Keeping patients safe: Institute of Medicine looks at transforming nurses' work environment

In November 1999, the Institute of Medicine (IOM) released To Err Is Human: Building a Safer Health System, which brought to the public's attention the serious--and sometimes deadly--dangers posed by medical errors occurring in healthcare organizations. Exactly 4 years later, an IOM committee released a new report that focuses on the need to reinforce patient safety defenses in the nurses' working environments.     

Promoting patient safety: one company's example

Patient safety has become a key issue in health care since the Institute of Medicine (IOM) released the report To Err Is Human: Building a Safer Health System. This landmark report examined the extent of preventable patient injuries and deaths occurring in US hospitals. It was estimated that between 44,000 and 98,000 people die annually as a result of medical errors and that nearly half were preventable. Subsequent studies suggest that the medical error rate is even higher. These statistics are a call to action for case managers to explore creative ways to implement patient safety practices in their systems and procedures.     

The IOM medical errors report: 5 years later, the journey continues

In 1999, the Institute of Medicine released a report, To Err Is Human: Building a Safer Health System, which shed a new light for providers and patients across the nation looking at patient safety and medical errors. Since then, new ways of addressing patient safety have emerged. But how far does the healthcare system still have to go?     

A user's manual for the IOM's 'Quality Chasm' report

Fifteen months after releasing its report on patient safety (To Err Is Human), the Institute of Medicine released Crossing the Quality Chasm. Although less sensational than the patient safety report, the Quality Chasm report is more comprehensive and, in the long run, more important. It calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity; and it asserts that those improvements cannot be achieved within the constraints of the existing system of care. It provides a rationale and a framework for the redesign of the U.S. health care system at four levels: patients' experiences; the "microsystems" that actually give care; the organizations that house and support microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action.     

Crossing the quality chasm: building a safe nutrition system

Recent reports to Congress and the public from the Institute of Medicine underscore concern about the quality of healthcare in America. The nutrition community has focused most of its attention on the report titled The Role of Nutrition in Maintaining Health in the Nation's Elderly, which evaluated nutrition services coverage for the Medicare population. Of equal importance was the recent publication of two reports from the Committee on Quality of Health Care in America: To Err is Human--Building a Safer Health System and Crossing the Quality Chasm--A New Health System for the 21st Century. IV nutrition support was a breakthrough in medical care that has become a standard tool in treating patients who cannot eat for prolonged periods of time. It is also a medical treatment that can result in harm to patients. As problems with patient safety associated with the use of IV nutrition were documented, safer methods to deliver this life-saving form of treatment were developed and evaluated. Although an interdisciplinary team approach has been shown to be the safest way to administer IV nutrition, this system is costly and not universally used. Alternatives to the interdisciplinary team approach should be evaluated to assure that patients receive optimum nutrition care. The tools that can be used to improve patient safety include self-assessment of practitioners who routinely use nutrition support in their practice, curricular-based continuing education programs, board certification in nutrition support practice, and the use of clinical guidelines to assist in making clinical decisions. By developing and promoting these tools, A.S.P.E.N. is committed to building a safe nutrition system so every patient receives optimal nutrition care.     

Improvements in the safety of patient care can help end the medical malpractice crisis in the United States

The publication of To Err is Human: Building a Safer Health System by the Institute of Medicine (IOM) in 1999 made the general public aware of the large number of patients that suffer preventable medical injuries in hospitals throughout the United States. Improvements in patient safety are needed to reduce this high incidence of medical error and must include the establishment of a culture of safety in every healthcare facility. A culture of safety is characterized by honesty, transparent error communication, and a systems analysis approach to medical error prevention. This type of medical culture can serve as the foundation for sustained improvements in patient safety and will help provide permanent relief from the medical malpractice crisis. Health policymakers should create policies that encourage hospital executives to establish and maintain cultures of safety in their institutions.     

Crossing the quality chasm: implications for health services administration education

Programs in Health Services Administration (HSA) should respond to the mandate to improve patient care as put forth by the Institute of Medicine (IOM) and other reports on the proliferation and consequences of medical errors. This article will identify a framework to base curriculum change, competency areas, and educational methods to impart quality improvement knowledge and skills. The first six competency areas reflect the six redesign imperatives from the IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001): redesign of the care process; use of information technologies; knowledge and skills management; development of effective teams; coordination of care; and use of performance and outcomes measurement. Based on a literature review, five additional areas were identified: strategic quality planning; programs for patient safety and risk management; change management; roles of stakeholders, payers and regulators; and development of a learning environment and blame-free culture. Examples of curriculum content are provided from HSA programs at Georgetown University, University of Washington, and University of California at Berkeley.     

