Patient Safety

Changing the systems that lead to mistakes

By William G. Gamel, M.D., CEO, TMF Health Quality Institute

This past summer, President Bush signed the Patient Safety and Quality Improvement Act of 2005. The Act encourages physicians to voluntarily report medical errors to a Patient Safety Organization. The PSO will take that information, evaluate it and then create patient safety improvement strategies. (1)

The passage of the Patient Safety and Quality Improvement Act was one of the American Medical Association’s top legislative priorities this year. As a past president of TMA, I believe that this act will help the health care system move away from shifting blame on individual physicians to focusing on open discussions and creating systems that encourage patient safety.

Patient safety isn’t a new topic. In 1999, the Institute of Medicine published “To Err is Human: Building a Safer Health System.” The report reveals that our health care system is subject to preventable errors from a variety of sources. (2) (p26)

The Need to Change

According to the IOM report, death rates in our hospitals due to preventable adverse events range from a low of 44,000 to as many as 98,000. (2) (p26) The report cites that most adverse events are caused by errors. (2) (p29)

Preventable adverse events are one of the top causes of death in the United States, exceeding breast cancer, motor vehicle injuries or AIDS. (2) (p26) In addition, preventable adverse events cost the nation between $17 billion to $29 billion. (2) (p27)

So who’s responsible for these losses? The IOM report stresses that most medical errors are system derived. (2) (p49) In fact, some believe that at least 80 percent of medical errors are system derived. (3) This means that no matter how good we are as physicians, the system is setting us up to fail.

Even with all these findings, most individuals today still believe that bad physicians are to blame for medical errors and that if these bad apples are removed, everything will be okay. (4)

I beg to differ. While every profession has a few bad apples, all physicians were attracted to medicine because we wanted to treat and heal our patients.

Barriers to Change

Five years after the IOM report was published, there have been small changes to improve patient safety in our health care system. Even so, there are barriers that continue to prevent advances in patient safety: (4)

1. A complex health care system that is specialized and often
   interdependent. (4)
2. A culture of medicine that places emphasis on individualism and
   autonomy. (4)
3. Physicians’ fear of disclosure or admission of medical errors due to a concern over potential malpractice claims. (4)
4. A lack of strong patient safety measures that health care organizations can use as they are trying to change their systems. (4)
5. A current reimbursement system that inadvertently rewards errors by paying for additional services due to error without incentives to reduce recidivism and rework. (4)

Achieving Patient Safety

It is critical that leaders make patient safety a strategic priority and make it their key focus. They must work on assessing their current culture and changing it to support the patient safety effort. The culture must praise open discussions of errors so that staff members feel comfortable sharing and everybody learns from these errors. (5)

In addition, all key stakeholders must support patient safety. Leaders must spend time with their staff and discuss safety issues with them on a regular basis. Having regular safety briefings with the staff can help transform the culture, increase awareness about patient safety and create a fear-free environment. Once the dialogue has begun, organizational quality and safety goals must be set. (5)

Being committed to patient safety means that an organization provides support to staff and to patients and their families when a medical error occurs. The organization’s leaders must take care of their employees and ensure their safety, as well as rewarding those who embrace and follow patient safety protocols. Some health care organizations incorporate safety and quality into its employees’ compensation plan. (5)

Adopting health information technology is also important in advancing patient safety. The U.S. Department of Health and Human Services believes that medical errors can be reduced by the adoption of health information technology. (6) Texas state legislators also believe that technology is important in health care. Early this summer, the legislature formed the Texas Health Care Information Technology Advisory Committee to develop a long-range plan for health care information technology in Texas. (7)

Finally, redesigning systems and improving reliability are essential in achieving patient safety. A reliable health care system ensures that the right care is provided for every patient every time. Health care organizations today are learning from the manufacturing industry by applying many of their philosophies, including lean thinking. Many hospitals are redesigning their processes to increase standardization and to include checks for accuracy. In addition, health care organizations that are successfully redesigning their systems are taking a proactive approach and teaching their staff how to avoid errors. These organizations are conducting simulations to teach staff to identify problems and the effects of their responses. (5)

Change Takes Time

Making patient safety part of a health care organization doesn’t happen overnight. I’ve been a physician for over 40 years, and I’ve learned from my experiences that change takes time. However, it’s our responsibility as leaders in the health care community to start the dialogue about the importance of patient safety and the systems that are setting us up to fail.

