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President's MessageTo Err Is Human…Building A Safer Health SystemA. Allen Seals, M.D., President |
The Institute of Medicine (IOM) has recently released its highly anticipated, and widely reported, document on health system errors and, as predicted, it has created a firestorm of activity both in the media and now on the political stage in Washington. Some news services reported that over 51% of Americans closely followed media coverage of the IOM report. Although some physicians have reacted negatively to the report, most physicians have recognized that the IOM report has given medical leaders the initiative to re-examine issues related to patient safety and overall quality of care. Decreasing health system errors is not only an important ethic of the medical profession, but also is a high priority for the AMA/FMA/DCMS. Accordingly, when Senator Jim Jefford (R-Vermont, Chairman, Senate Committee on Health, Education, Labor and Pensions) recently convened a hearing on this subject, the AMA asked Dr. Nancy Dickey, a practicing family physician from College Station, Texas and immediate past-president of the AMA to present testimony. Jacksonville physicians could not have been better represented. This of course comes as no surprise to all area physicians who attended a DCMS sponsored dinner honoring Dr. Dickey during her recent visit to Jacksonville. The AMA strongly supports the basic principle underlying the IOM report that the health care system needs to transform the existing culture of blame and punishment that suppresses information about errors, into a culture of safety that focuses on openness and information sharing to improve health care and minimize adverse outcomes. The IOM report also highlighted the need for a system-wide approach to minimizing adverse outcomes and thereby improving safety and quality; instead of focusing on individual components of the health system in an isolated and punitive manner. However, Dr. Dickey pointed out that the AMA sharply disagrees with the point of the IOM report recommending a mandatory system for reporting deaths or serious adverse outcomes. A federal effort to collect data on physicians and other health care providers under the guise of "quality improvement" would become a medical witch-hunt of unprecedented proportions. Moreover, simply focusing on finding the individuals who may or may not have contributed to an error completely ignores the epidemiological research approach that has characterized so many notable advances in the quality and safety of patient care. Two examples from quality of care research point out the problems with the IOM's recommendation on mandatory reporting. The Anesthesia Patient Safety Foundation was founded to prospectively determine what constituted "best practice of anesthesiology". However, the fear of legal retribution was so pervasive, that anesthesiologist reviewers were forced instead to examine quality issues surrounding only cases that had already been legally settled or closed; thus needlessly delaying reviews of newer procedures and drugs. In contrast, the Centers for Disease Control and Prevention along with numerous hospital epidemiologists have systematically undertaken thousands of scientific investigations of endemic hospital infections. These studies were done in a blame-free environment in which learning and research were fostered. Infectious disease experts noted that prior efforts using a mandatory system often lead to incorrect and misleading information on the source of hospital infections. The overall results of the open "blameless" CDC program has been that hospital acquired infection rates have declined precipitously. As all practicing physicians are acutely aware, individual accountability for negligent or incompetent actions is already firmly ensconced in our judicial system for physicians and other health care workers. However, it is this very same fear of legal liability (or more likely the misapplication of perceived liability) that stands as the single greatest hurdle to pioneering patient safety efforts. Any federal approach to improving patient safety must, at a minimum, include a non-punitive mechanism for reporting incidents, post-incident evaluations for identification of system changes to prevent subsequent occurrences, and legislative protection from discovery of all aspects of information gathered to improve patient safety. In consideration of legislation to reduce medical errors and improve medical safety and quality of care, legislators should first recognize that the vast majority of medical errors are not intentional and must be distinguished from negligent practices. Adding more regulations and mandates are not the answer to improve patient safety; whereas nationwide dissemination of identified solutions to common medical errors will do a great deal more to reduce health care system errors than a mandatory reporting system. Policy makers should move ahead with the more productive recommendations in the IOM report that call for the transformation from a culture of individual blame (that suppresses useful medical information) to a more open and scientific evaluation of medical errors. This will likely require much needed liability protection to the organizations already providing scientific quality studies. As has been done with widely accepted practice guidelines (that have proven to improve patient care), legislators should also direct funding to support quality of care research grants to areas where information would lead directly to reduced medical errors and overall improvement of hospital care. To err is human, but the building of a better, safer, and more error-free health care system must include all components of the health care system working together in a positive, collaborative manner. March, 2000/ Jacksonville MedicineWhat's New
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