops each year.
As a new addition to the ULP portfolio products, we hope that today's call and the other calls in this audio teleconference series will provide a forum for discussion between our audience of policymakers and researchers, like those joining me for our discussion today.
So we'd appreciate any feedback you have on these teleconferences. Please E-mail your comments to the AHRQ User Liaison Program at info@ahrq.gov.
And our first question is from Jerry from the MCH Bureau. Hello, Jerry.
JERRY HOOD, MCH BUREAU: Hello. I am with the Maternal and Child Health Bureau, and we are obviously interested in children's health issues. I wondered if there are any estimates among these numbers of the number of proportion of children that are affected?
LEAPE: There really aren't. We've been asked that question before. The medical practice study in New York looked at the entire population, but the number of children that were represented was too small to come to any conclusions as to whether the hazard is greater or less in pediatrics.
And I'm a pediatric surgeon, by the way, and spent 25 years taking care of children. And one would think maybe the risk is higher because, of course, the variation is so much greater. The dose of medication—the same medicine has different doses for different size children, and so there are more opportunities for errors. But I don't think we have any facts on that. I'm not aware of a good study that shows that it's either better or worse.
HOOD: OK. Thank you.
DIBIASI: OK. Here's a question from Jean Stewart from the Texas Department of Health. And the question is: A system established to report data on agreed-upon critical indicators needs to be as non-punitive as possible to encourage complete and accurate reporting. How will oversights, including onsite State agency surveys be handled so as not to discourage complete and accurate reporting?
CORRIGAN: Well, I'll take a shot at that. The recommendations from the IOM Committee are for two types of reporting systems. As I said earlier, one of those would be for the incidents that resulted—errors that resulted in very serious harm, death, or permanent injury that's very serious.
Those are the kinds of errors that it's hard to hide. Usually there's more than one individual who knows about them when they happen. There are also, I would point out, the kinds of errors that is very clear in the AMA's Code of Ethics that there's a responsibility to immediately inform the patient or their family that the error has occurred.
So we think that, in those particular instances, that the issue of possible underreporting as a result of a mandatory system, has perhaps been blown out of proportion—that in those instances, one can require reporting and have responsibly good compliance with it.
In the case of voluntary reporting, which is really for the vast majority of errors, mainly those that don't result in serious harm; in those instances, we think that you need to have those peer review protections extended to the voluntary reporting systems so that there is absolutely no concern on the part of individual providers or others who might choose to raise something to that particular system—to the awareness of that system. They should feel that there's no concern about potential liability issues because it would be protected.
DIBIASI: Janet, let me ask you, what has happened since the report was issued?
CORRIGAN: Well, the response has been just phenomenal. It's far exceeded any of our expectations, I think. We were really pleased to find out that 51 percent of the American public, apparently, closely followed this issue and the news coverage of it during the month of December. And that came from an opinion poll conducted by the Kaiser Family Foundation at the end of the year.
And that's just really encouraging, just in terms of overall public awareness and the likelihood that this issue is going to continue to get a good deal of attention. It's something we're going to have to respond to—it isn't go away.
But several other actions have been taken. Almost immediately after the report was released, the President issued a directive to the Quality Interagency Coordination Task Force, which is the group that represents the various Federal programs involved in healthcare when it comes to quality. And he asked them to evaluate the IOM recommendations and come back with a plan for taking action, for implementing the recommendations that they felt that were appropriate within Federal programs.
And the QuIC came back with that plan, as it's called, the Quality Interagency Coordination Task Force. And the President endorsed it. And now we're seeing really a lot of initiatives being taken within the Agency for Healthcare Research and Quality, within HCFA, Medicare, and Medicaid, and the VA, and the Department of Defense, and the Federal Employees Health Benefits Program.
And I think some of your future speakers in this series will be talking to that—Dr. John Eisenberg, really is the acting chair of that group, and is providing a tremendous amount of leadership in this area.
The other thing, though, that started to happen almost immediately upon the report's release were Congressional hearings. And we've now had a series of hearings that have taken place both in the Senate and in the House. And there are numerous bills that have been drafted and are subject to debate.
And hopefully, we'll begin to see some legislation coming, because we do need some legislation for appropriations and creation of that Center for Patient Safety and to make sure that we have adequate dollars for the kind of applied research that's needed. But also to extend those peer review protections to the voluntary reporting systems, among other things.
Lastly, we've seen actions taken by private business. There's a group called the Leapfrog Group, which represents quite a few of the large Fortune 500 companies. And that is a group that has decided that patient safety is going to be one of their top three priorities for the coming years. And I think healthcare organizations can expect to see a variety of provisions and incentives built into contractual arrangements with insurers.
DIBIASI: Let's go to the phones. We have Sandra from the State of Colorado's Division of Workman's Comp. Hello?
