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National Summit on Medical Errors and Patient Safety Research
North American Spine SocietyAdditional Statement, Submitted by David Wong, M.D., M.Sc., FRSC(C), Chairman, NASS Task Force on Medical Errors, and Pam Hayden, Manager, Clinical Care, North American Spine Society 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 Scope of the Problem The North American Spine Society (NASS) is a multidisciplinary organization that advances quality spine care through education, research and advocacy. NASS has nearly 3,000 members representing the spectrum of spine care providers, including orthopaedic surgeons, neurosurgeons and physical medicine and rehabilitation specialists among others. NASS' interdisciplinary outlook and review of the IOM report highlight the following areas of concern for NASS regarding prevention of medical errors:
Importance of Education NASS believes physician and patient education are the key to prevention of medical errors. Although evaluation and implementation of prevention systems is an important aspect in the prevention of medical errors, of prime importance is the prevention of human error. This is one of the most difficult aspects of patient safety to address. NASS believes that positive, preventative education at all levels of participation in health care is a crucial component to combating human error and, ultimately, reducing medical errors. NASS is presently considering initiatives in the following areas: Physician Education Physicians need more education on how to protect their patients from medical errors in all healthcare settings. Most physician training is in the arena of clinical care, not healthcare administration and error prevention. Education regarding the areas in which errors are likely to occur, can promote awareness among physicians about what they can do and watch for to protect their patients regardless of setting. Physicians can be powerful advocates of change in hospitals, labs, ambulatory care settings, etc. Professional organizations are in a unique position to reach and educate these healthcare professionals by the nature of their ability to provide meetings, advocacy for key topics and influence their members in policy arenas. According to the IOM report, there are few instances where patient safety is specifically included on meeting agendas. NASS plans to address, and hopefully pre-empt, these issues through emphasis on the importance of continuing medical education and plans to include an error prevention component as part of its future CME activities. NASS has also developed clinical guidelines for low back pain directed at the first contact physician through the spine care specialist. Plans for future initiatives, in response to the IOM's report on medical errors and anecdotal reports of wrong site surgery, include efforts to prevent wrong site surgery through a "Sign, Mark and X-Ray" (SMAX) campaign to encourage surgeons to preoperatively sign or mark the symptomatic extremity so that the side of surgery can be easily identified by patient, staff and physician. Part of the SMAX program would be to confirm proper levels intraoperatively by using an appropriate marker and intraoperative x-rays. A program is also planned for physicians to take a copy of a patient education device (see below) into the operating room as a means of verifying the correct surgery levels when comparing to x-rays. Patient Education As consumers of health care, patients share in the responsibility for their own health and safety and can be the ultimate guardian of their health. Patients and physicians need to understand that patient education can go a long way to assisting in the prevention of errors in their care. Although sometimes time-consuming for a busy medical practice or hospital, patient education not only is helpful to the patient in managing and actively cooperating in his care, but also helps protect and prevent medical errors that may affect the healthcare provider as well. Both in and outside of their own practices, healthcare professionals are also influential advocates in the area of patient education and wield a level of credibility with both patients and healthcare settings to help assist in the development and promotion of information dissemination. NASS plans to take advantage of these opportunities through patient education initiatives including:
Voluntary Reporting Voluntary, non-punitive reporting must be part of any system of error prevention, internal or external. The only way to truly identify and prevent errors is through truthful reporting by healthcare professionals without fear of repercussion. Two types of review may be most palatable to providers: (1) peer-review, with a waiver of liability within the legal system; or (2) anonymous reporting. Mandatory, punitive reporting drives incidents underground where there is no chance of redress. Research Questions That Need to Be Funded and Addressed NASS views funding of pilot projects by federal agencies as a key component to identifying and addressing medical errors within the U.S. health system. Many healthcare organizations and professional organizations are uniquely qualified to research the types of errors that occur in their specialties, geographic areas or patient populations. NASS has identified the following areas for research:
Communication of New Knowledge: Most Applicable Methods The most useful means of communicating new knowledge to professional associations such as NASS are via E-mail, Web site or mailing of hard copy materials to a named contact person. We can be assured that they are then received by an appropriate representative and disseminated to our members in a timely fashion. Conclusion It is NASS' belief that by determining appropriate physician and patient educational topics and arming healthcare providers and patients with information that many medical errors can be prevented. Current as of September 2000 Internet Citation: North American Spine Society. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/aspine.htm Return to Additional Statement Directory |