"The 1999 Institute of Medicine (IOM) report, 'To Err is Human,' shocked people and catalyzed a new focus on patient safety. As our understanding of patient safety and error reduction has matured, we recognized the untapped power and drama of the individual case presentation," said Robert Wachter, MD, associate chairman of the UCSF department of medicine and executive editor of the new series. "By presenting and analyzing individual cases, we can educate physicians to understand the role of both individual and systems factors that merge to create a medical error."
In the first article, "The Wrong Patient," two patient safety experts from The Mount Sinai School of Medicine in New York describe the 17 errors that allowed one patient to receive an invasive procedure intended for another patient at an unidentified institution. This, along with all other cases, is based on real experiences and includes analyses from the top experts in the field. However, cases do not originate from the experts' home institutions, nor do they identify hospitals or physicians, according to the editors.
"The incident reviewed in the first article raises disturbing questions about the adequacy of patient safety systems in hospitals," said Mark Chassin, MD, chairman of health policy at Mount Sinai School of Medicine and lead author of "The Wrong Patient." Chassin formerly served as New York State Health Commissioner.
"In the complex environment of the modern hospital, preventable injuries to patients are most often caused by a combination of breakdowns in communication and teamwork and faulty information systems. Industries such as aerospace have invested enormous resources to develop systems that minimize such breakdowns. By adapting these systems to health care, we believe that we can decrease error rates and do a much better job protecting patients," he said.
While this series of articles and conferences are indicative of the steep learning curve medical professionals must ascend to prevent errors and safeguard patient safety, what can patients do to protect themselves? Chassin comments, "Patients should be outspoken and not hesitate to ask questions of their caregivers about their medications, procedures and details of their care. Ideally, a patient in a hospital should have someone with them around the clock to act as their advocate, watchdog and an additional set of eyes. In reality, that's not an option for many patients. And it shouldn't be necessary. A hospital should be the safest place in the world."
When contemplating non-emergency care, consumers may also be able to make more informed choices about which hospital to go to by researching the comparative performance information increasingly available online. "A number of important initiatives have been undertaken to get hospitals to publicly disclose their progress towards safety programs, clinical outcomes, and even patient-reported experience. In California and other states, a growing body of consumer-friendly information about hospitals, readily available on line, will ultimately create a strong market incentive for hospitals to improve," said Mark Smith, MD, CEO of the California HealthCare Foundation and co-executive editor of the new series.
This first article was co-authored by Elise C. Becher, MD, MA, assistant professor of pediatrics and health policy at The Mount Sinai School of Medicine. Deputy editors of the series include: Kaveh Shojania, MD, UCSF assistant professor of medicine; and Sanjay Saint, MD, assistant professor of internal and general medicine at the University of Michigan. Kathy Dracup, PhD, dean of the UCSF School of Nursing, serves as advisor to the editorial team and Amy Markowitz, JD, is managing editor of the new series.
Future articles in the series will cover medication errors, the question of what constitutes an error, infection control, the patient's hospital experience as a target for quality improvement, diagnosing chest pain in the ER, and errors in end-of-life care.
Funding for the new series is provided by The California HealthCare Foundation. The Foundation is also funding live grand rounds-style presentations scheduled at several California hospitals in the next year.
The California HealthCare Foundation (www.chcf.org) is an independent philanthropy organization committed to improving California's health care delivery and financing systems. The Foundation's goal is to ensure all Californians have access to affordable, quality health care. CHCF's Quality Initiative serves as a catalyst for improving the quality and accountability of health care in California.
California HealthCare Foundation
Source: Judy Frabotta, (510) 587-3150
E-mail: Jfrabotta@chcf.org
Journal
Annals of Internal Medicine