ED, STATE OF COLORADO DIVISION OF WORKMAN'S COMP: Yes, this is actually Ed from the same division.
DIBIASI: OK.
ED: Question on—I'm not still sure what constitutes an error. Let me give you an example of something and you can tell me if it is the kind of error that you have in mind. It's become appreciated recently that the old advice is never to give analgesics to people with an acute abdomen is probably bad advice. So if someone is still following that advice and withholding analgesics from an acute abdomen, is that an error or is that just bad practice or what?
LEAPE: That's an important question, because what you're talking about is, if you will, the gray area that—what is the boundary between accepted practice and clinical judgment. And by definition, it's not an error unless you knew it was wrong. If you didn't do something and then look back and say, "I shouldn't have done that," or "I failed to do that."
So that's the way we've defined it because then it's quite clear-cut and nobody had any questions about it. Certainly, from a quality of care standpoint, that distinction is spurious because we want to make sure that people get the right treatment either way. It becomes an interesting question, at what point you say, "Wait a minute, it's time for everybody—everybody should know that." In which case, you can say it's an error that they didn't know better. But that gets to be a little bit sophistic.
So we would say it's an error when in retrospect you would agree that you shouldn't have done it that way—it is something you didn't mean to do. If you haven't been taught properly to know to mean the right things, then that's an educational and administrative problem that we need to deal with.
DIBIASI: Cheryl from the National Governor's Association. Hello?
CHERILYN CEPRIANO, NATIONAL GOVERNOR'S ASSOCIATION: Hello?
DIBIASI: Yes, hello.
CEPRIANO: Hi. This is an interesting system. I just was wondering if anyone has done any estimation on what it will cost the States to establish these voluntary-mandatory systems, and what types of—and what kind of results we could hope or expect to see after we do that?
CORRIGAN: Well, I'm not aware of anyone who has attempted to cost it out. However, it is important to note that there are a sizeable number of States that currently have some form of mandatory reporting systems.
And the National Academy for State Health Policy just did a—completed a survey of all 50 States, in terms of what they have in place and are trying to gather more information on how those systems currently operate. So we do have some models out there that can be studied to probably answer some of those questions.
One of the proposed responsibilities or functions of that National Center for Patient Safety, that I mentioned earlier, within AHRQ—that Center needs to provide assistance and support for efforts to evaluate what's currently going on within States so that we learn what we can from them; what works and what doesn't work. And to possibly also to fund some prototype systems and demonstration projects and gather information as we move forward on what the most effective way to set these systems up, and how we can get the greatest impact in terms of improving patient safety.
So there's clearly an evidence base out there and sites to be studied. But those studies and analyses and evaluations have yet to take place.
DIBIASI: OK. Next, John from the Indiana State Department of Public Health. Hello?
SPENCER, GUEST, INDIANA STATE DEPARTMENT OF PUBLIC HEALTH: Spencer. It's actually Spencer, just a guest here.
DIBIASI: OK.
SPENCER: The question was we have 30 articles that point to the serious medical error problem yet—and yet we don't even know if errors are increasing or decreasing and we're impressed that we're making so few. How do we come to the—that justification when we can't do the measurement? And then, how do we measure that peer review didn't—doesn't work already, if we're impressed that we're making so few and we can't measure the problem?
LEAPE: Must be some misunderstanding. I don't think any of us said have said that we're making so few. I think the evidence is all the other way around—that we're making a huge number.
Fortunately, most errors are not harmful. We've done some intensive studies of dosing errors and errors that nurses make in drawing up medicines and giving the patients. And we find that there are quite a few mistakes made but fortunately most of them don't harm patients—just a few of them do.
But because there are so many medicine doses given in a year, the total is quite a bit. For example, at Brigham and Women's Hospital in Boston, a teaching hospital, we estimated that there were 500 serious adverse drug events a year caused by errors. Now, that's against, maybe a half a million or a million doses. So the error rate is low but the actual injury is fairly substantial.
So I don't think there's any question it's a very major problem. What we're finding is that it isn't—it doesn't take much effort on the part of an interested group in a hospital to identify what some of their problems are and then go to work and measure the specific activity that will relate to it.
Let me give you a case in point. There's a lot of problem management of Warfrin, a cuminon, an anticoagulant. There's very good evidence that you'll have much less trouble with patients being underdosed than overdosed, which is another way of saying, having blood clots or having bleeding, which are the complications that occur with anticoagulants.
You have much less of that if you have—if set up a cuminon clinic, in which the dosing is managed by a nurse or a pharmacist on a continuing basis. And the reason for that's pretty simple, and that is when the doctors manage it, things tend to fall between the cracks because they're so busy and they don't get the information and they have trouble getting hold of the patient and one thing and another. So if you just change the system, you can reduce those errors. And all you have to do for measurement there is to just to check your PTTs and your dosing schedule.
