Improving Patient Safety — Five Years after the IOM Report
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《新英格兰医药杂志》
A 1999 report from the Institute of Medicine (IOM) featured a now-familiar statistic: 44,000 to 98,000 people die in hospitals each year because of preventable medical errors, making hospital-based errors alone the eighth leading cause of death in the United States, ahead of breast cancer, AIDS, and motor vehicle accidents. Regardless of debate about these estimates, they remain the standard for describing the scope of the nation's problem with medical errors.
(Figure)
Courtesy of the National Academies Press.
When the report, titled To Err Is Human: Building a Safer Health System, was released, these numbers caught the public's attention as few other health policy issues have done. A 1999 survey showed that the report was the most closely followed health policy story of the year.1 The subject also grabbed the attention of public and private organizations that were in a position to address the quality of U.S. health care. On December 7, 1999, President Bill Clinton signed an executive order requiring federal agencies and departments to develop, within 90 days, a list of activities to make patient care safer. As a result, new programs were initiated at numerous agencies.
In the private sector, health care purchasers, industry trade organizations, accrediting and standards-setting bodies, and others embarked on programs of their own. One of the more ambitious was that of the Leapfrog Group, a coalition representing large health care purchasers that has advocated "safety leaps" through the use of computerized order entry, evidence-based hospital referrals, and physician staffing in the intensive care unit. There is some evidence that these recommendations are being adopted: in surveys, 24 percent of responding hospitals said they had intensive care units staffed by intensivists in 2003, as compared with 12 percent in 2001, and the use of computerized physician order entry had increased from 2 percent to 5 percent.2
Among other organizations, the National Quality Forum has endorsed a range of patient-safety measures through its consensus process, the New York and Georgia hospital associations are using the patient-safety indicators developed by the Agency for Healthcare Research and Quality in their improvement efforts, the Joint Commission on Accreditation of Healthcare Organizations has adopted patient-safety goals as part of the accreditation process, and nearly all eligible hospitals are reporting data on the quality of care through the Center for Medicare and Medicaid Services. Most hospitals now have a written policy for informing patients or their families of a preventable medical error. And the American Board of Medical Specialties has expanded the requirements for maintenance of board certification to include demonstrated competence in providing safe, high-quality care. Furthermore, recently published studies document the effectiveness of system-based changes, such as reducing the work hours of medical personnel, in reducing the rate of errors.3
Congress has also joined the effort. The House of Representatives passed legislation in 2003, and the Senate passed related legislation in August 2004; these bills are intended to increase the reporting of medical errors and problems with patient safety. If the bills are reconciled, the legislation will establish greater protections for providers that report such information, as well as creating patient-safety organizations in the states to help analyze safety data and implement improvements.
The ultimate purpose of all these efforts, of course, is to protect the public. In our 2004 national survey, one third of respondents reported personal or family experience with medical errors, many of them causing serious health consequences.4 Unfortunately, despite five years of focused attention, people do not seem to feel safer. More than half (55 percent) of the respondents in our survey said that they are currently dissatisfied with the quality of health care in this country4 — as compared with 44 percent four years ago.5 In fact, 40 percent believe that the quality of health care has "gotten worse" in the past five years, whereas only 17 percent think it is better. And half are worried about the safety of their medical care.4
How can we increase confidence in health care, as we continue to address safety and quality? A major obstacle is the absence of a consensus on what specific efforts should be the focus of safety improvement, including how best to collect and report information on the quality and safety of hospitals and health care providers. Reaching that consensus will be difficult for many reasons. Perhaps most challenging is the gap between the steps identified as important by patient-safety experts and the views of health care providers. For example, according to a 2002 survey, a majority of practicing physicians see just two approaches as very effective in reducing errors: "requiring hospitals to develop systems to avoid medical errors" (55 percent) and "increasing the number of hospital nurses" (51 percent). Fewer physicians agree that other proposed measures would be very effective: limiting certain high-risk procedures to high-volume centers (40 percent), using only physicians trained in intensive care medicine in hospital intensive care units (34 percent), increasing the use of computerized ordering systems (23 percent), and computerizing medical records (19 percent).1
Physicians also strongly oppose public reporting of information on medical errors — perhaps because of worries about malpractice lawsuits, which physicians name as the top concern facing health care and medicine today.1 In stark contrast, 71 percent of the public believes that public reporting of medical errors by government agencies would be very effective in reducing errors, and 7 in 10 persons say that such reports would tell them "a lot" about the quality of a hospital or a health plan.4
Although these challenges are real, the issue of patient safety may be less difficult to resolve than many health care issues — such as covering the uninsured or providing prescription-drug coverage — since it does not involve the sort of ideological and partisan differences that stall action. And although it will take an investment of resources to tackle, we do not think it will require hundreds of billions of dollars, as these other issues do.
