Nurturing a Safety Culture: Where Do We Go from Here?

Additional Statement, Submitted by Josephine A. Sollano, MPH, Mary Reich Cooper, M.D., J.D., Steven J. Corwin, M.D., New York-Presbyterian, The University Hospitals of Columbia and Cornell, New York, NY

In response to the Institute of Medicine's (IOM) report on medical errors, NewYork-Presbyterian (NYP), a large academic health center (AHC) in New York City has established a structure to address medical errors and near-miss events. Because we believe strongly that quality improvement initiatives and efforts to reduce medical errors are concepts that are inextricably linked, NYP is presently evaluating and implementing a number of quality improvement projects with a strong eye towards the detection, reporting, and reduction of errors.

As a healthcare system in New York State, NYP complies with all federal, state, and local mandates regarding patient safety, has put into place a number of internal quality improvement programs, invested heavily in infrastructure and informations systems in order to create a climate in which precise and efficient health care can be delivered, carefully credentials physicians, and yet, we continue to find an acute need to pay particular attention to errors and near-miss events. While the debate ensues whether capturing denominator data on adverse medical events is to any avail, NYP wishes to learn from other industries such as aviation and petrochemical and develop systems that will arm leadership with the knowledge and understanding of where things may fall short. In our efforts to encourage the detection and reporting of adverse medical events, we have become acutely aware of a fundamental cultural shift that needs to take place in order to succeed. One of the research agendas, therefore, that NYP wishes to pursue involves the education and re-education of our practitioners in order to nurture a true safety culture.

Ingrained within the culture of healthcare, and in particular, at AHCs, is an unfaltering sense that one must provide the highest level, highest quality of tertiary and quaternary care to all in need. For decades, AHCs have indeed provided such care. The cultural beliefs present within AHCs are rooted in confidence and pride that are continually reinforced by the superior health outcomes of our patients. Moreover, the recognition that the number of inputs and the costs of those inputs necessary to deliver quality care at AHCs is greater than in non-academic health centers is commonly held.

Academic health centers, historically, early adopters of medical technology, have a particularly heightened sense of safety. Often times the full spectrum of adverse effects of medical innovations in use at AHCs is compassed by the depth and breadth of knowledge that would have been gained as a result of widespread use. For this reason, leadership, management, scientists, and healthcare providers at AHCs find it necessary to come to consensus on exact quality and safety precautions that need to be instituted for particular treatment modalities and services. Increasingly, large AHCs find themselves in the seemingly untenable position of ensuring that all patients receive the highest quality--highest tech care that is delivered in the safest environment as the schism between what needs to be done and what is "doable" widens, given the financial consequences of doing so.

Whilst AHCs sort out how to continue to be early adopters of medical innovation and deliver high-quality, tertiary and quaternary care, regulators at the national, federal, state, and local levels attempt to ensure that certain standards of quality are upheld. At the national level, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has instituted a number of policies that lay the foundation for major quality improvement efforts. Implemented in 1996, JCAHO began a Sentinel Event Reporting Policy that encourages the self-reporting of medical errors so that others can learn from the results of the root cause analyses. Other examples of regulation concerning quality and medical errors at the national and federal level include: the Health Care Financing Administration's Quality Improvement Program, the National Practitioner Data Bank, national efforts focused on credentialing of physicians and other health providers, efforts targeting the safe practice of medication administration, and most recently the establishment of the Quality Interagency Coordination task force.

At the state level a number of regulations and quality improvement programs exist. In New York State (NYS), where NYP is located, several regulations are in effect in an effort to increase quality and decrease adverse medical events. Most notably, The Bell Commission mandate, in effect for over a decade, stipulates that no medical intern or resident work more than an 80-hour work week average over four weeks with no more than 24 hours in any single work period. In addition, NYS put into place a system of mandatory reporting for poor outcomes of care - NYPORTS, and an ongoing quality improvement initiative in centers that provide adult and pediatric cardiac surgery and percutaneous transluminal angioplasty.