So there are a lot of measurements you can do that will improve quality and reduce errors without having to get into the business of measuring every mistake everybody makes, which of course, is hopeless.
DIBIASI: As a follow-up to that, Lucien, you know, you were talking about the problems in hospitals and gave that example. But do you think that there are one or two areas where hospitals and others could start to really address this problem, where we know interventions will work to reduce errors?
LEAPE: Well, yes. Medication errors is the area that's been most widely studied. Now, our original study—looking at the whole spectrum, found that about 20 percent—I think it was 19.4 percent to be exact—of all of the adverse events were related to use of the medication. So it's only a fifth of the problem.
On the other hand, it's the fifth that we know a lot about. And more specifically, the first and—Massachusetts Hospital Association, but now the American Hospital Association, has sent out to all of the hospitals in the United States a list of—I think it's 14 or 16, I forgot the exact number—of best medication practices. These are—these are specific practices that have been shown with good evidence and experience in many places, to really make a difference in reducing medication errors. Every hospital ought to make every possible effort to implement every one of these.
So, improving medication safety is something we know a lot about and hospitals can get to work on tomorrow. We also are learning more about—well, we're going to—let me also say, we know a lot about anesthesia safety, and people have made a lot of progress in that area. And I think we're beginning to learn more and more about how to improve care in emergency rooms.
But if you—if you were just starting out and you want a place to start, get your medication system under control.
DIBIASI: Now, if we know there are several bodies that provide oversight and accreditation for hospitals, why aren't these groups able to prevent medical errors? Are they failing?
LEAPE: Accreditation and oversight bodies have failed. And I think it's fair to say they have failed—I mean, we have a pretty bad situation—for the same reason that doctors and nurses and hospitals have failed. And that is the focus has been entirely on individual performance. And that's got to change.
Boards of Nursing are quick to reprimand or in some cases, remove the license from a nurse if she makes a serious medication error. There are certain States where this is required. If a patient dies because of a medication error, she'll lose her license.
That not only is inappropriate because those errors are almost never due to carelessness, they're due to bad systems. But one has to ask the question, why doesn't the Board of Nursing have as much interest in making sure that their nurses are working in safe conditions?
For example, where are the Boards of Nursing when it comes to setting standards for hours? We've just had a strike in Worcester, in Massachusetts—the nurses refusing to mandatory double shifts. And somebody asked me about that—I said it ought to be against the law to work a double shift. Where are the Boards of Nursing setting the standards for hours? Where are the Boards of Nursing setting the standards for staffing? When a nurse is taking care of three times as many patients as she normally does, of course she's going to make more mistakes.
But if we want to have safety, we need to have the State agencies getting involved in setting standards for safety and making sure the hospitals follow them. That's a very different thing from playing "Gotcha" for individuals who get trapped by bad systems.
So we're talking about a proactive approach, trying to make healthcare safe by making the conditions safe, instead of a reactive approach, which merely settles for punishing somebody who gets caught because they made a mistake that wasn't their fault in the first place.
So I think there's a lot the State agencies can do if they start thinking of it in a proactive fashion instead of punitive reactive fashion.
DIBIASI: (INAUDIBLE)
CORRIGAN: And the thing when it comes to the accredited entities, the Joint Commission, in fairness to them, they did try to take some steps in this direction by setting up a centennial event and reporting system a few years ago.
But one of the conclusions that the IOM Committee reached is that no individual body, whether it's an accreditor or a licenser or a professional society, is likely to have a lot of impact in this area, that what we really need is a much broader-based effort that puts a tremendous amount of pressure on the system to take action.
Because the centennial event reporting system that the Joint Commission attempted to put in place, unfortunately, there were very, very few hospitals that reported to it and submitted any information. Now, there's always the issue and the concern about the liability, and to my knowledge, it doesn't have peer review protections to make sure that that voluntary system would not be subject to some form of disclosure.
But I think there's also a good deal of resistance to any individual effort like that that is taken by a regulator or a private sector or a creditor. So if we can get many other groups involved, whether it's at the Federal level with leadership, the State governments, the private purchasers, the specialty societies—we need leadership at many different levels, and we need the pressure to come from many different directions to make sure that we can move forward on this.
DIBIASI: Well, as a follow-up to both of your points, how do you think is the reporting piece of this so controversial and raises so many fears? How would you suggest constructing a system to prevent errors without blaming someone?
UNIDENTIFIED PARTICIPANT: Well, of course, that's exactly what we have to do, and part of the—part of the controversy on the IOM recommendation about managed care reporting is the fact that people think of reporting itself as punitive. And in a sense it is. The hospital makes a public report of something that's gone bad. That's bad publicity and they—and they're very concerned about that.
