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National Summit on Medical Errors and Patient Safety Research
Additional Statement, Submitted by Senator Richard T. Moore Senate Chair, Committee on Health Care, Massachusetts State Senate 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 As a state legislator who has spent considerable time and effort to develop state policies and legislation to improve patient safety and reduce the prevalence of medical errors, it is clear that more evidence-based research is needed to convince both those whose career goal involves saving lives and managing disease, as well as those we are trying to serve—the American people of the magnitude of the problem and the need for action. First, based on the reaction from health professionals and the general public in the year since the release of the Institute of Medicine report, much more research needs to be conducted to develop a more precise estimate as to the true scope of the problem of medical error. The range suggested in the report if far too imprecise for a scientific study to be taken seriously. Furthermore, the studies, on which the IOM report was based, were focused on data from acute care hospitals. This data needs to be replicated and methods need to be refined to establish a smaller range of the scope of deaths and injuries from medical error in hospitals. If it is true that as much as 90% of health care today is delivered in settings other than acute care hospitals, we also need to research medical error in all types of health care. For example, we should look carefully at the findings of a recent University of Massachusetts Medical Center/Fallon Health Foundation study of medication error in long tern care settings. Clearly, with the expected doubling of those Americans receiving health care through nursing homes and other long term care facilities, this sector of our health care system cannot be ignored. Additionally, with the dramatic growth in outpatient treatment of a variety of health conditions, and the growing practice of surgical procedures and medication administration in doctor's offices or clinics—settings which are generally unregulated by states—the potential for medical errors and non-reporting of errors continues to grow. We must find methods to insure safety for patients and for health care personnel throughout health care, not just those who utilize acute care hospitals. It seems impossible to measure the President's goal of a fifty percent reduction in medical error in the next five years, or the success of any goal, unless we are able to establish a realistic baseline figure, and one which includes all health care settings. Second, there needs to be research on the various communications aspects of medical error. Communications is a problem in many ways. There is no uniformity among professionals or among government regulators as to the definition of what constitutes a medical error or a near error. A taxonomy of patient safety and medical error definitions and terms is needed. There is also little understanding among the public as to the meaning of patient safety or medical error. Some surveys have reported that the public believes patient safety involves issues such as not being raped in a hospital or mugged in a hospital parking lot, and that medical error relates to billing discrepancies. We need to find a way to communicate what we mean to patients, especially if we hope that they will take a greater responsibility for their own safety, and if we hope they will help us to collect reports of errors. Communications research must also take into consideration cultural and language differences among providers and patients. With the growing diversity of America, especially in urban areas, major communications gaps caused by translation mistakes or lack of awareness of cultural traditions and beliefs lead to error, and this area needs considerable research. Third, since states are the principal authorities for licensing of health professionals, for inspection of health facilities, and—in those states which require some type of medical error reporting—for the collection of data and analysis of causes of error, it is essential that states be directly involved in setting and implementing the medical error research agenda under broad nationally agreed guidelines. In addition to the National Center for Medical Error Research contemplated by the IOM report, there should be state and/or regional centers supported jointly by the Federal government, the states, and private sources. In Massachusetts, the Legislature is considering a proposal to establish the "Betsy Lehman Center of Patient Safety and Medical Error Reduction," named in memory of the Boston Globe and Worcester Telegram and Gazette, health reporter/editorial writer who lost her life as a result of medication error. The center would provide state level leadership in producing evidence-based research on medical error and propose and disseminate suggestions for improvements in our health system to reduce errors. A national research agenda should be proposed for all state/regional centers, however these centers should be free to establish local research priorities and to identify and research any local factors—perhaps based on demographics or environment—that might be lost on a broad, one size- fits-all national research agenda. Therefore, I would like to see federal and national foundation support for medical error research that, in part, offers resources targeted to state or regional research centers as well as national research efforts. Although states have been the major collector of data about medication error to date, most of the data is based on admittedly incomplete information from health professionals. In the litigious society in which we live, health professionals are understandably reluctant to confess errors or near errors for fear of litigation that could cost them financially, professionally, and personally. We need research in how to obtain accurate reports of errors and of near errors in ways which focus on improving health systems to reduce the potential for error. We need research on how best states can use the information collected from regulatory agencies to promote future reduction of medical errors. We also need to expand research on the use of information from patients through patient surveys or other means to help identify errors or systems failures that could or did lead to error. Fourth, current research suggests that approximately forty percent (40%) of all medical error occurs with regard to medication error. With the dramatic growth in the number and usage of prescription drugs in health care, research in medication error ought to be a top priority. We need to examine the education of physicians and other health professionals in the prescribing and monitoring of prescription drugs. We also need to examine how we can encourage medical school and health education to focus on working within a health care team. Currently, most medical schools offer little in the way of education in pharmacology. Even if this academic deficiency is corrected, it seems to be a growing impossibility that even human brains as capable as those found in most doctors and nurses are able to keep up with the quantum increases in the number of drugs, their uses, and their side effects. Add to this the growing incidence of herbal remedies, vitamins, and over the counter offerings, and the lack of understanding of the effects of combined use with prescription medication, and we have a prescription for disaster. Health professionals are not entirely to blame for medication error resulting from lack of education and understanding of drugs. Consumers, themselves, often don't follow doctor or manufacturer directions. The printing of small print directions on the bottle or in the package and the quickly read listing of possible side effects in pharmaceutical commercials, while meeting legal liability requirements, don't seem to be sufficient for reducing medication error. Therefore, we need to examine how we educate health professionals with regard to prescription drugs and we also need to examine how we educate patients to follow the directions for administration of these drugs. Certainly, with the shortage of nurses and pharmacists, and possible reduction in the supply of new physicians, we need to increase the use of technology in the ordering and dispensing of medication. Therefore, we need to examine ways to improve computerized prescription order entry and dispensing and to find the most cost-effective, therapeutic methods for deploying these systems in hospitals, nursing homes, neighborhood clinics, and doctor's offices. With regard to expanding resources for educating health professionals and the public to reduce medication errors and for increasing and improving technology applications in the ordering and dispensing of prescription drugs, the pharmaceutical companies, themselves, could and should play a prominent role. The significant resources invested by these companies in research and marketing of their products should include research in the areas of physician and consumer education and on the reduction of medication error through technology. Direct to consumer marketing, favored by many manufacturers, could serve as a positive force in helping to educate professionals and the public on safe medication practices. Research is needed on the impact of DTC advertising of drugs as well as to find the best means and the most effective message of delivering medication safety information to those who need it most. Therefore, the pharmaceutical manufacturers should support medication error reduction education as well as technology research and application through internal research and marketing programs as well as through significant investment in support of these areas by contributing to organizations such as the National Patient Safety Foundation or the Institute for Safe Medication Practices. There are many important research directions to pursue, and I commend those who organized this National Summit for initiating a dialogue that will save lives, save money, and increase confidence in our health care system. Current as of September 2000 Internet Citation: Moore, Senator Richard T. . Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/amoore.htm Return to Additional Statement Directory |