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Safety is the goal

by: LAWRENCE M. SHUER

In recent times we have seen more emphasis on patient safety in the health-care environment. This topic has been in the limelight since the Institute of Medicine issued a 1999 report titled, "To Err is Human." This report estimated that as many as 98,000 people die each year from errors that occur in hospitals - more than die from auto accidents, breast cancer or AIDS. This doesn't account for the errors that cause injury, but not death.

The Joint Commission on Accreditation of Healthcare Organizations has established a policy that calls on hospitals to voluntarily report health-care errors for what are described as "sentinel events." These events include medication errors, wrong-site surgery, delays in treatment, patient falls, patient death/injury in restraints, transfusion errors, anesthesia-related events, medical-equipment-related errors, etc.

After the incidents are reported, JCAHO requires that hospitals then perform a "root-cause analysis" to determine the cause of the event, followed by implementing a plan to prevent recurrence of such incidents. The sentinel events are then registered on the JCAHO Web site to help other hospitals take precautions to prevent similar tragedies.

Because of the high profile of this issue, improving patient safety has become an interest of the business community. Last year, many employers joined the Leapfrog Group, a consortium of Fortune 500 companies and health-care purchasers that have combined their purchasing power to advance the cause of patient safety. This group attempts to achieve its goal by rewarding hospitals that follow patient-safety guidelines with financial bonuses, preferential use and other market reinforcements. As of the end of last year, the group had 94 members and was growing rapidly.

Leapfrog identified three safety measures as an initial benchmark for examining hospital safety nationwide. Interestingly enough, the measures included use of an electronic physician order entry system to minimize prescription errors, assigning patients with specific conditions to hospitals with a known record of successfully treating such conditions and having physicians with critical-care training treat ICU patients.

Stanford has been involved in ongoing efforts to improve safety for our patients. The Quality Improvement Steering Committee is part of the hospital's mechanism to identify issues important to improving the quality of care institution-wide. This committee includes physicians, nurses and administrators actively interested in quality improvement. The committee has already been involved with projects to reduce patient falls, reduce mislabeling of patient lab specimens, etc. Additionally, the POE system has been a standing agenda item for the committee because of its many implications for patient safety, both bad and good.

The Care Review Committee is where most quality-assurance/peer-review matters are heard. When committee members hear of a misadventure involving patient care, they examine whether things could have been done differently to prevent the occurrence. When a systematic issue arises, the committee helps craft solutions to prevent future errors. One example in which the CRC has helped shape policy to improve patient safety is in the prevention of wrong-site (also known as "wrong-side") surgery. After hearing of a case in which surgery was performed on the wrong site, the committee suggested having patients mark the surgical site prior to venturing into the operating theater. As an added measure, we have attempted to have a "time out" in the operating room to give the surgical team one last chance to check and double-check amongst the surgeon, anesthesiologist and nurses that the planned procedure agrees with the schedule and consent documents, and is consistent with the radiographs in the room.

Our residents and medical staff are acutely interested in patient safety. Some concerns over our POE system have been raised, including workflow issues and patient-safety matters. This is somewhat ironic because the POE system is viewed as a method for improving safety, not impairing it. I can assure you that any POE-related safety issues that are raised will be dealt with expeditiously and have the highest priority.

I appreciate your continued efforts in improving patient safety.

If you have suggestions for improving patient safety or are aware of a problem that may put patients at risk, please contact:

Larry Shuer, chief of staff, at: lshuer@stanford.edu

Betsy Williams, chief operating officer, at: betsy.williams@medcenter.stanford.edu

Brenda Fisher, director of quality improvement, at: brenda.fisher@medcenter.stanford.edu