TAKE-HOME POINTS
■ Hundreds of patients die every day in the United States from preventable medical errors, and thousands are harmed.
■ In many cases, simple interventions and better education could greatly reduce these numbers.
■ The estimated annual cost of preventable medical errors is between $17 billion and $29 billion.
■ Reimbursement for certain medical services has become dependent on avoiding adverse outcomes.
■ PAs play a critical role in preventing medical errors and promoting patient safety.
Ten years ago, the Institute of Medicine (IOM) released the first of two pivotal reports that focused on various aspects of patient safety: To Err is Human: Building a Safer Health System (2000). A follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001), came out a year later (Figure 1). In To Err is Human, some alarming statistics for health care in the United States were revealed. The report said that at least 44,000 patients, and perhaps as many as 98,000 patients, die in hospitals each year as a result of preventable medical errors. High pressure, fast-paced environments such as intensive care units, operating rooms, and emergency departments are areas where mistakes and threats to patient safety are more likely to occur. To Err is Human discussed mistakes such as adverse drug events, improper transfusions, wrong-site surgery, suicides, restraint-related injuries, falls, burns, pressure ulcers, and mistaken patient identities; the report said such errors in hospitals were estimated to exceed annual deaths from motor vehicle collisions, breast cancer, and AIDS combined.
While preventable medical errors have an obvious economic cost (estimates between $17 and $29 billion per year), what is less appreciated is that they cause patients to lose trust in the heath care system and they decrease satisfaction for both patients and medical providers. The IOM report noted that even though individual providers can sometimes be at fault for medical mistakes, errors are more likely to be caused by faulty systems, processes, and conditions that lead providers to make mistakes or fail to prevent them.
EFFORTS TO IMPROVE PATIENT SAFETY
To fix this national problem, the IOM report introduced a four-tiered approach: (1) establish a national focus on this subject; (2) develop a mandatory, nationwide public reporting system; (3) raise performance standards; and (4) implement safety systems in health care organizations. Following the release of the first IOM report, Congress appropriated funds to the Agency for Healthcare Research and Quality (AHRQ) that supported a variety of efforts targeted at reducing medical errors.
The second report from the IOM, Crossing the Quality Chasm, placed more of a focus on an inconsistent and less-than-high-quality US health care delivery system. The report highlighted that our current system has more than just small gaps in care; instead, there is a chasm of care. To close this chasm, the IOM introduced six aims for improvement, built around the core need for health care to be safe, effective, patient-centered, timely, efficient, and equitable. To help achieve these six aims, the IOM committee put forth 10 rules of health care redesign:
1. Care is based on continuous (through all available communication avenues) healing relationships.
2. Care is customized according to patient needs and values
3. The patient is the source of control
4. Knowledge (from systems to patients and their families) is shared, and information flows freely.
5. Decision making is evidence-based.
6. Safety is a system priority.
7. Transparency (from systems to patients and their families) is necessary.
8. Needs of the patient are anticipated.
9. Waste of the system is continuously decreased.
10. Cooperation among clinicians is a priority.
This report concluded that stronger leadership at the system level, unobstructed access to all forms of available information technology, the alignment of payment policies that focus on quality improvement, and preparing the health care workforce to make a smooth transition into an evolving and revamped health care system are all required next steps to go down the path of health care safety redesign.