The 1999 landmark study titled To Err Is Human: Building a
The 1999 landmark study titled To Err Is Human: Building a
The 1999 landmark study titled To Err Is Human: Building a Safer Health System highlighted the unacceptably high incidence of U.S. medical errors and put forth recommendations to improve patient safety.
The 1999 landmark study titled To Err Is Human: Building a Safer Health System highlighted the unacceptably high incidence of U.S. medical errors and put forth recommendations to improve patient safety. Since its publication the recommendations in To Err Is Human have guided significant changes in nursing practice in theUnited States.In this Discussion you will review these recommendations and consider the role of health information technology in helping address concerns presented in the report.To prepare:Review the summary of To Err Is Human presented in the Plawecki and Amrhein article found in this weeks Learning Resources.Consider the following statement:The most significant barrier to improving patient safety identified in To Err Is Humanis a lack of awareness of the extent to which errors occur daily in allhealth care settings and organizations (Wakefield 2008).Review The Quality Chasm Series: Implications for Nursing focusing on Table 3: Simple Rules for the 21st Century Health Care System. Consider your currentorganization or one with which you are familiar. Reflect on one of the rules where the current rule is still in operation in the organization and consider anotherinstance in which the organization has effectively transitioned to the new rule.Post on or before Day 3 your thoughts on how the development of information technology has helped address the concerns about patient safety raised in the To Err IsHuman report. Summarize in one page how informatics has assisted in improving health care safety in your organization and areas where growth is still needed.References (mandatory)PLAWECKI L; AMRHEIN D. Clearing the err. Journal of Gerontological Nursing. 35 11 26-29 Nov. 2009. ISSN: 0098-9134.Wakefield M. K. (2008). The Quality Chasm series: Implications for nursing. In R. G. Hughes (Ed.) Patient safety and quality: An evidence-based handbook for nurses(Vol. 1 pp. 4766). Rockville MD: U. S. Department of Health and Human Services.Legal IssuesIve made a mistake. Thissimple statement or its merethought is enough to strike fearwithin the most experienced andknowledgeable of health care professionals.No matter how manytimes a procedure has been done ora medication administered there isalways the likelihood of preventableerror. Each year the publicis reminded of the potential formistakes as the media report medicalhorror stories where for exampleunknowing patients have surgeryperformed on the wrong body parta wrong medication administeredor a foreign object errantly leftinside their bodies. These reportshighlight the biggest fear of healthcare workerstheir own fallibility.Through carelessness assumptionovert act or omission the healthcare professional can easily errand cause harm to the patient. Inaddition to the pain caused to thepatient health care providers alsounderstand the devastating impactthat such errors can wreak on theirown personal and professional lives.The purpose of this article is toAbout the AuthorsMr. Plawecki is Registered NurseRehabilitation Hospital of Indiana Indianapolisand Dr. Amrhein is ResidentPhysician Family Practice Medicine BallMemorial Hospital Muncie Indiana.The authors disclose that they have nosignificant financial interests in any productor class of products discussed directlyor indirectly in this activity includingresearch support.Address correspondence to LawrenceH. Plawecki RN JD LLM RegisteredNurse Rehabilitation Hospital ofIndiana 4141 Shore Drive IndianapolisIN 46254; e-mail: Lawrence.plawecki@acecipd.com.doi:10.3928/00989134-20091016-01Clearing the ErrReporting Serious Adverse Events and Never Events in Todays Health Care SystemLawrence H. Plawecki RN JD LLM; and David W. Amrhein MDAbstractAbsent an infinitesimal percentage most Americans seek health care servicesdue to a legitimate health issue. Fundamental within this relationshipis the understanding that health care professionals will do everything withintheir power and expertise to alleviate the suffering of each patient theytreat. Unfortunately preventable medical errors do occur and the innocentpatient is left to suffer. In 1999 the Institute of Medicinereleased To Err Is Human: Building A Safer Health System thefirst mainstream publication calling for a change in theculture of health care and the eradication of preventablemedical errors. In the 10 years since its publicationfederal and state governments and agencieshave been proactive in attempting to meet therecommendations originally proposed in To Err IsHuman. This article will review what has been accomplishedin this time frame.iStockphoto.com/ Ireneusz Skorupa26 JOGNonline.comdiscuss the trend in todays healthcare systems toward the reportingof serious adverse events or neverevents as well as the impactbothimpending and currenton the roleof geriatric nurses.Refocusing andRebuil ding a Sa fe Heal thCa re SystemIn November 1999 the Instituteof Medicine (IOM) released aprofound call to action for everyoneinvolved in the health care community.This statement entitled To ErrIs Human: Building A Safer HealthSystem began with a grim statisticestimating that between 44000 and98000 people died per year frompreventable medical errors as hospitalpatients. The IOM (1999) reportdefined medical error as the use of awrong plan of action to achieve anaim or the planned actions failureto be completed as intended. Ineconomic terms these errors wereestimated to cost between $17 billionand $29 billion per year across thecountry (IOM 