___________________________________________ Medical Errors and the United States Healthcare System
• Address safety across the entire care continuum. Safety should be ensured in all healthcare settings, • Support the healthcare workforce. Provide support to all healthcare staff. • Partner with patients and families for the safest care. Communicate information and actively involve patient and families in their care. • Ensure t:hat technology is safe and optimized to improve patient safety. It is crucial to utilize benefits and minimize unintended hazards of health IT. THE ROLE OF INFORMATION TECHNOLOGY Although the appropriate use of information technology can help to reduce errors, challenges exist. Electronic medical records, electronic prescribing, bar coding of medications, and decision support systems have been shown to be effec- tive. However, many hospitals/organizations have been slow to invest in these technologies [1]. In addition, it has been reported that at least 50% of patient EHRs contain an error, many of which are related to medica- tions [8]. Overburdened providers may import inaccurate medication lists, propagate other erroneous information electronically by copying and pasting older parts of the record, or enter erroneous examination findings. EHRs may also lack critical information (errors of omission) because of limited interoperability among healthcare sites. Among primary care physicians sharing notes with patients, 26% anticipated that patients would find nontrivial errors that could therefore lead to medication errors, wasteful duplication, unnecessary or incorrect treatment, and delayed diagnoses. Despite these problems, systems for checking the accuracy of notes are almost nonexistent [8]. CONCLUSION As summarized in this activity, medical errors remain a signifi- cant challenge for all aspects of the healthcare system and error rates are significantly higher in the United States compared with other developed countries. Root cause analysis reports are a useful tool to determine the primary systems-based fac- tors of common medical errors. In the future, information technology, including electronic medical records, electronic prescribing, bar coding of medications, and decision support systems needs to be better, and more broadly, utilized in an effort to improve patient safety.
• The Patient Protection and Affordable Care Act also authorized three pay-for- performance programs that adjust Medicare payments to hospitals based on the quality of care delivered. The Hospital Readmission Reduction Program began in October 2012 and penalizes hospitals with higher-than-expected readmissions for beneficiaries initially admitted for selected conditions. The Value Based Purchasing Program began in October 2012 and provides penalties, as well as incentive payments, based on hospitals’ performance on quality measures, including reducing surgical site infections [53]. • The Hospital-Acquired Condition Reduction Program reduces payments to hospitals that are in the top quartile for hospital-acquired conditions; the program started on October 1, 2014 [53]. CMS has adopted AHRQ safety indicators encompassing pressure ulcer rate and DVT rate, among others, as well as measures from the CDC, such as central line-associated bloodstream infection and CAUTIs. • The Office of the National Coordinator is developing a system for reporting medical errors, similar to the method of Common Formats established by AHRQ, allowing hospitals to more easily and accurately collect data on errors, including critical information about where and when they occur. FUTURE EFFORTS TO ENSURE PATIENT SAFETY Since the launch of To Err is Human in 1999, a campaign to improve patient safety and reduce adverse events, improve- ments have been made in specific areas of care. However, much work needs to be done to continue to ensure patient safety in all healthcare settings. In 2015, the National Patient Safety Foundation described eight recommendations to continue improvements for patient safety. These recommendations are as follows [55]: • Ensure that leaders establish and sustain a safety culture. Safety should be engrained in the culture of healthcare facilities and promoted by leadership. • Create centralized and coordinated oversight of patient safety. Patient safety should be coordinated and monitored by safety and national organizations. • Create a common set of safety metrics that reflect meaningful outcomes. Standardized metrics that identify and measure risks should be used. • Increase funding for research in patient safety and implementation science. Research should be utilized to understand risks and how to best mitigate those risks.
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