February 2003 Bulletin

Patient safety is no accident

Medical errors seriously threaten orthopaedists’ autonomy as professionals

By James H. Herndon, MD
2003-04 AAOS President

Data from a recent study in the New England Journal of Medicine (Dec. 12, 2002) showed that 40 percent of patients have experienced a medical error – whether themselves directly or with a family member or friend. In addition, one third of doctors reported seeing a medical error.

Despite growing evidence growing that medical errors are a danger to many patients, it is disturbing to find resistant attitudes about this problem among many medical professionals. We, as physicians, have become too accepting of the level of errors as something that can’t be changed. I believe patient safety is the most pressing issue we face today. This problem has and will continue to erode public confidence in our profession. Major payors, businesses and government are also concerned about safety and quality.

We can’t ignore this issue. The environment and attitude needs to be changed. I believe it is time for medical associations to step up to the plate and help devise systems that help reduce errors. Quality of care and setting of standards should be in the hands of medical professionals. If we don’t take charge, others will take charge of us.

That is why I have decided to make patient safety and reducing medical errors the main focus for my platform as president of the Academy for 2003.

Patient safety movement

With publication of the 1999 Institute of Medicine (IOM) report, "To err is human," the issue catalyzed public, payor and medical concerns about health care quality, specifically patient safety and medical errors. What captured their attention was the estimate that as many as 98,000 deaths occur each year due to problems with patient safety and medical error.

In reporting its findings, the IOM defined patient safety as freedom from accidental injury; medical error as a failure of a planned action to be completed as intended, or use of the wrong plan to achieve an aim; and an adverse event as a serious injury or death resulting from medical management, not the underlying condition of the patient.

Interestingly, there were publications on medical error before the IOM study but it was the first to become widely available to the public. It also was the first to challenge professional medical organizations to make patient safety a priority, urged medical schools to include patient safety in their curricula and asked regulatory agencies to monitor patient safety data.

Physicians fail to see problem

Less than 25 percent of physicians "think it would be very effective to use computers to order drugs." This is an astounding statistic, given that the Leapfrog Group, a consumer-focused consortium of more than 130 public and private organizations that provide health care benefits, has targeted computer physician order entry as one of three practices that could prevent a substantial number of hospital deaths caused by preventable mistakes every year.

Why is it that we as physicians have not fully acknowledged patient safety as a problem? Unlike the public, physicians in general don’t believe the quality of medical care in the United States is a problem. In a survey by Robinson, only 35 percent of physicians viewed quality as a problem, as compared to 68 percent of households. Sixty percent of households felt there should be a national agency to address medical errors, only 24 percent of physicians agreed.

However, both the public and physicians felt reducing medical errors should be a national priority.

Barriers to improvement

T. J. Krizick1 identified five issues within the practice of surgery that have inhibited improvement in health care quality:

In a study by G.R. Baker in Canada2, other barriers include: Fear of punishment, professional censure and/or litigation; limited resources and staff; poor teamwork and communication; lack of time and competing priorities.

As Demming, the author of continuous quality improvement, pointed out for industry even a one-tenth of one percent error rate is too high. Health care has an error rate of one percent, ten times that of industry. The ethical imperative is to exhaust all of our efforts in correcting the processes and situations that lead to error.

I believe the Academy should seize this initiative and become a leading advocate for making quality a central focus of every orthopaedic provider’s practice.

What we need to do

Beecher and Chassin3 believe that physicians now enjoy a moment of tactical advantage and need to establish strong and visionary leadership in health care and quality improvement. The defining, measuring and improving of health care quality can be in the hands of physicians. They make the following recommendations:

Our Academy and its members need to support the development of data registries and the use of clinical trials to improve safety. Lucian L. Leape, MD, Adjunct Professor of Health Policy at Harvard School of Public Health, co-author of the IOM report and a leading health policy analyst whose research has focused on error prevention and appropriateness of care, has proposed a specialty-based reporting program where useful information provided by expert analysis could measurably improve patient safety.

Our professional organizations, our health care institutions and physicians should foster the understanding about safety. It is not easy to establish an improved patient safety program. It is a massive effort, needing input and participation from everyone. An extensive communication and education program is essential. Safety is an active process that systematically employs preventative and corrective actions to avoid injury. It is an attitude and a discipline. It must be part of the culture of any entity.

Education—changing the culture

Teaching the next generation of physicians, nurses and other health care providers is important. Currently, I know of only one residency program that has a curriculum on patient safety—the Family Medicine Residency Program at New York University, where a patient safety program is included in their core curriculum.

An important part of medical education is teaching and learning effective communication skills. It is imperative that students learn how to communicate effectively with patients and colleagues. I am pleased that our Academy’s Communications Skills Mentoring Program will soon include a module on patient safety.

We can help by partnering with our patients and the payors to move patient safety forward. You can see this approach at work in the Veteran’s Administration, one of the first systems to address patient safety in a significant way. In 1990, they required that all employees complete 30 hours of continuing education each year with 10 of those hours focused on quality improvement and 10 hours on patient safety. Simulators now allow doctors and nurses to practice procedures and emergency drills, to make mistakes and learn from those mistakes using equipment including computerized human dummies.

The Brigham and Women’s Hospital in Boston has established a physician order entry system which has reduced errors significantly. They also use information technology to monitor adverse drug events and to provide a system provider communication network, as well as computerized sign-outs.

The Academy will lead

The Academy’s first patient safety project was the "Sign Your Site" initiative, aimed at preventing wrong site surgery. It arose in 1997 out of a task force chaired by past president S. Terry Canale, MD. The task force recommended implementation of the "Sign Your Site" program as a way to reduce the number of incidents involving an incorrect surgical location.

More recently, the Academy has put in place an aggressive comprehensive program for developing, monitoring and evaluating a full range of activities that promote patient safety such as physician education, "best practices" initiatives and increased public awareness. Our new Patient Safety Committee will be instrumental in accomplishing these activities. You may read more about these projects in an accompanying article written by David Wong, MD, chair of the Patient Safety Committee (see p. 28).

Over the long term, major issues will require coordinated efforts amongst professionals, hospitals and our patients. Your Academy is partnering with such organizations as the Joint Commission on Accreditation of Healthcare Organizations, the Agency for Healthcare Research and Quality, and the National Quality Forum – a nonprofit membership organization created to develop a national strategy for quality measurement and reporting. We have also started our own Orthopaedic Patient Safety Coalition (see article beginning on page 29) and a public education campaign with the theme "Take Care: Patient Safety is No Accident."

We have made a good beginning. And, with your help, we will move the practice of orthopaedics to one without error— an achievement for which our patients will be eminently grateful.

References:

  1. Krizek, T.J., "Surgical Error: Ethical Use of Adverse Events," Archives of Safety, 135: 1359-1366, 2000.
  2. Baker, G.R. et al, ISQua, Paris, Nov. 2002
  3. Becher, E.C. and Chassin, M.R., "Taking Health Care Back: A Physician’s Role in Quality Improvement," Academic Medicine, 77: 953-962, 2002.


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