And we need to get beyond that. Mandatory doesn't mean a shaming. Mandatory merely means accountability. There are some models. We have a—we have a situation of our registration in medicine in Massachusetts as a mandatory reporting system in which hospitals have to report serious adverse events to them but it's done confidentially and it's done—the requirement is also that, in addition to reporting the event, they have to investigate it and find out what the causes are and make changes, and the board has to satisfied that they have made a good faith effort to make the changes and that they're doing the right thing. And if they're not satisfied with that, they continue to work with them until they do.
Now, that is a non-punitive system, but it's very mandatory and I think it works very well. Its biggest problem is it's underfunded. Somebody talked about where's the money for this. We never fund these programs adequately. But mandatory doesn't mean punitive. Mandatory merely means accountability, and unless we have accountability, it's going to be hard to get hospitals to do all the things they need to do.
UNIDENTIFIED PARTICIPANT: And in your opinion, if the data on medical errors is collected, who should have access to it and how should that be used? How should that information be used?
UNIDENTIFIED PARTICIPANT: We need to separate errors from injuries, and we also need to start with square one, which Janet mentioned before, but I'll say it again for emphasis, and that is, I don't think there's anybody, either at the policy level or at the AMA or professional societies, that don't agree that, if a patient has an injury that's caused by an error, they have a right to know that. The doctor has an ethical obligation to inform them, to tell them what happened. The patient has a right to know what went wrong.
Now, that should take place internally, and the hospital should be concerned about this, and it needs to have reporting systems internally that surface significant errors and set in place a process that's going to deal with them. People will not report if nothing happens. And so it's not enough for the hospital to say, "You've got to report these." Unless they do something with it, unless there's a real effort made to get to the bottom and try to change the system so it won't happen again, people won't report even if it is punishment free.
At the public level, I think we're talking about the accountability issue and getting information, and again, unless it's confidential, that information isn't going to be forthcoming. But it's hard to say that the Department of Health or the Board of Registration doesn't have a right to know about these things. I think we all agree they do. What we need is to have a situation where people feel safe in reporting it because they know the emphasis is on improvement and not on punishment, and that puts it right in the lap of the regulators.
If you punish people, they're not going to report. If you work with them and try to help things get better while insisting that they do what they need to do, I think you'll find it works. The Joint Commission has had good success with the hospitals that report to them. There's still a major problem I think with fear and concern that things aren't safe. We've got to make it safe, but that doesn't mean we don't hold their feet to the fire to do something.
UNIDENTIFIED PARTICIPANT: Let me ask both of you this question. I'm going to start with Janet. If you were a State leader and tomorrow you could take three action steps, what would they be?
CORRIGAN: Well, I think one of the first things I would do is to, if we did not have a mandatory reporting system in place, I would begin to think about how to get such a system in place, and I would start out very cautiously with a very narrow band of incidents being reported, get good experience with it, get competent staff on who know how to analyze those individual cases, conduct root cause analyses, and begin to try to change the culture within the State and within the healthcare organizations, because I do think the reporting part of it is critical.
I'd also probably try to convene stakeholders, whether that's leadership within the hospital governing boards, within the medical communities, the nursing community is important here too, the pharmaceutical—pharmacy community, the various groups that really are on the frontline that have to do something about this issue and attempt to begin to get a dialogue going for possibly some community-wide efforts to improve patient safety, begin to develop sort of a plan as to where some of the highest priorities might be, where you can get the biggest bang for the buck, where you'll maximize your payoff, but really begin to elicit the input and participation and collaborative efforts of all those different groups.
I guess one other thing I would do is to also really encourage representatives at the Federal level and our leaders within the Department of Health and Human Services in particular to really provide some technical assistance to the State and to express, by support from the state level, for their efforts to do things like develop standardized reporting formats that can be used in the mandatory systems.
And one of the fears that some of us have is that, as States begin to move forward—and many of them already are with this effort—that there are things that we could be doing together and collaboratively, and we'd probably do them much better as a group rather than reinvent the wheel, and we'd also have comparative data where we choose to go down and pursue different approaches, it would be nice to have in place some form of an evaluation so that we would know 2 or 3 years from now what worked best. (INAUDIBLE)
LEAPE: Well, I think I can endorse everything Janet said. Let me—let me offer another perspective.
I mentioned, I think we—the major thing we have to do is get our focus off punishment and onto prevention, to become proactive instead of reactive. And I don't think most state agencies and regulatory bodies are set up that way. And as a matter of fact, many of them, by legislation, are not set up that way. They're set up to be reactive and I think we need to change that.
The major action of safety occurs where care is given. That's not in the Department of Health or the Board of Registration. It's in the hospital or the doctor's office, and the question is, "What can the State agencies, boards, and regulatory powers do to improve safety where care is given?"