Moreover, there has already been some movement on a key front — the greater use of information technology. Although they offer no panacea, such technological solutions as computerized order-entry systems, bar coding of medications, electronic prescribing, and strategies for sharing information have the potential to make care safer. Also, the interest expressed in the Health Information Technology Framework recently released by the Department of Health and Human Services could galvanize further action, leading to greater safety improvements and more information for patients and providers to use in deciding on the services patients receive.
However, the 2003 IOM report on data standards for patient safety (Patient Safety: Achieving a New Standard of Care) makes clear that what is really needed is a culture that encourages the sharing rather than the hiding of errors and near misses. The principal obstacle to broader action is therefore not Congress or money but a lack of consensus among policy makers and the public, and especially among health professionals themselves, on which events should be publicly reported and what systemwide steps are needed to prevent avoidable harm. Reaching consensus will require a national dialogue and the recognition by physicians that business as usual will not improve patient safety.
In the past five years, many promising efforts have been launched, but the task is far from complete. If we do not expand and accelerate current efforts, we can expect future surveys to reveal a persistent lack of confidence in the safety and quality of the nation's health care system.
Source Information
From the Kaiser Family Foundation, Menlo Park, Calif. (D.E.A.); the Agency for Healthcare Research and Quality, Rockville, Md. (C.C.); and the Department of Health Policy and Management, Harvard School of Public Health, Boston (R.J.B.).
References
Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-1939.
The Leapfrog Group Hospital Patient Safety Survey, April 2003–March 2004. Washington, D.C.: Leapfrog Group, 2004.
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of eliminating extended work shifts and reducing weekly work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-1848.
Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School of Public Health. National survey on consumers' experiences with patient safety and quality information. Menlo Park, Calif.: Kaiser Family Foundation, July 5, 2004.
Gallup poll. Storrs, Conn.: Roper Center for Public Opinion Research, September 11, 2000.(Drew E. Altman, Ph.D., Ca)
(Figure)
Courtesy of the National Academies Press.
When the report, titled To Err Is Human: Building a Safer Health System, was released, these numbers caught the public's attention as few other health policy issues have done. A 1999 survey showed that the report was the most closely followed health policy story of the year.1 The subject also grabbed the attention of public and private organizations that were in a position to address the quality of U.S. health care. On December 7, 1999, President Bill Clinton signed an executive order requiring federal agencies and departments to develop, within 90 days, a list of activities to make patient care safer. As a result, new programs were initiated at numerous agencies.
In the private sector, health care purchasers, industry trade organizations, accrediting and standards-setting bodies, and others embarked on programs of their own. One of the more ambitious was that of the Leapfrog Group, a coalition representing large health care purchasers that has advocated "safety leaps" through the use of computerized order entry, evidence-based hospital referrals, and physician staffing in the intensive care unit. There is some evidence that these recommendations are being adopted: in surveys, 24 percent of responding hospitals said they had intensive care units staffed by intensivists in 2003, as compared with 12 percent in 2001, and the use of computerized physician order entry had increased from 2 percent to 5 percent.2
Among other organizations, the National Quality Forum has endorsed a range of patient-safety measures through its consensus process, the New York and Georgia hospital associations are using the patient-safety indicators developed by the Agency for Healthcare Research and Quality in their improvement efforts, the Joint Commission on Accreditation of Healthcare Organizations has adopted patient-safety goals as part of the accreditation process, and nearly all eligible hospitals are reporting data on the quality of care through the Center for Medicare and Medicaid Services. Most hospitals now have a written policy for informing patients or their families of a preventable medical error. And the American Board of Medical Specialties has expanded the requirements for maintenance of board certification to include demonstrated competence in providing safe, high-quality care. Furthermore, recently published studies document the effectiveness of system-based changes, such as reducing the work hours of medical personnel, in reducing the rate of errors.3
Congress has also joined the effort. The House of Representatives passed legislation in 2003, and the Senate passed related legislation in August 2004; these bills are intended to increase the reporting of medical errors and problems with patient safety. If the bills are reconciled, the legislation will establish greater protections for providers that report such information, as well as creating patient-safety organizations in the states to help analyze safety data and implement improvements.