The identification of best practices in teaching quality competencies for preparing future health care leaders

The mandate for quality in all aspects of clinical practice, service delivery, and management practice has never been greater. The Institute of Medicine's (IOM) landmark work To Err is Human heightened the urgency of this serious issue. In a follow-up report, the IOM's Crossing the Quality Chasm called for radical change to achieve numerous quality objectives throughout the continuum of the healthcare system including the preparation of future healthcare leaders. This study was conducted to assess how effectively healthcare management education faculty are meeting the challenge of integrating quality improvement into their curricula and how faculty perceived their quality expertise. Another goal was to identify the student learning assessment strategies, teaching methods, content, and resources utilized by faculty to achieve this integration and to suggest a framework for "best practices" in teaching quality competencies citing the literature. The study's findings raise a number of important issues with respect to the ways in which QI is conceptualized and integrated into curricula and concludes that there is substantial need for 'quality improvement' in healthcare management education faculty's approaches to the teaching of QI.     

A new health system and its quality agenda

This article reviews recent work on healthcare quality, highlights findings and recommendations of the Institute of Medicine (IOM) reports on medical errors and quality, and describes response to the reports to date. In it, Detmer, chair of the IOM's Board of Health Care Services and a member of its Committee on Quality of Health Care in America, identifies implications of the reports for healthcare delivery organizations and professionals and outlines ways organizations and professionals can improve the six dimensions of patient quality defined by the IOM. Sustained efforts at the point of care and in policy development are needed to overcome cultural inertia, realign incentives, support innovation, and address technical and human resource issues. Success requires that healthcare executives embrace the goal of transforming the healthcare sector into a true system and provide leadership for their organizations and communities in this most fundamental of challenges for twenty-first century healthcare.     

To the class of 2005: Will you be ready for the quality revolution?

BACKGROUND: Graduates are becoming aware of the vast changes occurring in the health care and scientific environments, which will place unprecedented demands on them. A SECOND REVOLUTION: It has been suggested that the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm have alerted healthcare professionals and managers to system defects, enlisted a broad array of stakeholders in the agenda, and accelerated changes in practice needed to eliminate errors and unnecessary deaths. It is now commonplace for comparative data on the effectiveness of hospitals and medical groups to be published in this new age of transparency. Coalitions of employers are now urging the adoption of safer practices in hospitals. In addition, the science of quality improvement has flourished and become robust. COMING CHANGES AND POSSIBILITIES: The changes over the next five years will be breathtaking. Those doctors and hospitals with the best clinical outcomes will benefit from seeing more patients and may even be paid more by Medicare, Medicaid, and insurance companies. Patients will access, via the Web, the latest quality information and make more informed choices about where to seek their care. The environment in which care is provided is also undergoing a major transformation. Hospital buildings themselves are becoming more healing, safer places. Graduates may ask themselves, "Will my residency adequately prepare me to understand and apply the science of quality improvement and evidence-based practice?"     

'The rest of the iceberg': IOM looks at quality

The Institute of Medicine's Committee on Quality of Healthcare in America released a sweeping 300-page report March 1 that claims fundamental changes are needed in the American health care system if 'the quality gap' that currently exists is to be eliminated. In his introductory remarks, committee chair William Richardson said the IOM's previous report on medical errors, the controversial To Err Is Human, represented 'the tip of the iceberg. Other defects beyond safety are even more widespread'.     

Transforming healthcare: IOM panel discusses vision and reality after Crossing the Quality Chasm

Almost 3 years ago, the Institute of Medicine (IOM) released its pivotal report, Crossing the Quality Chasm, which challenged the healthcare community to reevaluate and reinvent the way it provides care. In January, the IOM hosted an invitational summit in Washington, DC to look at whether that vision is becoming a reality across the country and in local communities. The summit focused on five priority areas: asthma, chronic heart failure, major depression, diabetes, and pain control in advanced cancer.     

Patient safety: mindful, meaningful, and fulfilling

Five years after the landmark report of the Institute of Medicine To Err Is Human (Kohn, Corrigan, and Donaldson 2000), many are asking, "Is U.S. healthcare safer?" A number of articles addressing this question have been written, interviews with nationally recognized patient safety leaders have been published, and governing boards of many healthcare organizations are examining reports of care provided by their institutions. Robert M. Wachter, writing in the November 2004 issue of Health Affairs, concludes that, "At this point, I would give our efforts an overall grade of C+, with striking areas of progress tempered by clear opportunities for improvement." We describe in this article the pursuit of a culture of safety at William Beaumont Hospital in Royal Oak, Michigan. Our experience has offered us the opportunity to ponder a number of key questions: How does leadership guide an organization toward a culture of safety? Does culture truly drive behavior, or is it really the reverse? How can a culture of safety be measured or observed? What levels of resources and commitment are required for success? Is safety all about systems and processes, or are core values also involved? What role does the patient play in ensuring safe care? We attempt to offer guidance, and share lessons learned, for each of these important questions.     