And I would suggest that the main thing they can do is to set standards. We mentioned the best medication safety practices. Those were not developed by the Department of Public Health or the Board of Registration and pharmacy and nursing and whatever. They were developed by the Hospital Association and others and—well, that they were, but it raises a question of, "How come? Why didn't we have these kind of standards out there?"
I would think we could make tremendous progress if we—if the boards of medicine, nursing, pharmacy, and others were to convene expert panels to set standards for the working conditions, for the hours, for supervision, for staffing ratios, as well as specifics about those practices. If we want to have safe care in hospitals, we need to define what that is, and we need to define what the conditions are that lead to safety, and that seems to me to be the role of the regulatory agencies—to help the hospitals practice safely by defining what it is, and then of course, having a mechanism for making sure that they're doing it.
But all of this is in terms of a proactive preventive approach rather than a reactive and punitive approach. I'm not suggesting that would be easy, but I think it's time we think about that, because hospitals are going to move faster if somebody shows them more clearly what they need to do, and that's a role that state agencies can play.
UNIDENTIFIED PARTICIPANT: And (INAUDIBLE), as you indicated before, it's not only a problem in hospitals. I mean, we also have this situation with ambulatory care settings.
LEAPE: Absolutely. In fact maybe we ought to focus our attention there because we've done so little there.
UNIDENTIFIED PARTICIPANT: What happens—if States do nothing about patient safety, where does that leave us?
LEAPE: Well the healthcare organizations are going to move ahead anyway, and the purchasers, as Janet's already indicated, (INAUDIBLE) group in others, are beginning to put the pressure on. (INAUDIBLE) will be developing some of the best practices into some (INAUDIBLE) those we hope so that if the States do nothing, safety will not grind to a halt, but it's not much question that the State's going-the State agencies' can facilitate that process and can make it go faster, so that's what we need to see.
I think there's a great deal of interest of safety at all levels. Doctors and nurses are very interested in safety. They don't like to hurt people, and so the movement, so to speak, is going to go ahead regardless of what you do. I think the point is you can make it go a lot better.
UNIDENTIFIED PARTICIPANT: Janet?
CORRIGAN: I would only return to the-I guess the point made earlier that if—we've had some discreet efforts that were attempted in the last 5, 6, 7 years. I mean, the Joint Commission Sentinel event system. The AMA put in place a National Patient Safety Foundation, and that started to convene different groups and develop a research agenda and undertake various educational efforts. And those have all been very laudable efforts. They're good attempts to try to address this issue.
But what we're trying to do is a little bit different now from those past events is to get a really comprehensive broad-based effort or initiative in place, because somehow those individual efforts just haven't made much of an impact. So if the States chose to do nothing or a particular State chooses to do nothing, Lucien's correct—there will still be other efforts that go on. But it's important to emphasize that you've got a real responsibility here and unless everybody pitches in—well, maybe I should just say we think our chances of achieving that threshold improvement in the next 10 years are much better if everybody pitches in.
UNIDENTIFIED PARTICIPANT: And how do you see them pitching in? How do the States and the Federal Government—how can they work together on this?
CORRIGAN: Well, that Center for Patient Safety is intended to be the focal point for many of those initiatives: funding for collaborative efforts for educational programs, for technical assistance are the kinds of activities that our committee anticipated that Center for Patient Safety would undertake. The other thing that's important to point out is that the National Academy for State Health policy, under Trish Reilly 's leadership, is really doing a wonderful job I think, to try to get the ball rolling here and has a lot of potential to help to begin to encourage both educational programs, as well as collaborative efforts across States, whether it's in terms of developing model legislation, of looking at these various programs that are in place and learning from them in terms of reporting.
That's a—there are different ways that you can collaborate with other groups both amongst yourselves, state level individuals, but also between the Federal—the Federal level, the State level, and the private purchasers and other private stakeholders.
UNIDENTIFIED PARTICIPANT: OK. Let me go to the phones right now. We have Sandra with a follow-up question from the State of Colorado's Division of Workers' Compensation—Sandra.
ED: Yeah, it's Ed again. In terms of...
UNIDENTIFIED PARTICIPANT: I'm sorry.
ED: ... trying to figure out some measure of attributable risk and so forth, we hear a lot about the impaired physicians. Is there any estimate of the proportion of errors that are committed by impaired professionals?
LEAPE: I'm not seeing any measurement of that. We have carried out several fairly large studies of medication errors in hospitals, you know, over a 6-, 9-, 12-month period, and we were surprised to find that we didn't identify any of these errors as being the result of impaired physician (INAUDIBLE), you know, some of them could've been and we didn't know but it was not at all apparent to the people identifying the events.
