AAMC Reporter, October 2000: National Summit Proclaims 'War on Medical Errors'

VOLUME 9, NUMBER 13

JORDAN J. COHEN, M.D., PRESIDENT

OCTOBER 2000

National Summit Proclaims 'War on Medical Errors'

By Barbara Gabriel

Susan Sheridan's voice trembles as she continues her testimony. "Today Cal is starting kindergarten unable to walk or crawl and is hearing and speech impaired. He drools and has uncontrollable movements of his arms and legs." Cal, Sheridan's son, suffered brain damage shortly after birth as a result of a series of medical errors related to blood incompatibility.

Sheridan's confidence in this country's health care system was further eroded four years later when her husband had a tumor removed from his spine. Told that the tumor was benign, Sheridan's husband was released from the hospital without further treatment, only to be admitted again six months later when the tumor recurred in a more aggressive form. This time he was told the tumor was malignant. It was only after Sheridan requested her husband's medical records that they discovered that the pathologist had in fact originally diagnosed the tumor as cancerous.

Sheridan's testimony began the National Summit on Medical Errors and Patient Safety Research, held on Sept. 11 in Washington, D.C. Organized and sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Quality Interagency (QuIC) Task Force, the summit is part of the government's response to the Institute of Medicine's report, "To Err Is Human: Building a Safer Health Care System," which made headlines last November with its estimate that as many as 98,000 people die each year as the result of medical errors. The summit convened five panels comprising delegates from medical associations, health care providers, business groups, insurers, academia, consumer groups, and others who testified before a steering committee representing organizations that fund patient safety research. The 18-member steering committee, chaired by AHRQ Director John M. Eisenberg, M.D., is responsible for crafting a national research agenda on medical errors and patient safety.

"If to err is human, to do nothing about it would be inhumane," said Dr. Eisenberg in his opening remarks at the summit. "We need to treat medical errors the way we treat other health-related epidemics; like the war on cancer and the war on heart disease, the war on medical errors must start with research."

Many of the 25 individuals who testified before the committee concurred that changes must take place in the health care system before meaningful patient safety reforms can occur. Most salient was the recognized need for cultural changes in the practice of medicine, particularly a shift away from a "culture of blame" to a "culture of safety." Emphasizing this point, Gordon Sprenger, president and CEO of Allina Health System and former chairman of the American Hospital Association, said, "Improving patient safety requires us to create a culture that is open to discussing errors when they occur…a culture that encourages us to learn from failure."

Panelists emphasized that essential to this cultural change is the recognition that most medical errors are the result of flawed systems rather than of individual mistakes. "Human errors almost always result from defective systems," said Saul Weingart, M.D., Ph.D., representing the Harvard Executive Session on Medical Error and Patient Safety. As a result, Dr. Weingart said, "research in patient safety must attend to organizational obstacles …Since improvements take place in real organizations, the laboratory for medical error research must encompass the clinical settings where patients receive care."

The reporting of medical errors was universally recognized by panelists as an essential element to any approach toward enhanced patient safety. The pros and cons of mandatory versus voluntary reporting were debated, with many panelists arguing that mandatory reporting laws are inherently punitive and contribute to a culture of secrecy among health care providers who fear retribution in the form of malpractice lawsuits. "If providers fear litigation based on information provided about errors or even 'near misses,' they will certainly have a strong incentive to underreport as well as a disincentive to report events internally," said Marie Dotseth of the Minnesota Department of Health.

Summit attendees also touched on the need to include patient safety in medical education - an area the AAMC is addressing through its Expert Panel on Quality of Care, an element of the ongoing Medical School Objectives Project. This panel, composed of leaders in the field of quality of care, will produce a report on what medical students should know about quality of care, including methods and tools of continuous quality improvement. When completed, the report will be distributed to all U.S. medical schools for guidance in revising their curricula.

Other themes emerging from the summit included the need for a better business case for quality controls, the problem of effectively disseminating information about safety controls, the issue of hospital understaffing, the use of technologies to guard against communication errors, and the need to strengthen team dynamics among health care workers.

Underlying all of these recommendations was a call to action to implement effective patient safety controls as soon as possible. "We want to underscore the urgency of error and its importance as a strategic priority for health care organizations," stressed Dr. Weingart.