Issue Brief - MCIC Vermont Patient Safety Documents

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4 The Commonwealth FundTable 2. Most Highly RatedPatient Safety Practices• Appropriate use of prophylaxis to prevent venous thromboembolismin patients at risk.• Use of perioperative beta-blockers in appropriate patientsto prevent perioperative morbidity and mortality.• Use of maximum sterile barriers while placing centralintravenous catheters to prevent infections.• Appropriate use of antibiotic prophylaxis in surgical patientsto prevent postoperative infections.• Asking that patients recall and restate what they have beentold during the informed consent process.• Continuous aspiration of subglottic secretions (CASS) toprevent ventilator-associated pneumonia.• Use of pressure-relieving bedding materials to prevent pressureulcers.• Use of real-time ultrasound guidance during central lineinsertion to prevent complications.• Patient self-management for warfarin (Coumadin TM ) toachieve appropriate outpatient anticoagulation and preventcomplications.• Appropriate provision of nutrition, with a particularemphasis on early enteral nutrition in critically ill and surgicalpatients.• Use of antibiotic-impregnated central venous catheters toprevent catheter-related infections.Source: Making Health Care Safer: A Critical Analysis of Patient SafetyPractices. 2001. Evidence Report/Technology Report: Number 43. Agencyfor Health Care Quality.interventions. 20 The IQIs measure the quality ofcare in hospitals and include inpatient mortality forcertain procedures and medical conditions; utilizationof procedures for which there are questions ofoveruse, underuse, and misuse; and volume of proceduresfor which there is some evidence that ahigher volume of procedures is associated withlower mortality. 21 The PSIs detect potential adverseevents such as surgical complications and iatrogenicconditions associated with hospitalization. 22The Quality Indicators (QIs) have been adoptedfor use by many hospitals and provider organizationsacross the country interested in performancemeasurement. 23Error-Reporting SystemsPerhaps the most controversial of the IOM recommendationsdealt with error-reporting systems.Research suggests that health professionals arereporting errors more truthfully than in the past. 24However, evidence also suggests that when physiciansdo disclose errors, some craft their statementsto avoid admission of guilt or explicit discussion ofthe error. 25 Doctors cite the fear of malpractice litigationas the principal reason why their error disclosureoften falls short of being truthful andcomprehensive. Physicians also state that greaterlegal safeguards are necessary for a mandatoryreporting system to be successful. 26 Advocates ofvoluntary reporting argue that the current faultbasedsystem, which places blame on the individual,will result in underreporting and functions as asignificant disincentive to disclose error.Proponents of mandatory reporting argue that voluntaryreporting will not produce complete information,making it less valuable for identifyingtrends, ensuring corrective action, and issuing publicreports. 27Experts differ regarding the most effectivereporting system. Some suggest that voluntary systemscombined with strict confidentiality may bethe best method to encourage health professionalsto report mistakes. 28 Others argue that mandatorysystems are most effective, given research showingthat hospitals report fewer care-related injuries instates with voluntary systems than in states thatmandate reporting. 29Prior to the IOM report, 15 states hadmandatory reporting systems. 30 These states variedin their definitions of adverse events. The IOMreport defined an adverse event as a serious injuryresulting from medical management, and not from31, 32the underlying condition of the patient.Numerous bills dealing with these issues remaindeadlocked in state legislatures. 33 Currently, 22states have mandatory reporting systems, covering63 percent of the U.S. population. 34 However, therelease of medical error data is sporadic across the
Medical Errors: Five Years After the IOM Report 5various systems. Generally, states that introducemandatory systems establish them in statute, ratherthan regulation. These systems protect collecteddata and only release data in aggregate form. Ofthe 22 states, seven release incident-specific data.Fourteen states issue or plan to issue aggregatereports. Of these, five issue or plan to issue aggregatereports with individual facilities identified. 35Performance StandardsBoth public and private health care systems havetried to elevate performance standards since releaseof the IOM report. The Joint Commission onAccreditation of Healthcare Organizations(JCAHO)* has begun to enforce a broad set ofstandards focusing on patient safety. 36 These includerevisions to existing standards in order to supporterror-reduction programs in accredited organizationsas well as to develop new safety standards. 37 JCAHOincorporated these standards into its survey process,which evaluates safety and quality for nearly 5,000hospitals. As part of its accreditation program,JCAHO also requires hospitals to conduct rootcauseanalyses of adverse events, a process to get atthe factors leading to errors. JCAHO encourages,but does not require, hospitals to report adverseevents. Recently, JCAHO began developing program-specificpatient-safety goals for each of itsaccreditation and certification programs. JCAHOalso surveys health care organizations that use newmedication management standards. 38,39The Patient Safety Task Force within theDepartment of Health and Human Services coordinatesa joint effort among HHS agencies toimprove existing systems and integrate data onmedical errors. 40 The task force has initiated twostrategies to create a coordinated reporting system.The first relies on the Agency for HealthcareQuality and Research to support a series ofdemonstration projects to identify the causes of* JCAHO is an independent, not-for-profit government organization thataccredits and evaluates more than 15,000 health care programs andorganizations.errors and to develop evidence-based systems fortheir reduction. In FY 2001, AHRQ awarded $25million to 24 demonstration projects. The secondstrategy is to develop national benchmarks forpatient safety promotion. In the short term, thegoal is to develop accurate assessments of adverseevents. In the long term, this project aims to collectreliable rates of patients’ error risk to be usedto compare progress in error reduction acrosshealth care facilities. 41Most notable in the private sector forimproving performance standards has been theLeapfrog Group, a consortium of several Fortune500 companies and other private and public healthcare purchasers. The Leapfrog Group encourageslarge employers to reward health plans and hospitalsthat make breakthrough improvements inpatient safety and quality. Several U.S. purchasersestablished the organization in 2000 to develop acommon set of purchasing standards to promotepatient safety and care quality. The consortium alsoasks hospitals to report publicly on how they meetfour standards, or “leaps,” proven to reduce preventablemedical errors: computerized physicianorder entry, evidence-based hospital referral, ICUphysician staffing, and the National QualityForum’s safe practices. 42Safety Systems within Health Care OrganizationsThe IOM report placed medication errors amongthe most common preventable mistakes in hospitals,contributing to more than 7,000 deaths annually.43 One recent study found that medicationerrors occur in nearly one of every five doses inhospitals and skilled nursing facilities. 44 To reducemedication error, the American HospitalAssociation (AHA), Health Research andEducation Trust (HRET), and the Institute forSafe Medication Practices (ISMP) have formed apartnership to promote safety. Since publication ofthe IOM report, the partnership has distributedthe ISMP Medication Safety Self Assessment to
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Issue Brief - MCIC Vermont Patient Safety Documents

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