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Why patient safety matters

Lisa Mustone Alexander, EdD, MPH, PA-C

Lisa Alexander serves as the Assistant Dean for Community-Based Partnerships, George Washington University School of Medicine and Health Sciences, Washington, DC. She is the Chair of the AAPA Quality Care Committee and a practicing clinician in a local community health center. She has indicated no relationships to disclose relating to the content of this article.

During the past decade, the ascension of the quality care movement into the national spotlight can be attributed to the publication of two Institute of Medicine (IOM) reports. The first, published in 2000 and entitled To Err Is Human: Building a Safer Health System,¹ was followed a year later by Crossing the Quality Chasm: A New Health System for the 21st Century.² The first report focused primarily on the high incidence of medical errors and examined some of the systemic institutional flaws that contribute to the problem. The second publication provided a broader framework for improving the health care delivery system, building on a foundation that emphasizes patient safety but extends to all aspects of service delivery. Both reports helped to catalyze a widespread dialogue among health professionals and their respective professional organizations on these important issues of patient safety, medical errors, and quality care.

Most providers believe that they provide high-quality care for all patients. However, the statistics do not seem to back up those claims. Each year, an estimated 44,000 to 98,000 patients die because of adverse events that occur during their interaction with the health care system.¹ Two of every 100 admissions to hospitals result in a preventable adverse drug event that produces higher costs, injury, and sometimes death.¹ And every time there is a medical error, patient trust in the health care system erodes—and future patient-provider interactions are adversely affected.

The Academy’s work in quality care

Even before the IOM reports were published, the Academy’s activities in this area were carried out through the Quality and Risk Management Committee. The focus of that committee was primarily on improving quality as a means of reducing professional risk. Most recently, the committee has looked more broadly at quality care, prompting a name change to the “Quality Care Committee” (QCC) in 2003.

After the IOM reports were published, the committee worked with the AAPA Board of Directors and House of Delegates to redirect activities and focus more on patient safety. During the past two years, the QCC has worked diligently to promote this agenda to the membership through innovative communication techniques such as clinician-focused articles that provide user-friendly examples of safety improvement strategies, continuing education programs, and policy briefs to the House of Delegates. The committee monitors the quality care literature and publishes regular communiqués in AAPA News. Most recently, the committee worked with AAPA staff to submit a funding proposal to the Agency for Healthcare Research and Quality for CME lectures on patient safety. Funding for this initiative will be provided through the grant award, and plans are in place to launch the program at the upcoming annual PA conference in San Francisco.

The AAPA Quality Care Committee seeks to increase the knowledge, awareness, skills, and leadership capacity of the Academy membership in the patient safety movement. It is important to remember that most medical errors occur because of systemic flaws in health care delivery, not because of malicious intent or incompetence on the part of clinicians. PAs must be aware of how these flaws can be corrected and of the role they can play in helping to institutionalize these systemic improvements.

How we can improve care

In 2005, Dr. John Gosbee conducted a patient safety workshop sponsored by the QCC at the AAPA annual conference. The workshop introduced participants to the discipline of human factors engineering (HFE), which has been cited as an important institutional approach to improving patient safety and reducing medical errors. HFE examines human capabilities and limitations and applies the information gained to the design of safe, effective, and comfortable systems.³

During the workshop, Dr. Gosbee, who directs the National Center for Patient Safety within the Department of Veterans Affairs, provided instruction and gave participants the opportunity to conduct a human factor analysis. Essentially, this exercise is a deliberate and methodical examination of a delivery system within health care. It can be as simple as examining a delivery system for injectable drugs or as complex as reviewing a sophisticated surgical intervention. It breaks down the activity into its component tasks. Next, it analyzes each task in terms of physical demands, skill demands, mental workload, and other such factors, along with their interactions with aspects of the work environment, device design, and team dynamics. Standardizing medical equipment, instituting bar coding for pharmaceuticals, and reducing work hours of physician residents are just a few examples of changes resulting from HFE.

Patient safety officers are another approach to preventing medical errors. When adverse events are reported, the patient safety officer undertakes a root cause analysis of the event and reviews the entire case with the health care team. This role of patient safety officer is one that PAs are uniquely qualified to assume, and they should be encouraged to do so.

PAs can also be driving forces within their respective organizations to adopt and integrate technology into daily patient care routines. Electronic medical records, health information access, and electronic prescribing have all been shown to reduce medical errors, increase efficiencies within the practice setting, and enhance patient satisfaction. Since many PA educators introduce and integrate these technologies in the classroom, most graduates are skilled in utilizing such resources. However, after graduation, they often move into practices that are considered “low tech” and utilize technology for, at the most, e-mail and health research. Every PA should be among the legion of technology converts who promote technology and influence the decision making in a practice to integrate and adopt such safety measures.

A challenge to all PAs

The topic of patient safety matters most to those on the receiving end of health care—the patients. Since PAs pride ourselves on delivering patient-centered care, we must familiarize ourselves with the research and practices promoted by experts. Only then can we say that, as a profession, we practice high-quality care. •

REFERENCES

1.
Committee on Quality of Health Care in America, Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

2.
Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

3.
Gosbee JW. Introduction to the human factors engineering series. Jt Comm J Qual Saf. April 2004;30(4):215-219.