Initiative Aims to Improve Patient Safety

The Medical College of Wisconsin is spearheading an effort to identify the causes of medical errors in hopes of preventing accidental deaths and injuries at medical facilities in Wisconsin. A report from the Institute of Medicine of the National Academy of Sciences recently estimated that errors at U.S. hospitals cause the deaths of between 44,000 and 98,000 patients each year.

"Avoidable deaths occur in hospitals and other healthcare settings, and the underlying problems continue to claim lives," said William R. Hendee, PhD, Senior Associate Dean for Research, Vice President for Technology and Dean of the Graduate School of Biomedical Sciences at the Medical College. In addition to leading the Medical College initiative, he is chair of the Education and Liaison Program for the National Patient Safety Foundation (NPSF).

Dr. Hendee is convening several meetings of healthcare leaders, providers, industry decision-makers and representatives of public interest and patient advocacy groups to identify how errors occur and how they may be prevented. Participants include attorneys, pharmacists, representatives from payer groups and such as Froedtert Hospital and Children's Hospital of Wisconsin (major affiliates of the Medical College), and the American Association of Retired Persons, the Medical Society of Milwaukee County, HealthSystem Health Maintenance Organization, and others.

In October 1999, 150 key community and healthcare leaders convened at the Medical College for the first Wisconsin Patient Safety Summit, organized in partnership with the NPSF, to produce a participant-supported action plan for the state's acute care facilities to improve patient safety and reduce healthcare errors.

Summit speakers included representatives from the Anesthesia Patient Safety Foundation (APSF), NPSF and the American Society for Quality (ASQ). Since 1984, the APSF has made concerted efforts to foster research about preventable anesthesia injuries, to encourage programs that reduce such injuries, and to promote the communication of ideas and information about the causes and prevention of anesthesia injuries.

Continuous learning is key to NPSF's mission and its attempts to move healthcare organizations beyond blaming to a culture in which errors and near-misses can be explored openly. Meanwhile, ASQ has offered a set of tools for solving problems and reducing errors in existing processes. The tools focus on understanding existing processes; using available data to understand interactions among variables to get to the root cause of problems; finding appropriate, proven solutions to problems; implementing solutions; and putting measurements in place to sustain improvements.

Other summit speakers included a pilot/attorney who suggested developing a culture of safety like the airline industry has, and Peter Layde, MD, Professor and Chief of Research in the Medical College Department of Family and Community Medicine, who recommended applying injury control science to patient safety by looking at all preventable injuries rather than just those caused by error.

Wisconsin pharmacists are working with the state legislature to develop an incentive program through Medicaid to prevent and intercede in errors, and the program could be further expanded.

"We are looking for problems, patterns and ways to reduce errors," Dr. Hendee said. "Most mistakes happen not because of ineptness or recklessness but because, in the normal course of events, mistakes occur and there are no checks and balances to prevent them. Many of the deaths that do occur, for example, appear to be caused by medication errors." Medication errors can occur at any point between the time a physician writes a prescription to when the medication is given to the patient.

In a Florida case, a syringe containing adrenaline, a heart stimulant, was placed next to one containing a local anesthetic. When the adrenaline syringe was picked up and used by accident, the injection killed the patient, an 11-year-old boy.

Examining problems that can lead to medical errors is difficult because there is an inherent fear among hospital staff that if they own up to mistakes, they open the door to finger-pointing, as well as litigation. A culture of fear and blame can cause individuals not to report mistakes.

Establishing a demonstration facility as a patient safety model that addresses changes in culture, including more open communication, is one of the goals of Dr. Hendee's efforts. Creating buy-in from all areas of the healthcare community and building a coalition to set priorities and implement the action agenda developed at the patient safety summit are key steps in the near-term to improving patient safety.

For more information, contact the Medical College Office of Continuing and Professional Education at 414-456-4896.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.