Innovations in Patient Safety

1. Innovations in Patient Safety Helen Burstin, MD, MPH Director, Center for Primary Care, Prevention, and Clinical Partnerships Academy Health June 6, 2004

2. Bridging the Quality Chasm Where Where We We Are Want To Be Implementation Health IT Education Diffusion Adoption TRIP

3. Clinical Procedure Landmark Trial Current rate of use Flu Vaccine 1968 64% (2000) Pneumococcal Vaccine 1977 53% (2000) Diabetic Eye Exam 1981 48.1% (2000) Mammography 1982 75.5% (2001) Cholesterol Screening 1984 69.1% (1999) Diffusion of knowledge Balas EA, Boren SA., Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000.

4. Patients’ care often deficient, study says. Proper treatment given half the time. On average, doctors provide appropriate health care only half the time, a landmark study of adults in 12 U.S. metropolitan areas suggests. RAND Study: Quality of Health Care Often Not Optimal Medical errors corrode quality of healthcare system Medical Care Often Not Optimal Failure to Treat Patients Fully Spans Range of What Is Expected of Physicians and Nurses Study: U.S. Doctors are not following the guidelines for ordinary illnesses The American healthcare system, often touted as a cutting-edge leader in the world, suddenly finds itself mired in serious questions about the ability of its hospitals and doctors to deliver quality care to millions. .

5. To Err is HumanBuilding a Better Healthcare System • 1999 IOM Report • Between 44,000 and 98,000 die as a result of medical errors annually • Would be the 8th leading cause of death • Ranks higher than MVAs, breast CA, AIDS • Total costs: $17-29 billion

6. 44,000-98,000 Lives Based on extrapolation from two studies: • Analysis of New York hospitalizations: adverse events occurred in 3.7% of which 27% were negligent and death occurred in 13.6% (Brennan et al, NEJM, 1991) • Analysis of Utah and Colorado hospitalizations: adverse events occurred in 2.9% of which about 30% were negligent and death occurred in 6.6% (Thomas, Medical Care 2000)

7. Medical Injuries During Hospitalization Based on 18 types of medical injuries: • >32,000 attributable deaths occur annually • 2.4 million extra days of hospitalization • $9.3 billion excess charges (Zhan, Miller; JAMA 2003)

9. HHS Reports: Quality and Disparities in Health Care • First national comprehensive efforts to measure the quality of health care in America and prevailing disparities in health care • Presents data for clinical conditions, including cancer, diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory disease • Includes data on maternal and child health, nursing home and home health care, and patient safety Reports available at: http://www.qualitytools.ahrq.gov

10. National Healthcare Quality Report: Missed Opportunities • Only 20.9% of patients with diabetes receive all recommended tests • 90% of adults are screened for high blood pressure – but only 25% are controlled • Nearly 1/3 of adults and children with asthma do NOT receive effective Rx • Almost 20% of persons with a usual source of care report that they are not asked about medications to prevent interactions

11. A Culture of Safety • Non-punitive policies to address adverse events • Organizational commitment to open communication about errors to encourage reporting, analysis, prevention and mitigation • Alignment between legal and clinical staffs to ensure openness without compromising the organization

13. Stages of Problem Recognition • “The data are wrong.” • “The data are correct but it isn’t a problem.” • “The data are right, it is a problem but it isn’t my problem.” • “I accept the burden of improvement.”

14. Innovations in Patient Safety • Panelists (i.e. the innovators): • Ada Sue Hinshaw • Brent James • Jonathan Perlin