At a local level and more importantly, programs and initiatives at NYP, clearly address quality improvement and the reduction of medical errors. A comprehensive quality structure, complete with case managers, clinical practice managers, quality assurance and performance improvement specialists, data analysts, and outcomes and health services researchers, exists at NYP. Through a hierarchical reporting relationship, matters of quality and errors report to both the Medical Board and the Quality Assurance Sub-Committee of the Board of Trustees. Under the aegis of the Chief Medical Officer, a multidisciplinary team meets bi-weekly to discuss sentinel events and root causes analyses. Similarly, the Clinical Care Evaluation Committee meets monthly to discuss the NYPORTS.

At the urging of, and with the support of, The Chief Executive Officer, The Executive Vice-President, and the Senior Vice President and Chief Medical Officer, NYP leapt into action immediately following the release of the IOM report. A multidisciplinary team of researchers was assembled from the AHC as well as from the Department of Public Health and Law School of Cornell University, and from the faculty of the Schools of Public Health and Law from Columbia University to specifically address a research agenda concerning medical errors. Thus far, response to a request for applications by AHRQ was submitted as well as a small grant was successfully obtained from an extramural funding source to examine the rate of misdiagnosed acute myocardial infarctions in the Emergency Departments.

In addition to the Committee on Research for Medical Errors, a hospital-wide error reduction committee was formed with its four component subcommittees. The subcommittees are composed of interdisciplinary teams from the Emergency Departments, Peri-Operative Services, Obstetrics and Gynecology, and Medication Administration. Besides the effort to evaluate the rate of misdiagnosed myocardial infarctions before and after the creation of a chest pain center, a web-based, voluntary, self-reporting system for near miss events is being trialed in each of the Emergency Departments at NYP. The Peri-Operative Services team has initiated standardized protocols concerning surgeries involving laterality as well as the standardization of surgical preparation of the operative site. The Obstetrics and Gynecology team has standardized policies and procedures across three active labor and delivery sites, standardized data and information forms, and is currently seeking extramural funding to develop a risk scoring system that will assist in the prediction of poor maternal and fetal outcomes. And lastly, the Medication Administration team is test piloting a web-based self-reporting system, MedMARX, a product of the U.S. Pharmacopoeia, at one of NYP's clinical sites, has initiated protocols related to anticoagulation therapy and has standardized protocols regarding the use of electrolyte replacement therapy in pediatric populations. Additionally, we utilize technology for physician order entry and rules assisted decision-making on multiple units.

It is evident that NYP has invested a tremendous amount of time, effort, and resources into evaluating and modifying our processes. Notwithstanding, we continue to experience errors, whether they are repeated ones, variations on previous errors, or new ones. In parallel with our efforts to address a rather complex set of issues from a systems perspective, we believe that our attention should be turned to a more fundamental concern. Perhaps, the overarching issue prevailing in the detection, reporting, and reduction of medical errors and near miss events relates to the adoption of a safety culture with its incumbent attitudes, beliefs, and perceptions. The research agenda, therefore, that NYP wishes to further concerns those attitudes and beliefs and the ability to bring about a cultural shift among our direct care providers as well as all members of the NYP staff.

The research questions that we submit are three.

1. How can we best engage physicians, nurses, other direct care providers and hospital staff to participate in a safety culture?
2. How can we create a passion for detection, reporting, and reducing errors in a manner that is not overwhelmed by short cuts and uninformed decision-making that occurs to expedite patient care?
3. How best can we standardize the dissemination of information within a safety culture?

We thank you for the opportunity to submit our thoughts and research questions on this most important topic.

Respectfully,

Josephine A. Sollano, MPH Director, Institute for Clinical Excellence (212) 305-0074

Mary Reich Cooper, MD, JD Vice President, Clinical Practice Evaluation (212) 305-5050

Steven J. Corwin, MD Senior Vice President Chief Medical Officer (212) 746-4068

Current as of September 2000

Internet Citation:

Nurturing a Safety Culture: Where Do We Go from Here? Additional Statement, Submitted by Josephine A. Sollano, Mary Reich Cooper, Steven J. Corwin. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/asollano.htm

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