Improving Patient Safety

Tools and Strategies for Quality Improvement

Raghav Govindarajan, Harleen Kaur, Anudeep Yelam, Harleen Kaur, Anudeep Yelam

• Publisher: Productivity Press
• Year: 2019
• ISBN:
  9780429647116
• Edition: 1
• Topic: Business
• Subtopic: Operations
• Index: Business

Based on the IOM's estimate of 44, 000 deaths annually, medical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human facturs, E.H.R., etc. and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.

Chapter 1

Introduction to Patient Safety and Medical Errors

Nakul Katyal

University of Missouri

Introduction

Patient safety and healthcare-related errors have now become an important healthcare issue worldwide. In recent years, there have been improvements in regard to improving the patient safety, and many quantifiable problems have been addressed such as medication errors, healthcare-associated infections, and postsurgical complications. Comparatively, diagnostic errors have received less attention, even though landmark patient safety studies have consistently found that diagnostic errors are widely prevalent. Many recent studies have reported on the incidence, scope, and cost of adverse events related to healthcare errors. In a Harvard Medical Practice Study, diagnostic errors accounted for 17% of preventable errors in hospitalized patients. In a medical chart review of 30,121 patients admitted to 51 acute care hospitals in New York State, in 1984, Brennan et al. reported that preventable adverse events occurred in 3.7% of admissions. Medication errors and adverse drug events have been extensively investigated because they are both relevant and preventable. In a study carried out by Bates et al. in two teaching hospitals in Boston, 1% of the events were noted to be fatal, 12% were life-threatening, 30% were serious, and 57% were significant. Of the adverse events, 42% classified as life-threatening or serious were preventable. The medication errors were associated with the use of analgesics, antibiotics, sedatives, chemotherapeutic agents, cardiovascular drugs, and anticoagulants.¹ In a 2004 review of 25 years of malpractice claims, diagnostic errors were the leading cause of a claim (28.6%) and resulted in the highest proportion of total payments (35.2%). Further, diagnostic errors more often resulted in death than other causes (40.9% versus 23.9%) and were responsible for payments of US$38.8 billion.

Source of Errors in Healthcare

The literature identified two broad sources of error: human error and systemic error. Human error is further divided into random/personal error and systematic error. Random errors are those isolated personal errors that cannot be explained by underlying causes, external forces, or preceding events, and are due to personal behavior in a particular situation. Systematic errors, on the other hand, are those human errors that are not isolated but occur regularly due to some underlying undetected causes such as software or transfer errors. Figure 1.1 shows the sources and causes of errors in healthcare.²

Figure 1.1 Sources and causes of errors in healthcare.

Types of Medical Errors

The most widely used classification in regards to medical errors is by the Institute of Medicine (IOM). Table 1.1 represents different types of medical errors as per the IOM approach.

Table 1.1 Type of Medical Errors Following IOM Approach

Terminologies in Patient Safety

The Hospital Survey on Patient Safety Culture, released in November 2004, was designed to assess hospital staff opinions about patient safety issues, medical errors, and event reporting. The survey includes 42 items that measure 12 areas, or composites, of patient safety culture.³ Each of the 12 patient safety culture composites is listed and defined in Table 1.2.

Healthcare Statistics

The first comparative database report, released in 2007, included data from 382 U.S. hospitals. The survey was designed to assess hospital staff opinions about patient safety issues, medical errors, and event reporting. The survey also included two questions that ask respondents to provide an overall grade on patient safety for their work area/unit and to indicate the number of events they reported over the past 12 months. The 2016 user comparative database report included data from 680 hospitals and 447,584 hospital staff respondents. The average hospital response rate was 55%, with an average of 658 completed surveys per hospital.³

Table 1.2 Patient Safety Culture Composites and Definitions

Table 1.3 shows the average percent positive response for each of the 12 patient safety culture composites across hospitals in the 2016 database.

Table 1.3 Composite-Level Average Percent Positive Response—2016 Database Hospitals

The areas of strength or the composites with the highest average percent positive responses were as follows: teamwork within units (82% positive), supervisor/manager expectations and actions promoting patient safety (78% positive), and organizational learning—continuous improvement (73% positive).

The areas with potential for improvement or the composites with the lowest average percent positive responses were as follows: nonpunitive response to error (45% positive), handoffs and transitions (48% positive), and staffing (54% positive).

REFERENCES

1. La Pietra, L., et al., Medical errors and clinical risk management: State of the art. Acta Otorhinolaryngol Ital, 2005. 25(6): pp. 339–346.

2. Maamoun, J., An introduction to patient safety. J Med Imaging Radiat Sci, 2009. 40(3): pp. 123–133.

3. Study. Available at: www.ahrq.gov/professionals/quality-patient-safety/index.html. Accessed on July 25, 2018.

Chapter 2

Developing an Outline for Patient Safety Curriculum

Nakul Katyal

University of Missouri

ACGME Standards for Quality Improvement and Patient Safety Curriculum

The past decade has seen remarkable changes in healthcare system with an extensive focus on the need for quality improvement and patient safety (QI/PS).¹ This focus has resulted in the introduction of newer innovations in QI/PS education among U.S. medical schools and teaching hospitals. Resident participation is critical in quality improvement projects as they have the firsthand knowledge of the areas that need improvement.¹ Moreover, educational quality improvement projects can teach them core improvem...