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Health Care Error Reports and
Publications
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"Detailed information on
medical malpractice judgments, settlements and arbitration awards against
physicians in fifteen states is now available on-line, at
www.healthgrades.com,
as part of HealthGrades’ physician quality reports for consumers" ~ Inside
Indiana Business.Com Report at
Pennsylvania Health Care Cost
Containment Council Report
1st annual report for the New Jersey Patient Safety Initiative provides a
summary of the 2005 activities of the Patient Safety Initiative and the reported
events/related RCAs for that year. The New Jersey reporting system is based on
the NQF "never events." This Patient Safety Initiative web site includes a
link to the report, newsletters and other materials. www.nj.gov/health/hcqo/ps
No-Fault Compensation in New Zealand: Harmonizing Injury Compensation, Provider
Accountability, and Patient Safety ( Health Affairs, Jan./Feb.
2006). In this Fund-supported study, former Harkness Fellows Marie Bismark
(2004-05) and Ron Paterson (2002-03) compare New Zealand's no-fault compensation
system for medical injuries to the malpractice approach in the United States.
The authors find New Zealand's Accident Compensation Corporation (ACC) is simple
for patients to navigate and produces more-timely decisions for a greater number
of patients. However, concerns about the program remain: 30 years after
implementation of the ACC, New Zealand's hospitals are no more or less safe than
those in other industrialized countries, the study finds.
Kaiser Permanente's Experience of Implementing an Electronic Medical Record: A
Qualitative Study ( BMJ, Dec. 2005). As part of a research team
cofunded by the Garfield Foundation and the Fund, J. Tim Scott (Harkness Fellow
2002-03), based at the University of St. Andrews School of Management in
Scotland, interviewed doctors, managers, and office staff involved in selecting,
testing, and implementing an electronic health record (EHR) system at Kaiser
Permanente Hawaii. According to the study, the keys to successful EHR
implementation are a participatory selection process, maintaining flexibility in
roles and responsibilities, and decisive leadership at critical stages
COPING WITHOUT
HEALTH INSURANCE
November 28, 2005 - A PBS
report on the plight of those living without health insurance.
www.pbs.org/newshour/bb/health/july-dec05/insurance_11-28.html
Maximizing the Use of State Adverse Event Data to Improve Patient
Safety
An October 2005 report by Jill Rosenthal and Maureen Booth
This report reviews key findings
from a summit of state officials who administer reporting systems.
The meeting also included data analysts and data users (providers,
purchasers, and consumers). The purpose of the summit was to
identify mechanisms and tools used to improve data integrity, event
report analysis, and data feedback and dissemination. The report
focuses on these issues and raises a number of challenges and
opportunities that states encounter as they attempt to improve their
databases and the usefulness of the data for improving patient
safety.
www.nashp.org/psdataresources
Study finds US Pediatric medical errors kill 4500 children a year
http://bmj.bmjjournals.com/cgi/content/full/328/7454/1458-b
Report on state-based safety centers
that have the goal of reducing medical errors
www.nashp.org/Files/final_web_report_11.01.04.pdf
Study: Hospital errors cause 195,000 deaths Report doubles
earlier Institute of Medicine estimate.
www.healthgrades.com/media/english/pdf/HG_Patient_Safety_Study_Final.pdf
Commonwealth Fund
"Hospital Quality: Ingredients for Success"?
www.cmwf.org/programs/quality/meyer_hospitalquality_761.asp
Agency
for Health Care Research & Quality's
"Patient
Safety Interim Report to Congress"
www.ahrq.gov/qual/pscongrpt
AARP
Medical Error and Patient Injury: Costly and Often Preventable
http://research.aarp.org/health/ib35_medical_prn.html
The Commonwealth Fund
January 2004
Mirror, Mirror on the Wall: Looking at the Quality of American Health
Care through the Patient's Lens -By Karen Davis, Ph.D., et al
www.cmwf.org/programs/international/davis_mirrormirror_683.pdf
Report on the response to a
California law (SB 1875) addressing medication safety
www.chcf.org/topics/view.cfm?itemid=21576
Harvard
School of Public Health and Henry J. Kaiser Family Foundation
News Release, Dec. 12, 2002
4 IN 10 OF PUBLIC, MORE THAN ONE-THIRD OF PHYSICIANS SAY THEY
HAVE PERSONALLY EXPERIENCED MEDICAL ERRORS
www.kff.org/content/2002/20021211a/Medical_Errors_Release.pdf__
Institute for
Health Care Improvement
Pursuing Perfection: Raising the Bar for Health Care Performance
www.ihi.org/pursuingperfection
HealthWeb
Health Data Resources by State
www.healthweb.state.me.us/st_health_res.asp
__________________________________________________________________________
Future Perfect, Inc.
Richard A. Pistolese
Research Director
www.chiropediatrics.com
"Medical Error"
www.wcwf.org/research/medical.htm |
Commonwealth Fund
April 2002: Study Estimates 8
million American Families Experienced a Serious Medical or Drug Error
www.cmwf.org/media/releases/davis534_release04152002.asp |
| National
Patient Safety Foundation survey depicting that 100 million Americans
have been injured or know someone who has been harmed by medical error.
Executive Summary
www.npsf.org/html/pressrel/execsum4.htm |
National
Survey on Americans as Health Care Consumers: An Update on the Role of Quality
Information
This
survey of Americans by the Kaiser Family Foundation and the Agency for Health
Care Research and Quality (AHRQ) shows that the recent attention to medical
errors may have entered the public's consciousness since it is now among the
public's leading measures of health care quality
http://kff.org/content/2000/3093/ |
RAND
Non-profit
institution that helps improve policy and decision making through
research and analysis
P.O. Box 2138, 1700 Main Street, Santa Monica, CA 90407-2138
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Publications
Rosenthal , Jill, Maureen Booth and Anne Barry. Cost
Implications of State Medical Error Reporting Programs: A Briefing Paper. Portland,
ME: National Academy for State Health Policy. 2001.
