To Err Is Human Building a Safer Health System (2000) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-16
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, or AIDS (16,5161.6 Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors result 1
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Every year, over 6,000 Americans die from workplace injuries.8 Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annually.9 Medication-related errors occur frequently in hospitals and although not all result in actual harm, those that do, are costly. One recent study conducted at two prestigious teaching hospitals, found that about two out of every 100 admissions experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,700 per admission or about $2.8 million annually for a 700-bed teaching hospital.l° If these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole.
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Licensure and accreditation confer, in the eyes of the public, a "Good Housekeeping Seal of Approval." Yet, licensing and accreditation processes have focused only limited attention on the issue, and even these minimal efforts have confronted some resistance from health care organizations and providers. Providers also perceive the medical liability system as a serious impediment to systematic efforts to uncover and learn from errors.1l The decentralized and fragmented nature of the health care delivery system (some would say "nonsystem")
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All adverse events resulting in serious injury or death should be evaluated to assess whether improvements in the delivery system can be made to reduce the likelihood of similar events occurring in the future. Errors that do not result in harm also represent an important opportunity to identify system improvements having the potential to prevent adverse events.
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This report addresses issues related to patient safety, a subset of overall quality-related concerns, and lays out a national agenda for reducing errors in health care and improving patient safety. Although it is a national agenda, many activities are aimed at prompting responses at the state and local levels and within health care organizations and professional groups.
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Factors in the external environment include availability of knowledge and tools to improve safety, strong and visible professional leadership, legislative and regulatory initiatives, and actions of purchasers and consumers to demand safety improvements. Factors inside health care organizations include strong leadership for safety, an organizational culture that encourages recognition and learning from errors, and an effective patient safety program.
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To make significant improvements in patient safety, a highly visible center is needed, with secure and adequate funding. The Center should establish goals for safety; develop a research agenda; define prototype safety systems; develop and disseminate tools for identifying and analyzing errors and 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.
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In this instance, reporting is often manclatory, usually focuses on specific cases that involve serious harm or cleath, may result in fines or penalties relative to the specific case, ancl information about the event may become known to the public. Such systems ensure a response to specific reports of serious injury, hold organizations ancl providers accountable for maintaining safety, respond to the public's right to know, ancl provide incentives to health care organizations to implement internal safety systems that reduce the likelihood of such events occurring.
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Congress should · designate the National Forum for Health Care Quality Measurement and Reporting as the entity responsible for promulgating and maintaining a core set of reporting standards to be used by states, including a nomenclature and taxonomy for reporting; · require all health care organizations to report standardized information on a defined list of adverse events; · 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 action as needed with health care organizations. Should a state choose not to implement the mandatory reporting system, the Department of Health and Human Services should be designated as the responsible entity; and · designate the Center for Patient Safety to: (1)
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RECOMMENDATION 6.1 Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by health care organizations for internal use or shared with others solely for purposes of improving safety and quality. The committee believes that 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.
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RECOMMENDATION 7.1 Performance standards and expectations for health care organizations should focus greater attention on · ~ patient safety. · Regulators and accreditors should require health care organizations to implement meaningful patient safety programs with defined executive responsibility.
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~ practitioners anc corrective action are ~mportant to a comprehensive safety program. Responsibilities for documenting continuing skills are dispersed among licensing boards, specialty boards and professional groups, and health care organizations with little communication or coordination.
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should increase attention to the safe use of drugs in both preand post-marketing processes through the following actions: · develop and enforce standards for the design of drug packaging and labeling that will maximize safety in use; · require pharmaceutical companies to test (using FDA-approved methods) proposed drug names to identify and remedy potential sound-alike and look-alike confusion with existing drug names; and · work with physicians, pharmacists, consumers, and others to establish appropriate responses to problems identified through postmarketing surveillance, especially for concerns that are perceived to require immediate response to protect the safety of patients.
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In addition, a meaningful patient safety program should include defined program objectives, personnel, and budget and should be monitored by regular progress reports to governance. RECOMMENDATION 8.2 Health care organizations should implement proven medication safety practices.
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Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I
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12. Milstein, Arnold, presentation at "Developing a National Policy Agenda for Improving Patient Safety," meeting sponsored by National Patient Safety Foundation,Joint Commission on Accreditation of Health Care Organizations and American Hospital Association, July 15, 1999, Washington, D.C.
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