AAMC Reporter, February 2000: Teaching Hospitals, Medical Schools Combat

Volume 9,
Number 4

Jordan J. Cohen, M.D., President

February 2000

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Teaching Hospitals, Medical Schools Combat Error

by Gina Shaw

At a December Rose Garden event attended by national health care leaders, President Clinton calls for strong steps to improve health care quality.

Since the December release of "To Err Is Human," an Institutes of Medicine report on medical errors, members of Congress, policymakers, and the President have issued calls for action. Just days after the report's release, Vermont Senator Jim Jeffords held Congressional hearings, and President Clinton ordered agency officials to report back to him within 60 days as to which of the IOM's recommendations on medical error reduction should be implemented.

At the AAMC, President Jordan J. Cohen, M.D., has convened a task force of senior staff to examine the issue. Among the initial recommendations: the Association should gather information on "best practices" in medical error reduction at COTH hospitals around the country.

So what are teaching hospitals doing to reduce medical errors? At Boston's Dana-Farber Cancer Institute, the answers range from "blue skies and vapors to specifics," says COO James B. Conway. "One of the key aspects here is that the leadership of the institution is on top of the issue of patient safety and talks openly about it," he says. "If there are systems failures, you will always see members of the executive leadership involved in discussions about remedies."

Dana-Farber got a stark lesson in medical errors in 1995, when Boston Globe columnist Betsy Lehman died there from a chemotherapy overdose. The incident led to a host of new safeguards at Dana-Farber, many of which have been implemented at a number of other Massachusetts hospitals.

"We see computers as our single most successful tool in reducing medical errors," says Conway. As part of a joint venture with Brigham & Women's Hospital, Dana-Farber has access to the BIX computer system for adult cancer care, a physician order system that in essence, makes certain types of medical errors impossible.

"If you're ordering a particular medication for a specific patient, the computer will tell you such things as the route of administration and the appropriate doses. For example, it will check doses against the patient's weight and body mass," says Conway. "If you want to do something different, you can't just override the computer. It either forces you to order it in the prescribed way or leave the system and get specialized permission to do it another way."

In partnership with Brigham, Dana-Farber has expanded the computerized medication system further into chemotherapy administration. The two institutions are now involved in a joint project, which also includes the Massachusetts General Hospital, to develop an advanced chemotherapy order system where all orders will be protocol-driven.

But error reduction isn't all about computers, Conway notes. One of Dana-Farber's most effective strategies for reducing medical errors has been its family-faculty program, which involves patients and family members at all levels of institutional planning (see "Family-Centered Care: Today Pediatrics, Tomorrow the World," AAMC Reporter, August 1999). "Most of our active committees have patients and family members sitting on them. We don't have to wait three or six months or a year for surveys to tell us what's up," says Conway. "We've built up, through our relationships with patients and families, a system in which if there's something that's not working, we know that right away, not only by memo, but through personal contact."

At Duke University Hospital, institutional leaders approach quality and performance improvement using the "balance scorecard," a continuous quality improvement technique borrowed from industry. The scorecard examines important determinants of organizational performance, and within four categories-the internal business perspective of the institution, the financial perspective, the "customer" (patients and referring physicians) perspective, and learning and growth opportunities and satisfaction in the workforce-sets up key performance measures and indicators.

"Each of those perspectives is considered equally. You need to focus on all four indicators in a balanced fashion and have key indicators in each area," explains Peter Kussin, M.D., associate professor of Medicine and chief medical officer at Duke Hospital. "If you look at Duke's organizational balance scorecard, in the internal business quadrant, several of the indicators of performance are related to medical errors. We look at our nosocomial infection rate, we look at our medication errors, and we look at a conglomerate indicator of patient safety and patient incidents-falls, patient complaints, and bad outcomes of any type."

Duke has sorted medical errors into three major categories: medication errors, infection control, and, as Dr. Kussin says, "everything else." Dr. Kussin chairs Duke Hospital's pharmacy and therapeutics committee, which reviews and seeks to reduce medication errors. "It remains to be shown that any other technique but continuous quality improvement will ever work to reduce medical errors."

Duke has taken the same approach to infection control, in an effort led by Daniel Sexton, M.D., professor of Medicine. "Whenever a quality issue has come up in infection control, Dan has developed rigorous, benchmark, gold-standard ways of looking at the problem, addressing it, fixing it, and then going back and checking." In the last review done by the Joint Commission on the Accreditation of Healthcare Organizations, Duke Hospital received accreditation with commendation, Dr. Kussin notes.

Karen P. Haynes, director of Quality Accreditation and Licensure for Florida's Shands Healthcare, shares Dr. Kussin's view that continuous quality improvement is the key to reducing medical errors. "We're always looking at what types of issues are popping up and where we're seeing trends," she explains. "The minute something's identified, we kick off the appropriate total quality improvement team to open up everything, no holds barred, and facilitate change. It's looked at by each individual department: pharmacy, risk management, quality. We'll involve all the disciplines associated with a particular issue."

Medical schools and teaching hospitals must lead the effort to reduce medical errors, Dr. Kussin believes. "Academic health centers need to be absolutely exemplary in admitting that we have a huge opportunity to improve care and reduce variance. We need to be the thought leaders in developing protocols and guidelines using evidence-based medicine, and we need to extend that teaching back to the medical student level," he notes.

Information: Dr. Korn, (202) 828-0509