And so I don't think we have any measure of that. I think it's a—I think it's a serious problem. My impression is it's not a very big problem, but I don't really know, to be honest.
UNIDENTIFIED PARTICIPANT: Let's go to Mary from the Health Facilities Licensing and Certification. Hello?
MARY, HEALTH FACILITIES LICENSING AND CERTIFICATION: (INAUDIBLE)
UNIDENTIFIED PARTICIPANT: Mary ?
MARY: Yeah.
UNIDENTIFIED PARTICIPANT: Go ahead. Your question.
MARY: (INAUDIBLE)
UNIDENTIFIED PARTICIPANT: Pardon me?
MARY: I have to move more toward the phone (INAUDIBLE)
UNIDENTIFIED PARTICIPANT: OK.
MARY: I have mixed feelings about some comments made with regards to (INAUDIBLE). First, it's nice to hear the nurse, some realistic understanding of why errors occurred with the business with the double—with the double shifts and the short staffing and the high patient loads.
But when I see people identify the State as a primary place for change to come from, I think it allows private industry to say, "Yeah. Well, you can say that, but where's the funding going to come from? And you need to give us some money." And it's so disheartening that the industry as a whole, despite the fact that it could be the most powerful, with the number of physicians that exist and the number of nurses that exist, that why the standard of care has to applied from an outside external agency like the State or even the Federal Government.
We're not organized collectively as a healthcare provider, and we are allowing ourselves—physicians and doctors included—to allow other things to (INAUDIBLE) our standard of care like money, environment, location, and the like. And I personally don't see without other resources happening how the State is going to be able to take anything on other than regulating errors that already reported, like Delaware already has a mandatory reporting on long-term care and children, and punitive is the only way to handle that because of the manpower piece.
So I just—I just really—I find it very disheartening to hear the focus say, "The State should do this and the State should do that," because as a State that does, it's not any more successful than any place else.
CORRIGAN: I think there's been a little bit of a misunderstanding. Our comments, or at least mine (INAUDIBLE) I think Lucien's as well, to a great extent have been geared towards what States can because you happen to be the audience that we're addressing. The IOM committee's recommendations do not put any more or less responsibility on States for taking action then they do on the Federal Government or on private purchasers or on professional associations and leaders within the professional groups and that's medical, nursing, pharmacy, and others.
I think what we've tended to focus on here today are the kinds of things that States can do because we assumed that that would be what you would be most interested in, at least those that are primarily listening to them but I can't emphasize enough the plan that's laid out by the IOM committee is a very balanced one that has an important and significant role for each of the major stakeholders, whether they're on the public sector side, the private sector side, the healthcare delivery, healthcare financing, or regulatory side.
LEAPE: I'd like to make two comments in addition to exactly what Janet said. As far as I can see, the States have done almost nothing about this in the last few years, and the health—and I think that's too bad and I think it would be good if they did a lot more. I can understand the fiscal constraints, and there too we have to address that in the political process but the fact is a lot of healthcare organizations are making a lot of changes even in a time when the—when the cost issue is a very major one.
I know a hospital, for example, that lost $100 million last year. They've got a very big problem. They're going to bail themselves out, but they also made safety one of their three major corporate objectives. They're moving ahead on that because it's the right thing to do, and they can do a lot without spending a whole lot of money.
A lot of the changes that need to be made are changes in the way we do our work that the people who do the work can figure out and can make. Implementing most of their changes in the medication safety does not require—for example, does not require a big expense. So what we see is, when hospitals and healthcare organizations get serious about safety, they find ways to do it. I think the State should help on that, but I think it's going to happen whether they do or not.
UNIDENTIFIED PARTICIPANT: And one route we didn't talk about in terms of having a role in helping out on this issue are the patients and their families. What role do you think they can take in reducing medical errors?
UNIDENTIFIED PARTICIPANT: The most—this hits on something that's—I think very important, and interestingly enough is going to be part of the centerpiece of the next report the Institute of Medicine comes out with, which has to deal with the organization of healthcare practice.
It's becoming more and more apparent that safe care as well as quality care in every respect depends on having the patient central to their treatment. Now, that sounds kind of obvious, except those of us who work in hospitals know that that's not the way it always goes. And the whole concept of the patient having much more play and much more active role in taking responsibility for their care I think is—has a tremendous amount of promise.
When I say responsibility for their care, I don't mean it's the patient's job to keep you from making a mistake, but what I do mean is that informed patients are safer patients, and so to the extent that, when you are a patient, you really understand what your treatment is and why you're getting the tests you're getting and why you're getting the medicines you're getting, what they are and what they look like and how often you get them and what the risks are and so forth, it's an extent that you understand all that and are a meaningful partner in the care. You are in a much better position to identify and head off mistakes that people might make.