Rosenthal , Jill et al. Current State Programs Addressing
Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives.
Portland, ME: National Academy for State Health Policy. 2001 .
Riley, Trish. The Flood Tide Forum, Improving Patient
Safety: What States Can Do About Medical Errors. Portland,
ME: National Academy for State Health Policy. 2000.
Rosenthal, Jill and Maureen Booth. How Safe is Your
Health Care? A workbook for states seeking to build accountability
and quality improvement through mandatory reporting systems. Portland,
ME: National Academy for State Health Policy. 2001 .
Rosenthal, Jill and Trish Riley. Patient Safety and
Medical Errors: A Road Map for State Action. Portland, ME: National Academy
for State Health Policy. 2001 .
Flowers, Lynda and Trish Riley. State-based Mandatory
Reporting of Medical Errors: An Analysis of the Legal and Policy Issues.
Portland, ME: National Academy for State Health Policy. 2001 .
Rosenthal, Jill, Trish Riley and Maureen Booth. State
Reporting of Medical Errors and Adverse Events: Results of a 50-State Survey. Portland,
ME: National Academy for State Health Policy. 2000 .
Order NASHP Publications on line:
http://nashp.org/store/prodpage.cfm?CategoryID=2#3
Summary
- to learn more access full document
ERROR:
Is defined as the failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim. * May include
"near misses"
Adverse Event:
Injury caused by medical management rather than by the underlying
disease or condition of the patient.
Preventable Adverse Events:
Errors which result in serious harm or death.
All adverse events resulting in serious injury or death should be evaluated
to asses whether improvement in the delivery system can be made to reduce the
likelihood of similar events occurring in the future.
Building safety into processes of care is a more effective way to reduce
errors than blaming individuals. The focus must shift from blaming
individuals for past errors to a focus on preventing future errors by designing
safety into the system. When an error occurs, blaming an individual does
little to make the system safer and prevent someone else from committing the
same error.
Results of Study in Colorado & Utah imply that @
least 44,000 die each year as the result of medical errors. Results from New
York Study imply 98,000 deaths each year.
* When using the lower estimate, medical errors exceed the eighth leading
cause of death in our country. Claiming more lives than automobile accidents,
breast cancer or aids.
Total National Costs of preventable adverse events are estimated to be
between $17 billion and $29 billion, and estimated to be between $37.6
billion and $50 billion for Adverse Events - of which health
care costs represent over ½. According to the American Society for
Quality, that calculates to $900 per hospital admission.
Major force for Improving Patient Safety:
External Environment: Knowledge & Tools to improve safety,
professional leadership, LEGISLATIVE & REGULATORY Initiatives, and actions
of purchasers & consumers to demand safety improvements.
Inside Health Care Organizations: Strong Leadership for safety, a safe
environment that encourages recognition and learning from errors & an
effective patient safety program.
Identify & Learn from errors through the immediate & strong MANDATORY
reporting efforts; as well as the encouragement of voluntary efforts - with the
aim of making sure the system continues to be made safer for patients.
Patient Safety Center:
Define prototype safety systems; develop & disseminate tools
for identifying & analyzing errors & evaluate approaches taken; develop
tools and methods for educating consumers about patient safety; issue an annual
report on the state of patient safety, and recommend additional improvements as
needed.
Reporting Systems:
A.) Accountability of health care organizations; fines - penalties
B.) Respond to the public’s right to know.
Collecting Reports and Not Doing anything with the information serves no
useful purpose.
Recommendation 5.1
A nationwide mandatory reporting system should be established
that provides for the collection of standardized information by state
governments about adverse events that result in death or serious harm. Reporting
should initially be required of hospitals and eventually be required of other
institutional and ambulatory care delivery settings.
* Congress should provide funds and technical expertise for state governments
to establish or adapt their current error reporting systems to collect the
standardized information, analyze it and conduct follow up actions with health
care organizations.
Recommendation 5.2
The development of voluntary reporting efforts should be
encouraged.
The Center for Patient Safety:
Should fund and evaluate pilot projects for reporting systems, both within
individual health care organizations and collaborative efforts among health care
organizations.
The Committee believes there is a role both for mandatory, public reporting
systems and voluntary, confidential reporting systems.
"Information about the most serious adverse events which result in harm
to patients and which are subsequently found to result from errors should NOT be
protected from public disclosure."
Recommendation 7.2
Professional Societies should make a visible commitment to patient safety by
establishing a permanent committee dedicated to safety improvement. Including:
A.) Develop a curriculum on patient safety and encourage its adoption into
training & certification requirements.
B.) Disseminate information on patient safety to members through special
sessions at annual conferences, journal articles & editorials, newsletters,
publications & websites on a regular basis
Harvard Medical Practice Study
The proportion of Adverse Events attributed to errors was 58%
The proportion of Adverse Events due to negligence was 27.6%
13.6% of adverse events studied resulted in death & 2.6%
percent caused permanent disabling injuries.
Study of Adverse Events in Colorado & Utah
Adverse Events occurred in 2.9% of hospitalizations
The proportion of Adverse Events due to negligence was 29.2%
The proportion of Adverse Events that were preventable was 53%
Deaths resulted in about 1 out of every 11 negligent adverse
events
Study of Adverse Events in New York
13.6% of adverse events resulted in deaths.
About 1 in 4 negligent adverse events led to death.
Adverse Events occurred in 3.7% of hospitalizations
The proportion of Adverse Events that were preventable was 58%
