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In the months since the release of the IOM report, many questions about the data have arisen. The distinction between error and preventable adverse event may seem insignificant, but it is not. Despite these questions, the IOM report itself is largely constructive rather than critical. I think that most of us in the health care provider community recognize in this the clear ring of truth. Meanwhile, medicine has become exponentially more complex, in both its scientific underpinnings and escalating administrative burdens superimposed by a nation struggling with how to finance its health care. Today, health care organizations are increasingly adopting systematic approaches to quality improvement. Acceptance of this concept represents a sea change in attitudes within health care organizations and has created an atmosphere fortuitously receptive to the IOM report. Nevertheless, as Brennan points out in his New England Journal article, medical errors have been declining in recent years, especially in areas such as anesthesia.
First, Emory Healthcare leadership is deeply committed to patient safety and minimizing medical errors. Full and accurate reporting of preventable adverse events is an important element of error-reduction programs. Despite these efforts, no health care organization knows the precise rates of preventable adverse events. For almost 10 years, Emory Hospitals have used clinical pathways to help reduce preventable adverse events, such as pressure sores and postoperative blood clots.
Nevertheless, because of the inherent high risks of the medication process, we are further increasing our emphasis on medication safety. The joint P&T group is dissecting the medication process from physician's order to administration of the medication by the nurse. We are addressing the physician-ordering step first and have agreed on a small number of basic standards for clear and acceptable orders. We implemented these ordering standards in July to coincide with the arrival and orientation of new residents.
In the long run, information technology will go a long way to help reduce medical errors and increase patient safety. This is a rapidly evolving field, and we anticipate declining costs and more ease of implementation. Despite the major challenges currently confronting the American health care system, I believe that we are on the verge of a "golden age" of health care. Endocrinologist Bill Bornstein is associate administrator and chief quality officer for Emory Hospitals. Second, these estimates are for deaths only and do not include negative effects that are associated with disability or discomfort.
If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.
The high cost of the health care system is considered to be a deficit, but to be tolerated under the assumption that better health results from more expensive care.
Of 13 countries in a recent comparison3,4 the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. Among 29 countries, the United States is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population. It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to more treatment.
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Medication Error Reporting Systems and Disclosing Medication Errors to Patients and Families. At least 44,000 to 98,000 deaths may occur annually as a result of medical errors in US hospitals.


To a large extent the initial reaction was, "yes, we can and should strive to reduce errors." The accuracy of the numbers was viewed as perhaps not so important. It is clear that errors are underreported and that such review is necessary to ascertain the true rate of "preventable adverse events." This latter term is used synonymously with medical error in the IOM report. He points out in a recent article in the New England Journal of Medicine that preventability is often a subjective concept and that, in most cases, direct evidence of actual errors was not seen in the chart. For example, investigators in these studies assumed that many post-operative hemorrhages and wound infections could have been avoided with more scrupulous care. In July, the Journal of the American Medical Association ran point-counterpoint articles on the IOM report.
The report emphasizes that the cause of most of these events is neither negligence nor carelessness but, rather, the result of the inevitability of human errors.
Unusual hours of continuous work during and after training have been part of the price of admission and a badge of honor.
Until recently, American society has eagerly accepted our model of infallibility almost to the point of questioning natural mortality itself.
Though coming to health care later than to many other industries, the methods of systems gurus such as Edwards Deming and Joseph Juran are being widely embraced. All agree that medical errors are vastly underreported, primarily because of liability concerns. For some time now, anesthesiologists have focused on simple but important measures to reduce errors -- gas fittings that prevent the connection of wrong gases, consistency among anesthesia machines as to the direction in which controls operate, and work hours based on human performance data, to name a few. The components of Emory Healthcare were early adopters of system redesign for process improvement and have been using these techniques for the past decade or so.
Only by knowing the rate of such events can we measure the effectiveness of our error-reduction efforts.
We strive to create a nonpunitive culture in which reports of such events are truly valued. Painstaking chart review, like that done in the Harvard Medical Practice Study and the Colorado and Utah hospital study, is likely to remain the gold standard for the foreseeable future, and, as already pointed out, even this approach has its limitations. Emory Hospitals already have in place many of the medication safety measures recommended by the IOM.
This year, Emory Hospitals have designated medication safety as one of their prime performance improvement focus areas.
We know from the literature that the majority of errors in this process occur at the physician-ordering step. These include a clear and legible signature and contact number to facilitate contacting the physician for clarification when a potential error is intercepted by the downstream safety net. In parallel, a series of educational initiatives are targeted at existing residents and attending physicians.
Emory Hospitals are rolling out a new antibiotic order form in parallel with the new ordering standards. For example, optimally designed and implemented interactive direct physician order-entry systems with real-time decision support will have enormous beneficial effects on quality, safety, efficiency, and costs of care.
The increase in diagnostic and therapeutic tools over the past two to three decades is staggering. This term is defined as induced in a patient by a physician's activity, manner, or therapy. In any case, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. These numbers, if accurate, would make hospitals the eighth leading cause of death in America and do not even include medical errors in the outpatient setting. The areas of greatest controversy continue to center on error reporting, especially liability protection and whether error reporting should be mandatory or voluntary. What exactly constitutes a medical "error?" Is the death rate due to medical errors really analogous to a large jetliner falling out of the sky every day or two?
The 1991 Harvard Medical Practice Study reviewed hospitalizations in 1984 and identified 98,000 deaths related to errors. Clement McDonald and colleagues of the Regenstrief Institute of the Indiana University Center for Aging Research argue that the number of deaths attributed by the IOM report to "preventable adverse events" is exaggerated. The theme is not that we must "do better" as individuals but rather that we must acknowledge our individual fallibility and implement systemic approaches to reducing and intercepting errors.