And there are hospitals that are now beginning very active programs of this patient partnering in the belief that it will make things a lot safer. I think it's a very welcome step, and I predict we're going to see a lot more of it in the next 5 or 10 years.
UNIDENTIFIED PARTICIPANT: (INAUDIBLE) of an added help, AHRQ has actually published 20 tips for consumers to prevent medical errors and you can find that on the AHRQ Web site. That's info@ahrq.gov
LEAPE: It's an excellent list, as a matter of fact.
CORRIGAN: And just to add a couple of other things. I think that as more and more care shifts outside of hospitals, and as we increasing use the Internet for communication, it's going to become even more critical that patients are kept very informed and on top of what their treatment is and that they feel very comfortable asking all those questions.
One other point is that if you go one step beyond the patient and think in terms of consumers overall, we think it's really important that consumers be aware of the errors issue and the need to improve patient safety, because they also can put leverage on the healthcare system, whether it's in the decisions they make in terms of selecting providers and institutions and groups that they choose to go to, but also in terms of policy initiative. When you have the public at large with you, you're more likely to have good, informed, active policy debates that lead to taking action both at the national level and at the State and local levels.
UNIDENTIFIED PARTICIPANT: Well, I know we have some legislative offices on the phone today, and I think you touched upon it, but the danger for policymakers if they ignore this issue especially with the public being so aware of it. I would imagine it's pretty considerable.
UNIDENTIFIED PARTICIPANT: I think it is. I think that there is a danger over the Long-Term if we don't start to take action here and get on top of it, that there will be a loss of public confidence, both in the healthcare system and in our elected representatives, and the public sectors' ability to safeguard individuals. So I think it's very important to take action in that sense.
The other thing is that it isn't going to go away. We all know what Lucien earlier, whether it's getting better or worse in terms of patient safety. There isn't good hard data. Many would argue that if we don't take action, though, and really begin to get those better systems in place, that it may very well get worse simply because there's more technology coming online, that the medical knowledge base is increasing at an exponential rate, numbers of drugs to choose from, so complexity is going up.
So now is really the time to begin to get on top of this issue and think of—get our institutions thinking about how they can reorganize and design safer systems, standardized processes, simplified processes, so that that will move towards greater safety.
Lastly, I'd point out that there's a—there's a dollar cost here involved in this. We pay a price for these errors, and especially when they do result in harm, and that's (INAUDIBLE) estimated to be somewhere between about $17 billion and $29 billion for the Nation as a whole. The preventable adverse events result in lost income, lost household production, disability, as well as increased healthcare costs when people suffer an injury that has to be treated.
UNIDENTIFIED PARTICIPANT: We have a call from—or a question, rather, from John from the Florida Legislature, a couple of questions. The first is, how will the proactive non-punitive confidential reporting system be impacted by the civil liability or the tort concerns of doctors, nurses, and healthcare institutions?
CORRIGAN: Could you repeat the first part? A proactive non-punitive what system?
UNIDENTIFIED PARTICIPANT: Confidential. How will they be impacted by tort concerns of doctors, nurses, and healthcare institutions?
LEAPE: Well this is—this is the major barrier right now for cooperation and collaboration by physicians in safety programs. They are so afraid of being sued, and that fear is not totally unrealistic. I mean, they do get sued. And so physicians, understandably, that we are very insistent that any system that tries to look at errors and make an investigation and so forth be protected with confidentiality protections.
In most States, they are under the peer review statutes, but it still is a major barrier. Those of us that think the answer to this is to have a much more equitable compensation scheme. Janet just mentioned the number of the costs that are associated with medical injuries that people tend to overlook, lost work and that sort of thing. And it certainly does not seem to be either fair or appropriate that the patient has to pay for an injury caused by their treatment.
And yet there are very few systems—the VA is one by the way—in which they compensate people for injuries. My own belief has been that if patients were compensated for the cost of the injuries, they'd be much less likely to sue, and we're a long way from getting that. But the concern about malpractices is a very real barrier and hospitals that have made progress have dome so by really making sure that the people that have looked at the activities of the investigation and change related to error are kept confidential so that people are not exposed to extra risk.
UNIDENTIFIED PARTICIPANT: And the second question is, for purposes of the State regulation of healthcare providers, did you distinguish remedial efforts to prevent medical errors and disciplinary sanctions?
CORRIGAN: Well, our report speaks to the importance of improving the continuing medical and nursing education programs, and also to strengthening things like board certification and re-certification periodically, to begin to really incorporate an assessment of the—how safe of a provider's practice is and their knowledge of safety sciences.
So have they—are they really up to date on what kinds of things are particularly important in creating a safe environment, and that's a—that's a training and an educational issue and we think that that is particularly important.
