Innovations in Patient Safety

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Innovations in Patient Safety

• Helen Burstin, MD, MPH
• Director, Center for Primary Care, Prevention,
• and Clinical Partnerships
• Academy Health
• June 6, 2004

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Bridging the Quality Chasm
Where
Where We We Are
Want To Be
Implementation
Health IT
Education
Diffusion
Adoption
TRIP
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Diffusion of knowledge
Balas EA, Boren SA., Managing Clinical Knowledge
for Health Care Improvement. Yearbook of Medical
Informatics 2000.
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RAND Study Quality of Health Care Often Not
Optimal
Medical errors corrode quality of healthcare
system
Medical Care Often Not Optimal Failure to Treat
Patients Fully Spans Range of What Is Expected of
Physicians and Nurses
Study U.S. Doctors are not following the
guidelines for ordinary illnesses
The American healthcare system, often touted as a
cutting-edge leader in the world, suddenly finds
itself mired in serious questions about the
ability of its hospitals and doctors to
deliver quality care to millions.
.
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To Err is HumanBuilding a Better Healthcare
System

• 1999 IOM Report
• Between 44,000 and 98,000 die as a result of
  medical errors annually
• Would be the 8th leading cause of death
• Ranks higher than MVAs, breast CA, AIDS
• Total costs 17-29 billion

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44,000-98,000 Lives

• Based on extrapolation from two studies
• Analysis of New York hospitalizations adverse
  events occurred in 3.7 of which 27 were
  negligent and death occurred in 13.6 (Brennan et
  al, NEJM, 1991)
• Analysis of Utah and Colorado hospitalizations
  adverse events occurred in 2.9 of which about
  30 were negligent and death occurred in 6.6
  (Thomas, Medical Care 2000)

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Medical Injuries During Hospitalization

• Based on 18 types of medical injuries
• gt32,000 attributable deaths occur annually
• 2.4 million extra days of hospitalization
• 9.3 billion excess charges
• (Zhan, Miller JAMA 2003)

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HHS Reports Quality and Disparities in Health
Care

• First national comprehensive efforts to measure
  the quality of health care in America and
  prevailing disparities in health care
• Presents data for clinical conditions, including
  cancer, diabetes, end-stage renal disease, heart
  disease, HIV and AIDS, mental health, and
  respiratory disease
• Includes data on maternal and child health,
  nursing home and home health care, and patient
  safety

Reports available at http//www.qualitytools.ahr
q.gov
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National Healthcare Quality Report Missed
Opportunities

• Only 20.9 of patients with diabetes receive all
  recommended tests
• 90 of adults are screened for high blood
  pressure but only 25 are controlled
• Nearly 1/3 of adults and children with asthma do
  NOT receive effective Rx
• Almost 20 of persons with a usual source of care
  report that they are not asked about medications
  to prevent interactions

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A Culture of Safety

• Non-punitive policies to address adverse events
• Organizational commitment to open communication
  about errors to encourage reporting, analysis,
  prevention and mitigation
• Alignment between legal and clinical staffs to
  ensure openness without compromising the
  organization

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Stages of Problem Recognition

• The data are wrong.
• The data are correct but it isnt a problem.
• The data are right, it is a problem but it isnt
  my problem.
• I accept the burden of improvement.

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Innovations in Patient Safety

• Panelists (i.e. the innovators)
• Ada Sue Hinshaw
• Brent James
• Jonathan Perlin