The Psychophysics of Transition to Long Term Care

More than a decade after the publication of To Err Is Human, cognitive error remains a mystery to physicians. Competent and conscientious physicians rarely recall making a single cognitive error, yet this must be central to the explanation for inappropriate physician nonadherence to evidence-based guidelines. Published information regarding cognitive error in the medical literature is scarce and widely scattered. We do know that cognitive error is induced by complexity, duress, and uncertainty, conditions that regularly confront long term care physicians when they assume care of a new patient at the skilled nursing facility. Negative attitudes and low expectations of care are common among new patients and families. This is compounded when care is assumed by an unfamiliar physician. The initial disquiet and negative misconceptions of patients and families regularly make the transition one of the most error-prone events in medical practice. On the brighter side, the transition provides an excellent opportunity to study cognitive error. Cognitive errors at transition typically begin with a decision to avoid mention of necessary changes to flawed treatment plans already in effect. This is done as a temporary measure to avoid further stressing the patient and family. But what appears to be an ideal compromise is a risky option and should be avoided. Evading the issue introduces long-term risk to the patient. In addition, although it is seldom acknowledged, evading change often has a negative impact on local standards of care. Five cognitive principles are presented as root causes of cognitive error. Six contextual factors are identified that are endemic to nursing home practice, making the physician even more error prone. Because mistrust is central to dysfunctional decision making at the transition, strategies are presented to expedite gaining trust. This article makes the case for adding training in the cognitive psychology of medical decision making to core requirements for certification in medical direction.     

Data as a catalyst for change: Stories from the frontlines

The landmark 1999 Institute of Medicine report, “To Err Is Human,” challenged us all to reduce the number of preventable medical errors. While vulnerabilities and patient harm continue at unacceptable rates, there are also many success stories. This article presents a series of case studies that illustrate how healthcare organizations have used data—quantitative, qualitative, and comparative—to address vulnerabilities and guide meaningful change to improve patient safety. These examples are drawn from the data‐sharing community of CRICO Strategies, a division of the Risk Management Foundation of the Harvard Medical Institutions, Inc. (CRICO). CRICO's data‐driven strategy uses intelligence from thousands of medical malpractice cases across the country to examine what has gone wrong and why, and to help members and clients manage their risk and provide better care.     

The role of leadership in instilling a culture of safety: lessons from the literature

The publication of To Err Is Human has highlighted concern for patient safety. Attention to date has focused primarily on micro issues such as minimizing medication errors and adverse drug reactions, improving select aspects of care, and reducing diagnostic and treatment errors. However, attention is also required to a macro issue--an organization's culture and the level of leadership required to create a culture. This article discusses the concepts of culture and leadership and summarizes two paradigms that are useful in understanding the precursors of medical errors and developing interventions to prevent them: normal accident theory and high-reliability organization theory. It also delineates approaches to instilling a safety culture. Normal accident theory asserts that errors result from system failures. An important element of this perspective is the need for a system that collects, analyzes, and disseminates information from incidents and near misses as well as regular proactive checks on the system's vital signs. Four subcultures are necessary to support such an environment: a reporting culture, a just culture, a flexible culture, and a learning culture. High-reliability organization theory posits that accidents occur because individuals who operate and manage complex systems are themselves not sufficiently complex to sense and anticipate the problems generated by the system. Lessons learned from high-reliability organizations indicate that a safety culture is supported by migrated distributed decision making, management by exception or negotiation, and fostering a sense of the "big picture." Lessons from other industries are also shared in this article.     

What is driving hospitals' patient-safety efforts?

The Institute of Medicine's report To Err Is Human described the alarming prevalence of medical errors and recommended a range of activities to improve patient safety. Three general mechanisms for stimulating hospitals to reduce medical errors are professionalism, regulation, and market forces. Although some believe that market forces are becoming more important, we found that a quasi-regulatory organization (the Joint Commission on Accreditation of Healthcare Organizations) has been the primary driver of hospitals' patient-safety initiatives. Professional and market initiatives have also facilitated improvement, but hospitals report that these have had less impact to date.     

Operating safely in surgery and critical care with perioperative automation

A study by the Institute of Medicine (IOM) found that as many as 98,000 Americans die each year from preventable medical errors. These findings, combined with a growing spate of negative publicity, have brought patient safety to its rightful place at the healthcare forefront. Nowhere are patient safety issues more critical than in the anesthesia, surgery and critical care environments. These high-acuity settings--with their fast pace, complex and rapidly changing care regimens and mountains of diverse clinical data-arguably pose the greatest patient safety risk in the hospital.     

Understanding diagnostic safety in emergency medicine: A case‐by‐case review of closed ED malpractice claims

The report Improving Diagnosis in Health Care calls for collaboration between professional liability insurance carriers and health care providers to identify opportunities to improve diagnostic performance. We used this collaborative approach and involved risk management/patient safety professionals and emergency medicine physician reviewers to analyze diagnosis‐related emergency medicine closed claims from a large malpractice insurer. Our aim was to identify opportunities for risk reduction and to develop an approach for improving at‐risk processes. Analysis of these cases revealed several missed opportunities in the diagnostic process. A collaborative approach offered greater insight into diagnosis process failures that may not have been evident if cases were reviewed in silos. Focused review findings led to a multidisciplinary improvement collaborative to develop clinical guidelines for improving at‐risk practices and informed a simulation‐based training initiative.