As Lucien said earlier, there's -we believe only a small fraction of errors that are attributable to incompetent provider and impaired provider and in those instances, it really is important that the State licensing programs take appropriate action.
UNIDENTIFIED PARTICIPANT: Janet, if people what a copy of the IOM report, how can they get it?
CORRIGAN: Well, you can order a copy from the National Academy Press, and the Web site is http://www.nap.edu.
UNIDENTIFIED PARTICIPANT: OK. Well, I'd like both of you to wrap up, if you would, some closing thoughts. Why don't we go to Lucien first?
LEAPE: Well, I think—they've been suggested by the questions, I think people that in State agencies are very well aware from their past experience that it's hard to get the right kind of support for programs. There are a number of excellent programs that just have never been adequately funded, and I think the question is whether now the climate has changed enough, there's enough publicity, enough interest at the national level, enough people raising questions that State legislatures can see the wisdom of investing more in forward-looking programs.
I think the way to get that money is to have forward-looking programs—that is to have programs that will—that will enhance safety and recognize that enhancing safety isn't a matter of just catching the bad guys. Most of what State boards do, I think, is deal with the problem providers—substance abuse, and really reckless behavior and so forth and clearly that needs to go on. We need to have those disciplinary efforts.
But I think we can do a lot more for safety if they get into the prevention field and work with healthcare organizations to make them safer. That is going to take money, and it seems to me that it's never been easier to make that case than it is now. A lot of people know about the Institute of Medicine reports. There's talk at the national level, in the newspapers. I can't imagine your State representatives aren't aware of this, and I think it's an opportunity to come forward with some really creative and forward-looking programs and get the support they need, and I wish you well in doing it.
UNIDENTIFIED PARTICIPANT: Janet.
CORRIGAN: Well, I would certainly second that. It's very well said by Lucien. I think it's just too important an issue to not do anything, to not take action. We can't allow ourselves to be paralyzed by concerns over the debate on individual numbers, and we can't be paralyzed by liability issues, or by payment and cost issues. They're all there, but I think we can find solutions to them as we start to move forward. And there's really a very real responsibility here to be a part of the solution to this effort.
I would also say I think that we'll all be pleasantly surprised that, as each different group, whether it's the public or the private sector, or the national and the State or the local levels, professional groups, as each one begins to take a few steps forward, I think we're going to see that there's a lot of synergy there and a tremendous amount of support for addressing this issue. That's one of the positive things about medical errors is that everybody agrees there's things that just shouldn't happen, and we've got the knowledge base and the technology at our fingertips to be able to address a lot of these problems today.
UNIDENTIFIED PARTICIPANT: Janet Corrigan and Dr. Lucien Leape, thank you very much. You've given us a lot to think about.
If we didn't get to your question today, you can E-mail them to us at info@ahrq.gov and depending on the number of questions, we'll try to answer them directly. Again, we'd appreciate any feedback you may have about the AHRQ teleconference series by E-mailing comments to info@ahrq.gov. We also encourage you to send us any researchable questions you're facing at the State or local level for AHRQ's consideration, because we're planning the agency's research priority.
I mentioned at the beginning of the show that we have copies of the audio teleconference available for purchase and we will have them available several weeks after the series is completed. The cost for the series will be $6, or for $25 you can order a complete tape set of all sessions recorded at the ULP March 2000 workshop on this subject.
If you need any information about ordering, you can go to the AHRQ Web site and once again, that's www.ahrq.gov, then select State and Local Policymakers. Or you can call the AHRQ Publications Clearinghouse. The number is 1-800-358-9295, and just ask for audio tapes AHRQ-00AV11 for the workshop tapes and AHRQ-00AV11A for the audio conference tapes. And the tapes are entitled "How Safe is Our Healthcare System? What States Can Do To Improve Patient Safety and Reduce Medical Errors."
Also, we'll soon be posting on the AHRQ's Web site a summary of the March 2000 ULP workshop about medical errors.
We hope you'll join us for the next two teleconferences in this series. The next one will be on Wednesday, May 24th from 2:00 until 3:30 p.m., and the topic will be "How States Can Improve Patients' Safety and Reduce Medical Errors." And on June 5th from 2 to 3:30 p.m. we'll be talking about "A Systems Approach to Improving Safety: Translating Lessons from the Aviation Industry." If you haven't already registered, please fax your registrations form to 1-877-207-5481 or call 888-739-2195.
We look forward to having you join us, and thanks for being with us today.
OPERATOR: Thank you, ladies and gentlemen, for attending the conference call today. At this time, the conference has concluded. You may all disconnect.
Internet Citation:
How Safe Is Our Healthcare System? Understanding Medical Error. Transcript of part one of the series of National Audio Teleconferences sponsored by the User Liaison Program, Agency for Healthcare Research and Quality, conducted on May 18, 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/trulp518.htm
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