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Health Care Error Reports and Publications
Public Citizen (May 27, 2009)
Hospitals Drop the Ball on Physician Oversight www.citizen.org/documents/1873.pdfReport on Healthcare Reform Submitted to The Obama-Biden Transition Team
Consumers Advancing Patient Safety (CAPS) and the Coalition for Quality and Patient Safety of Chicagoland announced today the release of their report submitted to the Obama-Biden Transition Team and Health and Human Services Secretary-designate Tom Daschle. The target audience for this Health Community Discussion were key stakeholders in greater Chicagoland who already are active in the patient safety and quality improvement change work. Those stakeholders include among others, healthcare organization leaders, patients and family members, consumer advocates, employer representatives, physicians and other clinicians, state and county government representatives, educators and other advocates for transformation of healthcare. www.patientsafety.org/file_depot/0-10000000/20000-30000/24986/folder/58345/Obama-Biden+Health+Community+Discussion+Report+010709+Chicagoland.pdf
State of New Jersey releases its latest report highlighting preventable medical errors in the state's hospitals www.nj.gov/health/ps/index.shtml
United States Government Accountability Office
GAO Report to the Chairman, Committee on Oversight and Government Reform, House of Representatives. An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections. Sept. 2008
United States Government Accountability Office
GAO Report to the Chairman, Committee on Oversight and Government Reform, House of Representatives. Health-Care-Associated Infections in Hospitals. Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections. www.gao.gov/new.items/d08283.pdfAARP South Carolina Membership Survey: Quality of Care
Key findings include the following:
89% of the participants say that the current health care system needs change, with 52% believing that the system needs major changes.
85% support ensuring access to affordable, quality health care for all state residents.
More than 80% of participants identify controlling the cost of prescription drugs, improving the quality and safety of medical care, and improving the quality of nursing home and long term care as very or extremely important issues for them personally.
65% say they or a family member received care in a hospital in the past 3 years. Problems they experienced included not receiving legally required written information about how to get help when medical needs were not being met, not having personal needs taken care of in a timely fashion, and not being informed of medication side effects. Further, many believe that doctors and nurses did not spend enough time with the patient.
72% say that having an advocate with them in the hospital would make them much more comfortable.
A total of 1,080 AARP members age 50 and older responded to a mail survey during September 9-October 7, 2008. For more information, please contact Joanne Binette at 202-434-6303. (25 pages)Potentially Deadly Infection Doubles Among Hospital Patients Over Last 5 Years. AHRQ News and Numbers, Release date: April 23, 2008 www.ahrq.gov/news/nn/nn042308.htm
Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States
JAMA. 2007;298:1763-1771. http://jama.ama-assn.org/cgi/content/full/298/15/1763Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals 1993-2005 www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf
Patients in the United States have far less face time with primary care physicians than do patients in Australia and New Zealand, say the authors of a new Commonwealth Fund-supported study published in BMJ.
2005 Emergency Department Use in New Hampshire: A Comparison of the Medicaid and Commercially Insured Populations
www.dhhs.state.nh.us/DHHS/OMBP/LIBRARY/Data-Statistical+Report/emergency-use.htmThe Commonwealth Fund's 2006 Annual Report
Includes the results of the National Scorecard on U.S. Health System Performance. "According to the National Scorecard on U.S. Health System Performance, the United States scored just 66 out of 100 when comparing the nation's average performance on three dozen indicators against benchmarks set either within the U.S. or abroad." www.cmwf.org/usr_doc/site_docs/annualreports/2006/msg_pres01.htm
Hospital Quality Improvement: Strategies and Lessons From U.S. Hospitals
www.cmwf.org/publications/publications_show.htm?doc_id=471265&#doc471265Hospital Performance Improvement: Trends in Quality and Efficiency--A Quantitative Analysis of Performance Improvement in U.S. Hospitals
www.cmwf.org/publications/publications_show.htm?doc_id=471264&#doc471264Q Monitor: Ontario Health Quality Council: 2007 Report on Ontario's Health System http://ohqc.ca/pdfs/final_ohqc_report_2007.pdf
Issue of the Month: Bringing Patients to the Center of Hospital Care
www.cmwf.org/publications/publications_show.htm?doc_id=468284#issue"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 Report1st 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/psNo-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 stagesQuality Matters: Evaluating Evidence for Quality Improvement
www.cmwf.org/publications/publications_show.htm?doc_id=339493#issueNurse Staffing in Hospitals: Is There a Business Case for Quality? Needleman et al. Health Affairs.2006;
25: 204-211. http://content.healthaffairs.org 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.htmlMaximizing 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/psdataresourcesStudy finds US Pediatric medical errors kill 4500 children a year
http://bmj.bmjjournals.com/cgi/content/full/328/7454/1458-bReport 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.pdfCommonwealth Fund
"Hospital Quality: Ingredients for Success"? www.cmwf.org/programs/quality/meyer_hospitalquality_761.aspAgency for Health Care Research & Quality's
"Patient Safety Interim Report to Congress" www.ahrq.gov/qual/pscongrptAARP
Medical Error and Patient Injury: Costly and Often Preventable
http://research.aarp.org/health/ib35_medical_prn.htmlThe 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.pdfReport 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/pursuingperfectionHealthWeb
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.htmCommonwealth Fund
April 2002: Study Estimates 8 million American Families Experienced a Serious Medical or Drug Error www.cmwf.org/media/releases/davis534_release04152002.aspNational 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
Online RAND Health Research Documents
www.rand.org/publications/electronic/health.htmlTo Order Publications www.rand.org/cgi-bin/Abstracts/abdb.pl 2001 LRP-200109-07 Patients with Eventually Fatal Chronic Illness: Their Importance Within a National Research Agenda on Improving Patient Safety and Reducing Medical Errors. 2001 LRP-200107-07 No-Fault Compensation for Medical Injuries: The Prospect for Error Prevention. 2000 LRP-200003-04 Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado.
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National Academy
for State Health Policy An Act to Reduce
Medical Errors and Improve Patient Health: A Case Study from Maine Mandatory Reporting
Rules and Statutes listed by State
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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
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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%