Summary: Panel 3—Particular System Issues

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 3: Particular System Issues

This panel focused on very targeted areas that contribute to the research agenda on medical errors and patient safety: medication errors, hospital staffing, medical devices, and end-of-life care.

Michael Cohen, F.A.S.H.P., Institute for Safe Medication Practices

Dr. Cohen's testimony focused on why widely known and effective medication error reduction strategies have not been adopted, and on how to structure a nationwide communication initiative on medication error prevention. He suggested that research be done to identify:

• The current level to which known medication error reduction strategies have been adopted.
• Barriers that have led to the failure to adopt widely known medication error reduction strategies.
• The most effective ways to structure and fund a comprehensive nationwide communication initiative, taking advantage of current knowledge about medication error prevention to provide crucial information directly to all health care participants.

Patricia Underwood, American Nurses Association

Ms. Underwood's testimony focused on the relationship between working conditions in health care settings and patient safety. She suggested the following as priority areas: Research to evaluate the occurrence of medical errors in relation to the following variables:

• Patient-nurse ratio, severity of illness, mortality/morbidity rates, and length of stay.
• Research to examine the relationship between continuous hours worked by health care professionals and their ability to work safely and without errors.
• Research to evaluate the relationship between work environment and patient safety by assessing the following trends: work-related staff illness and injury rates, overtime rates, staff satisfaction levels, flexibility of human resources policies and benefits packages, use of supplemental staffing, and compliance with Federal, State, and local regulations.
• Research to compare the efficacy in reducing medical errors of institutions that have enhanced monitoring and reporting systems versus institutions where continuous quality improvement principles have been implemented as part of the organization's culture.

Mark Bruley, Emergency Care Research Institute

Mr. Bruley noted that while most medical errors have many causes, there are three constants in any accident: the medical device or technology, the procedure, and the resulting injury. He proposed a research agenda focusing on the interactions of these constants by addressing three key areas:

• Defining the extent to which medical devices contribute to medical errors, with a special focus on the technology-intensive medical specialties.
• Identifying what safety features or engineering controls (including those based on human factors research) can be employed to minimize the likelihood of medical errors.
• Determining whether the frequency and severity of device-related errors justifies the development of broader reporting and prevention interventions.

Joanne Lynn, M.D., M.A., M.S., RAND Center to Improve Care of the Dying and Americans for Better Care of the Dying

The end-of-life patient population is a very important target of safety research because they have more contact with the health care system (and are therefore at greater risk for error), and they are also physiologically more vulnerable to medication errors and other lapses in patient safety than healthier patients. Dr. Lynn identified five priority areas for research focusing on vulnerable populations:

• Research to examine alternative conceptual models for the current definition of "cause of death," and to determine when medical errors (that are part of a chain of causation leading to death) should be counted as a cause of death.
• Research to examine the magnified effects of routine errors on the vulnerable patient population in comparison to their effects on the more robust general patient population.
• Research to examine the effectiveness of subjecting errors of non-treatment or mistreatment of common end-of-life symptoms (e.g., pain, depression) to the same kinds of systems engineering, accountability, and national goal-setting that is being proposed for medication errors.
• Research to examine how provider and public health organizations can arrange services in a way that will provide efficient, sustainable, reliable, and safe care for the end-of-life population.
• Research to determine whether emergency hospitalizations of patients at the end of life should be considered potentially preventable adverse events and therefore significant risk factors.

Question and Answer Session

The following additional areas for research focus were discussed:

• Research must take a whole-system approach, and not just a provider-focused approach, to find a lasting solution.
• Research should examine the financial distress of hospitals and how it impacts on medical errors, with a special focus on staffing patterns.
• Research should identify the best components of other industries' safety efforts (e.g., aviation industry), and can also examine the adaptation and application of other industries' models to health care.

Current as of September 2000

Internet Citation:

Panel 3: Particular System Issues. Summary. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/sumpanel3.htm

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