Summary: Panel 2—Broad-Based System Approaches

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.

Panel 2: Broad-Based System Approaches

Recognizing that medical errors are the fault of systems and not of individuals, the purpose of hearing from this panel was to identify how improving patient safety can be a health care system-wide endeavor. It was generally accepted that reducing and preventing medical errors and improving the overall safety of the health care system will demand the collaboration and participation of all stakeholders. Some of the common themes raised by this panel were: confidentiality and protection, human factors, organizational/cultural issues, reporting systems, use of technology, and training of providers.

Gordon Sprenger, American Hospital Association

Mr. Sprenger emphasized that efforts to improve patient safety will be most effective if they are implemented across the entire health care system and in all clinical settings, including hospitals, nursing homes, and physicians' offices. He recognized that reducing errors will require the design and implementation of error-resistant systems, and proposed that there be:

• Research to study how to change the traditional culture of health care to one that encourages learning from failures. Research can identify what critical factors make for a more open learning environment and what regulatory and legislative changes are necessary for creating such an environment.
• Research to examine effective risk management strategies and safety practices from other high-risk fields, with a special focus on how to tailor these models to the health care environment.
• Research to build an evidence base for current safety practices in health care, with a focus on how they can yield safer systems.
• Research on human factors issues to help explain why errors occur and how systems should be organized to minimize errors.
• Research to identify the most useful technology for reducing medical errors, and to identify areas in which the industry should make an investment in such technology.
• Research to close the gap between knowledge and practice, with a special focus on communication in health care settings.
Research to study medical errors and patient safety in ambulatory care settings.

Saul Weingart, M.D., Ph.D., Harvard Executive Session on Medical Error and Patient Safety

Dr. Weingart outlined a research agenda calling for the study of patient safety innovation at the organizational level. He emphasized that medical errors must be studied at the level of deficiencies in the organizational process in order to arrive at solutions. In view of that, he proposed six research focal points:

• Collecting case studies of cutting-edge innovators in patient safety and identifying what factors allow for their success (e.g., organizational context, leader attributes, market conditions).
• Exploring new models for the dissemination of innovation designed to promote improvements in patient safety.
• Examining the cost and effectiveness for technological solutions to the medical errors problem, and also the limits of such solutions.
• Studying the impact of fiscal austerity on safety, with a special focus on the effect of high patient-to-nurse ratios on error, the relationship between competing markets for health care and hospitals' safety concerns, and whether safe organizations also deliver better (and more cost-effective) care.
• Examining the feasibility of establishing multi-site research laboratories for testing novel drug-delivery systems, reporting systems, order-entry systems, and other processes designed to improve patient safety.
• Developing a standardized instrument for measuring the effect of patient safety improvements, for the purpose of reporting to the public.

Robert Crane, Kaiser Permanente Institute for Health Care Policy

Mr. Crane proposed research that would combine both qualitative and quantitative approaches and would look across institutions and aggregations of data, providing opportunities for interdisciplinary collaboration to improve patient safety (which, he noted, will require assurances of confidentiality). He identified five areas of potential research and recognized their inter-relatedness, providing an opportunity to integrate them into broader studies:

• Research to synthesize current knowledge of best clinical practices and to evaluate those practices in order to facilitate the subsequent creation and implementation of successful practices. Such research could employ large integrated data systems (currently in place in many health care organizations) to find and study antecedent conditions of errors and high-risk situations that would signal a greater than usual rate of errors or adverse events in a specific practice.
• Research to study human factors and incorporate the information into reengineering specific processes for improving patient safety. Human factors issues include: what human factors lead to error, how knowledge of human factors can improve the effectiveness of error prevention strategies, and what the impact of training and team factors is on safety in hospital settings.
• Research to evaluate and validate the efficacy and cost-effectiveness of new technology designed to improve health care quality and safety, in order to help organizations prioritize their investments in such technology. In addition, research is needed to study how technology actually creates opportunities for new types of errors to occur.
• Research to evaluate existing medical errors reporting systems (e.g., State mandatory reporting systems) to determine their impact on the improvement of patient safety. Research is also needed to identify factors that underlie the success of such systems, with an emphasis on how causes of errors were translated into system changes for safety improvement.
• Research to identify the cultural factors at the health care team level that are needed to transform the current culture of blame. A standardized set of patient safety-oriented questions or a survey instrument could be developed for this purpose to allow for comparison across institutions.