The time has come for us to evaluate the processes and start making changes. I cannot tell you how sad I get when I’m reminded that 98,000 lives have been wasted because of the complexity of our health care system. It’s time that we as health care leaders unite and change the system. It won’t be the first time that an industry revamped itself. The manufacturing and aviation industry did it, so can health care.

As you start making changes in your organization, keep in mind John P. Kotter’s eight steps to successful changes in an organization. (8) He encourages organizations to:

1. Develop the sense of urgency for change.
2. Form a powerful coalition force that supports the change.
3. Create a vision that leads the organization in a clear direction.
4. Communicate that vision.
5. Empower others to act on that vision.
6. Plan, achieve and celebrate short-term goals.
7. Change systems and structure.
8. Make the change part of the culture.

TMF Health Quality Institute Can Help Achieve Patient Safety

TMF partners with physicians’ offices to help them:

• Adopt an electronic health records system that meets their needs. TMF will work with office staff to assess their needs, redesign their workflows and make changes that are appropriate for their offices.
• Adopt e-prescribing including decision support for drug selection, dosing and monitoring.
• Understand and assess cultural competency programs so that language and cultural differences won’t result in medical errors.

TMF partners with hospitals to help them:

• Assess their readiness to adopt health information technology systems (CPOE, bar-coding or telehealth).
• Assess their climate for organizational safety.

TMF partners with home health agencies to help them:

• Improve patient management of oral medication, so that patients take their medications correctly, thus decreasing the chances of medication errors.
• Implement a telehealth system, which would provide more frequent monitoring of patients. Telehealth systems decrease the chances for a patient deteriorating without intervention from the agency.

TMF partners with nursing homes to help them:

• Provide education and information on best practices to help them provide the safest and highest quality care possible by focusing on the individual resident when determining appropriate interventions.

For more information about TMF’s free services, please contact Abraham Delgado, M.D., F.A.C.P., Medical Director, at (800) 725-9216 or adelgado@txqio.sdps.org or visit our Web site at www.tmf.org.

Reference List

1. American Medical Association. AMA summary of S. 544 [Web page]. Washington: The Association, 2005. Available at www.ama-assn.org. Accessed August 2, 2005.
2. To Err Is Human: Building a Safer Health System [database online]. Corrigan J, Kohn LT, Donaldson MS: The National Academies Press, 2005. Available at: www.nap.edu. Accessed August 3, 2005.
3. Leonard MS, Frankel A, Simmonds T, Vega K. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Chicago, IL: American College of Healthcare Executives; 2004.
4. Leap LL, Berwick, DM. Five years after to err is human. What have we learned? JAMA. 2005; 293(19):2384-2390.
5. Institute for Health Care Improvement. Leadership guide to patient safety: Resources and tools for establishing and maintaining patient safety [Web page]. Massachusetts: IHI, 2005. Available at www.ihi.org. Accessed August 4, 2005.
6. United States Department of Health and Human Services. Value of HIT [Web page]. Washington: 2005. Available at www.os.dhhs.gov. Accessed August 12, 2005.
7. Texas Legislatures online. S.B. No. 45 [Web page]. Texas: 2005. Available at www.capitol.state.tx.us. Accessed August 12, 2005.
8. Kotter, JP. Leading change. Why transformational efforts fail? Harvard Business Review. 1995: 61-73.

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William G. Gamel, M.D., is a gastroenterologist from Austin, Texas. During his career, he spent 30 years in the private practice of gastroenterology and four and a half years as medical director of the fiscal intermediary Electronic Data Systems for Texas’ Medicaid program. Gamel also served as past president for both the TMA and the Travis County Medical Society. He currently serves as chair of the Texas delegation to the AMA and the AMA Council on Legislation. He began his work with TMF Health Quality Institute (TMF) after his election to the board in 2000 and, in 2003, assumed the office of president. In 2005, he became the chief executive officer of TMF.

TMF is a private, nonprofit organization focused on promoting quality health care through contracts with federal, state and local government entities, as well as many private organizations. TMF partners with health care providers to ensure that every person receives the right care every time.

For more information, go to www.tmf.org