CERTs.Article Archive.2001.09.13

CERTs Investigator testifies at National Summit on Medical Errors and Patient Safety Research
By Bettina N. Sebastian

Dr. Lucy Savitz, from the University of North Carolina at Chapel Hill, testified Monday in Washington DC at the National Summit on Medical Errors and Patient Safety Research, saying that the 7 research centers that constitute CERTs have been created to better understand the use of therapeutics, to reduce costs, and to improve the quality of health care.

Savitz is an assistant professor in the Department of Health Policy and Administration in the School of Public Health and Obstetrics and Gynecology in the School of Medicine. She is also an investigator in the UNC Program on Health Outcomes' CERTs. She was formally invited to present as a member of the panel testifying about reporting issues and learning approaches.

"I appreciate having this opportunity to address several important reporting issues and learning approaches related to our efforts to examine medical errors and patient safety," Savitz said in her testimony.

The top research issues in reporting and learning approaches are on many levels: establishing common definitions for what constitutes preventable adverse medical events, defining scopes on which adverse medical events can be prevented, understanding the opportunities and limitations of comparative analyses, and the benchmarking and reporting of this information.

"Currently, research in the area of patient safety and medical errors is plagued by the pervasive problem commonly encountered by health services researchers whereby key outcomes are not consistently measured and/or modeled," Savitz said.

This endeavor must begin with a good research base, which must be done by first identifying clinically relevant definitions. These definitions will later be expanded, as the program becomes efficient in the ability to measure data and reduce errors.

"For example, health service organizations do not necessarily have processes in place to capture near-misses and/or latent failures," Savitz said.

It is critical to know that adverse medical events can be either preventable or non-preventable, meaning that while some deaths are preventable, others are a natural consequence of a patient's condition. Treating all hospital deaths as "medical errors" compromises the understanding of these complex processes, Savitz said.

Key research questions will focus on how to use data and models to prevent future medical errors for at-risk patients and situations, and on determining the effects of cost-reductions due to staff cutbacks.

Answering these questions will require a pooling of resources across the health care industry. This will involve developing interventions that promote patient safety, followed by published articles in peer-reviewed medical journals. This will help identify the best practices, which can then be shared and adopted across the industry. Along with the adoption of such practices must be a system that educates health care workers in the application and interpretation of such evidence.

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