This fortuitous timing, in addition to the prestige of the IOM, may explain why the report is having such profound impact. Health care providers have generally ignored human performance studies, viewing them as being applicable to more mortal populations.
Huge liability has been assigned to what, in other settings, might be viewed as simple, inevitable errors.
The crux of the message is that better processes, not greater individual efforts, produce the greatest enhancements of quality and productivity.
Improved reporting of errors is not likely to occur without liability reform or at least protection.
The death rate from anesthesia has fallen progressively from one in 3,000 to 4,000 in the 1950s to an estimated current rate of one in 200,000 to 300,000. Second, although we have focused on improving patient safety and reducing preventable adverse events for some time, the IOM report is helping us increase awareness of these efforts and accelerate their pace.
Furthermore, analysis of these events gives us the opportunity to introduce system changes to prevent their recurrence. Moreover, this type of chart review is highly resource consumptive and impractical on a wide scale. Among these measures are the use of unit dosing, central pharmacy supply of high-risk medications, and pharmaceutical decision support. Fortunately, there are multiple downstream opportunities for these errors to be intercepted by the pharmacist, pharmacy information system, or nurse, for example.
This is one of those trivial sounding measures that can have dramatic impact and extend beyond medication orders to all orders. Such systems are presently extremely expensive, challenging to implement, and not really available "off the shelf." Poorly designed and implemented systems can introduce new sets of risks and problems.
In the meantime, there are plenty of opportunities to optimize manual processes to enhance safety. However, the enormous knowledge base now underpinning the practice of medicine has contributed to present discomforts. This would rank the lethality of US hospitals ahead of motor vehicle accidents, breast cancer, and AIDS.
In his rebuttal, however, Lucian Leape of the Harvard School of Public Health contends that the figures probably underestimate the problem. Furthermore, given the lack of excellent baseline data, improved reporting of errors will initially result in an apparent increase in errors. As one authority in this field has elegantly put it, each report of a preventable adverse event is a potential treasure. For the present, we must focus on putting in place systems of known benefit rather than waiting to be guided by precise metrics of error rates. We even use a robot (affectionately called Hal) in the pharmacy to dispense bar-coded medications into carts before they are taken to the floor. In addition, the pharmacy and therapeutics (P&T) committees of Crawford Long Hospital and Emory University Hospital (which also serves as the Emory Clinic P&T committee) meet jointly on a regular basis to focus on medication safety. Other elements of a minimally acceptable order include avoiding all but a few standard abbreviations and special rules for using zeros and decimal points. Only by aligning our understanding of human performance, process optimization, and information technology, can we truly deliver safe medical care and fulfill the promise of this unprecedented expansion of medical knowledge and tools. However, experts in the field agree that simple system-redesign measures such as those just described may deserve most of the credit. Such medications include those prescribed to treat allergic drug reactions and those that reverse the effects of narcotic pain relievers and certain sedatives.
The Harvard study identified 19% of the adverse events as drug related, while 14% were wound infections and 13%, technical complications. Readmission diagnoses are scanned for evidence of hospital-acquired infections or other possible adverse events.



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