Dale Bratzler, D.O., American Health Quality Association

Dr. Bratzler emphasized that a research agenda on patient safety must include studies identifying the most effective methods for facilitating changes in caregiving processes. To that end, he proposed two broad areas of research:

• Research to examine the best methods for identifying opportunities for clinical quality improvement. Specifically, the research needs to determine how much data is necessary to identify meaningful opportunities for improvement, and to examine the effect of mandatory reporting on successful identification of such opportunities.
• Research to examine the best methods for facilitating quality improvement efforts by practitioners and providers. Specifically, the research needs to identify best strategies for disseminating information about quality improvement to providers and practitioners. The effectiveness of error reduction efforts as they relate to facility attributes (e.g., size, location, affiliation with a larger organization) also needs to be examined. Finally, the research should study the ability of existing Peer Review Organizations (PROs) to serve as catalysts for quality improvement with health care providers and practitioners.

David Woods, Ph.D., Human Factors and Ergonomics Society

Dr. Woods' testimony placed a heavy emphasis on the need to create a useful partnership between the health care industry and the field of human factors engineering. Research in the human factors field, with a focus on underlying mechanisms and behavioral patterns, can provide a convincing basis for changing the system. He asserted that research must be done:

• To consider building a research agenda as an interdisciplinary partnership between the human performance specialties and various medical specialties. The health care industry can benefit from studying the formal and informal organizational basis of the successes of the safety program of the National Aviation and Space Administration (NASA).
• To develop and test interventions for reducing problems arising from breakdowns in human performance.
• To identify the sources of complexity that contribute to human performance problems in operating complex systems, to understand the strategies used for coping with complexity, and to devise better ways of helping people cope with complexity.
• To study the user-centered design of computer systems in other high-risk industries, and to create demonstration projects for user-centered design of information technology to ensure that benefits are gained while error-inducing designs are avoided.
• To understand the impact of new advances in the technology of "connectivity" (i.e., Internet, telecommunications) on the practice of medicine, and to direct these new advances to enhance patient safety.
• To examine how new technologies will affect roles, judgement, and coordination, which will reveal side effects that could create new systemic complexities.

Robert Wears, M.D., M.S., MedTeams Consortium

Recently, there has been a successful demonstration of the effectiveness of teamwork in emergency medicine and a growing availability of health care simulators. As a result of this, Dr. Wears proposed that further research should be conducted in four specific areas:

• Research to expand the use of patient simulators from a single practitioner focus to a team focus.
• Research to use simulators to identify appropriate team structures best suited to different settings of care.
• Research to investigate the use of simulation to reinforce, retrain, and refresh technical skills together with teamwork skills.
• Research to study the establishment of medical simulation centers of excellence.

Question and Answer Session

The following additional areas for research focus were discussed:

• Examining strategies for disseminating information across a health care "system" that is actually very fragmented.
• Identifying effective ways to translate what is already known into practice. Understanding how new technology will affect the current concept of teamwork (i.e., "computer-supported cooperative work").
• International examination of confidentiality protections given to health care providers, and whether such protections make a difference in error improvement.
• Hospitals and medical associations should work with their members to develop the need for research. Associations have the ability to bring together various parties and to engage them in the research process, so they remain vested in the research findings.
• Using large data sets to study errors in omission and commission. This endeavor will be greatly enhanced by the development of an electronic medical record by a number of organizations.

Current as of September 2000

Internet Citation:

Panel 2: Broad-Based System Approaches. Summary. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/sumpanel2.htm

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