National Summit on Medical Errors and Patient Safety Research
Summary: First Public Comment Session
On September 11, 2000, as part of the Government's response
to the Institute of Medicine's landmark November 1999 report,
To
Err is Human: Building a Safer Health System, the Federal
Quality Interagency Coordination (QuIC) Task Force sponsored a
national summit to help set a research agenda on medical errors
and patient safety. A summary of part of that Summit follows.
Other Summit information includes: Written Statements of panel testimony, Additional Statements, and Streaming Video.
First Public Comment Session
Adam Scheffler, M.A., L.S.W., Health Policy Consultant, Chicago, IL
Mr. Scheffler suggested that research literature in the area of risk perception/communication is
worthy of examination and testing in the health care industry to see how well it translates. He
emphasized that this should be part of a broader effort to begin to create a culture of
communication and data-sharing that involves patients in their own care.
John Wilson
Mr. Wilson noted that with regard to medication dosing errors, a "gold standard" drug delivery
system has already been established but abandoned due to costs. He proposed going back to
the "gold standard" and using it as the prototype when doing drug delivery research, and
comparing other methodologies against it.
Gregory Apelian, Tender Loving Care Ministries, Rio Ranch, NM
Mr. Apelian raised the need for better systems management, and in particular, a more
comprehensive data collection method so harmful drug dispensing errors can be readily
identified and appropriate interventions made.
Stephen Gleason, D.O., Ph.D., Iowa Department of Public Health
Dr. Gleason noted that it may be too early to begin inserting patient safety standards into
contractual relationships because several issues have not been fully examined. For example,
there has not been an examination of how to link provider behaviors to incentives (both
regulatory and financial), nor an examination of the combined regulatory burdens on providers
(from government and private payers). He also stressed the need for greater investment in
computer technology.
Paul Barish, M.D.
Dr. Barish suggested that a system of education and training of future providers is the most
lasting way to change the health care system. Education should begin at the undergraduate
level and continue through the graduate and CME continuum. He proposed research questions
to focus on how to create opportunities for education, to study the impact of curricula aimed at
enhancing patient safety, and to study the interaction between education and ultimate
performance.
Mary Cooper, M.D., New York Presbyterian Hospital
Dr. Cooper highlighted the issue of adopting a culture of safety, and suggested research to
study how to engage direct care providers in the area of patient safety so they feel a need to
provide such care to their patients.
Harvey Kaufman, M.D., Quest Diagnostics, Teterboro, NJ
Dr. Kaufman suggested that the research also focus on the following areas: comparing
organizations that have value missions and those that do not in terms of driving safety and
quality; examining processes in addition to outcomes; and studying successful approaches to
quality, and how they impact on quality and safety.
Greg Pawlson, M.D., M.P.H., National Committee for Quality
Assurance
Dr. Pawlson emphasized the need for Federal agencies and foundations to jointly fund research
to pull together different groups such as accrediting agencies, employers, insurers, hospitals,
and practitioner groups.
Joshua Rising, M.P.H., American Medical Student Association,
Reston, VA
Mr. Rising stressed the importance of examining different curriculum models that enable future
practitioners to work together to address the issue of patient safety. He also suggested research
to look at international models that have recognized the negative impact of overworking health
care professionals on patient safety and what efforts have been made to address the problem.
Current as of September 2000
Internet Citation:
First Public Comment Session. Summary. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/summorning.htm
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