|
National Summit on Medical Errors and Patient Safety Research
Baptist Memorial Health Care CorporationAdditional Statement, Submitted by Nancy A. Nowak, Vice President of Nursing, for Baptist Memorial Health Care Corporation The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summit’s goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs. Selected applicants testified at the summit as members of the witness panels. The remainder of the applicants were invited to submit written comments for consideration by the steering committee. One of these statements follows. Disclaimer and Copyright Statements The Medication System Variance (MSV) initiative is a system effort to focus on improving the medication use system. This initiative has been underway for over 2 years. Our initial goal (set in 1998) was to increase reporting. Recently, we updated our goal to include increasing reporting while reducing serious errors. We are currently identifying trends and improving the medication use system based on those trends and by implementing best practices. Voluntary reporting of errors has an inherit problem with capturing all variances that occur and remains a critical gap for improving patient safety. Direct observation is the most effective method for truly assessing the quality and safety of the medication use system. However, the challenge that presents itself involves the availability of resources to provide direct observation. Therefore, health care organizations rely upon voluntary reporting methods for collecting information concerning the medication use system and for making system improvements. A plausible research question would be "What is the impact that voluntary reporting methods have on improving the medication use system compared with direct observation?" Other factors that impact the medication use system as well as other systems within the health care environment include human factors and new technological advancements. New technological advancements are available to assist health care professionals with ensuring appropriate patient safety measures are in place. Checks and balances are necessary to provide a safe environment and to error proof our health care professionals. Currently, there are several types of technology that support safe practices; however, there is not one package that offers all aspects at a reasonable cost. Each, alone, addresses a small component for safe health care systems. Furthermore, the cost for new technology is prohibitive for most health care organizations especially with cost containment and cut backs on reimbursement. Therefore, it is essential that government and private insurers become an active participant in the quest for adding technological advancements into health care organizations. Research can assist with this venture. A research question should include "What can private insurers and government do to assist with making available (e.g., resources [financial], incentives, etc.) for all health care organizations aspects of technology so to improve the health care systems in all organizations?" In order to ensure that automation and technological advancements truly improve system, error-proof health care professionals and promote patient safety, health care organizations must first ensure high quality and safe work processes. Another research question should include "What are the characteristics of a health care organization's work processes where automation would improve patient safety?" The Human Factor element requires focused attention and impacts all health care organizations. For decades, the aviation and nuclear industry have conducted human error studies; however, human error studies specifically addressing health care industry are deficient. The health care industry continues to be challenged with human elements. Ensuring sufficient evidence and education is made available for those who impact health care is critical. This includes state and federal regulators. Still today, some state licensing bureaus take punitive action against health care providers (even though systems are at fault and not humans {e.g, Colorado}). This is a problem that stifles patient safety focused initiatives and leads to chaos and lack of uniformity. Effective prevention and management is critically dependent upon a reporting culture that is non-punitive. Without detailed analysis of mishaps, incidents, and near misses there is no way of knowing the recurrent error traps. Trust is a key element for a just reporting culture. A research question addressing human errors should include "What is the relationship between human factors and health care medical errors?" and "Why do health care organizations, state and federal regulators continue to utilize a punitive approach regarding medical errors - directed at the individual rather than focusing on the system failures?" As stated in the Institute of Medicine (IOM) report "To Err Is Human, Building a Safer Health System", a good deal of research has identified medication error as a substantial source of preventable error in hospitals. In addition to the MSV system initiative described earlier in this written statement, a system Legibility/Orders Collaborative focuses on improving the medication use system as well. The four components of this collaborative include: 1) standardizing required components of order sheets/progress notes form(s); 2) establishing documentation guidelines; 3) defining required medication order(s) elements; and 4) standardizing and defining a measurement process for continuous improvement. Adopting standardized prescribing rules, implementing standard processes for medication orders and physician order entry methodologies represent significant culture and practice changes. A research question should consider "What curriculum changes need to be made in entry level educational programs for health professionals (physicians, pharmacists, nurses and others) to incorporate medication safety?" The restraint initiative is a system endeavor to focus on restraint use. The recently revised Joint Commission restraint and seclusion standards emphasize the health care organization's provision of qualified, capable staff who are trained to defuse potentially dangerous situations safely and quickly and when necessary, to safely employ restraint and seclusion while minimizing trauma to the patient and staff. The focus on training and education seeks to increase staff skills in monitoring and evaluating patients and to promote effective communication between the staff and responsible physicians. The Health Care Financing Administration (HCFA) rule focuses on a licensed independent practitioner being required to conduct a face-to-face evaluation within one hour of an individual being placed in restraint or seclusion for behavioral health care reasons. This system initiative focuses on using least restrictive measures and is committed to moving toward a restraint free environment. Before applying restraints, the professional nurse must determine that the use of restraint outweighs the risk of not using restraint and that alternative measures have not successfully modified the behavior for which the restraint is applied. A research question may include, "What are the possible relationships between minimal use of restraints and other possible outcomes (use of alternatives, falls, elopement)? Another system initiative focuses on sedation and anesthesia care. Ongoing changes in the delivery of anesthesia including new drugs and increasing use in ambulatory settings prompted the Joint Commission to review and revise the anesthesia care standards. The new "Sedation and Anesthesia Care Standards" address four sedation levels and become effective January 2001. "What strategies need to be considered to improve and support safe sedation and anesthesia care?" In summary, the system initiatives described in this document focus on patient safety and continuous performance improvement. The amount of available information regarding safety is staggering and at times confusing. To assist in accessing and applying new knowledge and improved work processes please consider the following:
Current as of September 2000 Internet Citation: Baptist Memorial Health Care Corporation. Additional Statement by Nancy A. Nowak. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/abaptist.htm Return to Additional Statement Directory |