1999). These financialestimates include the costs of lostincome lost household productivityand the cost of the additional healthcare necessitated by the errors (IOM1999). The more specific recommendationsposited by the IOM (1999)for the prevention of medical errorsare discussed below.The IOM (1999) report recommendeda four-tiered approach toachieve a better safety record:l Establishing a national focusto create leadership researchtools and protocols to enhance theknowledge base about safety.l Identifying and learning fromerrors by developing a nationwidepublic mandatory reporting systemand by encouraging health careorganizations and practitioners todevelop and participate in voluntaryreporting systems.l Raising performance standardsand expectations for improvements insafety through the actions of oversightorganizations professional groupsand purchasers of health care.l Implementing safety systemsin health care organizations to ensuresafe practices at the delivery level.As a result of these broad recommendationsstate and federalgovernments agencies and healthcare institutions were given noticeabout the increased focus on theprevention of medical errors andconsequently the improved safetyof the patient receiving treatment.During the 5 years following theIOM (1999) report progress beganto be made.In 2001 the U.S. Congress appropriatedan annual budget of $50million for patient safety research(Leape & Berwick 2005). Fromthis appropriation the Agency forHealthcare Research and Quality(AHRQ) was codified as the federalagency to oversee patient safety andits improvement (Leape & Berwick2005). AHRQ became an importantplayer in the new patient safetymovement by evaluating health carepractices to determine effectivenesseducating health care institutionsabout how to best report errors andadverse events and creating a roadmapof evidence-based best practices(Leape & Berwick 2005).Using the roadmap createdby AHRQ the National QualityForum (NQF) (2007) created alist of 27 serious reportable eventsalso referred to as never eventswhich were offered as the basisfor a potential national reportingsystem chronicling patient safety.The serious reportable events maybe divided into six separate categoriesincluding surgical eventsproduct or device events patientprotection events care managementevents environmental events andcriminal events (NQF 2007). Forthe purposes of this article howeverthe individual events will not be discussedas the focus is to remain onthe implementation and evolution ofpatient safety standards.In 2005 the American MedicalAssociation (AMA) releaseda report by Leape and Berwickdetailing the effects of the originalIOM publication. The AMAreport while admitting there hadbeen little measurable effect afterthe release of the IOM report andthat no comprehensive nationwidesystem for monitoring had beenput into existence discussed howthe focus of patient care had shiftedfrom fixing blame to implementing aculture of safety (Leape & Berwick2005). This alone can be consideredan impressive feat in todays increasinglylitigious society. FurthermoreLeape and Berwick (2005) identifiedthe four areas the health care systemneeded to advance in the following 5years to facilitate the transition to apatient safety focus.First Leape and Berwick (2005)recommended the implementationof electronic medical records. It isargued that this implementation althougha substantial initial cost willsave the facility and pay for itselfdue to the decrease in charges of adverseevents and increase in efficien-Journal of Gerontological Nursing Vol. 35 No. 11 2009 27cy of staff. Second as more methodsare implemented newer and saferpractices will be proven. The finaltwo advancements named in theIOM (1999) recommendations canbe met as newly learned informationis disseminated through the healthcare system and ultimately trainingof health care workers continuesto evolve and improve. Last healthcare professionals should then beable to admit mistakes apologizeand improve communication withpatients as it has been found thatfull disclosure of a mistake does notincrease the risk of a lawsuit beingfiled (Leape & Berwick 2005).Where are we now?As the tenth year following To Erris Human (IOM 1999) is drawingto a close health care professionalscan readily see and appreciatethe changes being made to improvepatient safety and their own practice.An inexhaustive list comparing severalstates their attempts to improvepatient safety and new federal guidelinesare discussed below.MinnesotaIn 2003 Minnesota became thefirst state to adopt a never eventslaw (Minnesota Department ofHealth 2008). Initially this lawrequired Minnesotas hospitalsregional treatment centers and freestandingoutpatient surgical centersto report these never events to theMinnesota Department of Health(2009). These events were thenreported to the public by the MinnesotaDepartment of Health (2008)on an annual basis. In 2005 howeveran amended law took effectrequiring Minnesota hospitals to reportthe occurrence of a never eventpublicly to the Minnesota HospitalAssociations web-based PatientSafety Registry (Dotseth 2004).In addition Minnesota Statutes144.7065 (2005) requires applicablefacilities to investigate each reportedevent report the underlying causeof each event and take correctiveaction to prevent the recurrence ofsuch an event. Lastly an annual reportrequired by Minnesota Statutes144.7069 (2005) is published by theMinnesota Department of Healththereby providing a forum for hospitalsto share information and learnfrom each others errors.
. .
The post The 1999 landmark study titled To Err Is Human: Building a Safer Health System highlighted the unacceptably high incidence of U.S. medical errors and put forth recommendations to improve patient safety. appeared first on acecipd.com.