The ultimate purpose of all these efforts, of course, is to protect the public. In our 2004 national survey, one third of respondents reported personal or family experience with medical errors, many of them causing serious health consequences.4 Unfortunately, despite five years of focused attention, people do not seem to feel safer. More than half (55 percent) of the respondents in our survey said that they are currently dissatisfied with the quality of health care in this country4 — as compared with 44 percent four years ago.5 In fact, 40 percent believe that the quality of health care has "gotten worse" in the past five years, whereas only 17 percent think it is better. And half are worried about the safety of their medical care.4
How can we increase confidence in health care, as we continue to address safety and quality? A major obstacle is the absence of a consensus on what specific efforts should be the focus of safety improvement, including how best to collect and report information on the quality and safety of hospitals and health care providers. Reaching that consensus will be difficult for many reasons. Perhaps most challenging is the gap between the steps identified as important by patient-safety experts and the views of health care providers. For example, according to a 2002 survey, a majority of practicing physicians see just two approaches as very effective in reducing errors: "requiring hospitals to develop systems to avoid medical errors" (55 percent) and "increasing the number of hospital nurses" (51 percent). Fewer physicians agree that other proposed measures would be very effective: limiting certain high-risk procedures to high-volume centers (40 percent), using only physicians trained in intensive care medicine in hospital intensive care units (34 percent), increasing the use of computerized ordering systems (23 percent), and computerizing medical records (19 percent).1
Physicians also strongly oppose public reporting of information on medical errors — perhaps because of worries about malpractice lawsuits, which physicians name as the top concern facing health care and medicine today.1 In stark contrast, 71 percent of the public believes that public reporting of medical errors by government agencies would be very effective in reducing errors, and 7 in 10 persons say that such reports would tell them "a lot" about the quality of a hospital or a health plan.4
Although these challenges are real, the issue of patient safety may be less difficult to resolve than many health care issues — such as covering the uninsured or providing prescription-drug coverage — since it does not involve the sort of ideological and partisan differences that stall action. And although it will take an investment of resources to tackle, we do not think it will require hundreds of billions of dollars, as these other issues do.
Moreover, there has already been some movement on a key front — the greater use of information technology. Although they offer no panacea, such technological solutions as computerized order-entry systems, bar coding of medications, electronic prescribing, and strategies for sharing information have the potential to make care safer. Also, the interest expressed in the Health Information Technology Framework recently released by the Department of Health and Human Services could galvanize further action, leading to greater safety improvements and more information for patients and providers to use in deciding on the services patients receive.
However, the 2003 IOM report on data standards for patient safety (Patient Safety: Achieving a New Standard of Care) makes clear that what is really needed is a culture that encourages the sharing rather than the hiding of errors and near misses. The principal obstacle to broader action is therefore not Congress or money but a lack of consensus among policy makers and the public, and especially among health professionals themselves, on which events should be publicly reported and what systemwide steps are needed to prevent avoidable harm. Reaching consensus will require a national dialogue and the recognition by physicians that business as usual will not improve patient safety.
In the past five years, many promising efforts have been launched, but the task is far from complete. If we do not expand and accelerate current efforts, we can expect future surveys to reveal a persistent lack of confidence in the safety and quality of the nation's health care system.
Source Information
From the Kaiser Family Foundation, Menlo Park, Calif. (D.E.A.); the Agency for Healthcare Research and Quality, Rockville, Md. (C.C.); and the Department of Health Policy and Management, Harvard School of Public Health, Boston (R.J.B.).
References
Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-1939.
The Leapfrog Group Hospital Patient Safety Survey, April 2003–March 2004. Washington, D.C.: Leapfrog Group, 2004.
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of eliminating extended work shifts and reducing weekly work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-1848.
Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School of Public Health. National survey on consumers' experiences with patient safety and quality information. Menlo Park, Calif.: Kaiser Family Foundation, July 5, 2004.
Gallup poll. Storrs, Conn.: Roper Center for Public Opinion Research, September 11, 2000.(Drew E. Altman, Ph.D., Ca)