National Academies Press: OpenBook

To Err Is Human: Building a Safer Health System (2000)

Chapter: E Safety Activities in Health Care Organizations

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Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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E—
Safety Activities in Health Care Organizations

Numerous programs intended to promote patient safety can be found in hospitals, nursing homes, and other health care organizations. Hospitals, home health agencies, nursing homes, clinical laboratories, ambulatory surgery centers, and other health care facilities are licensed by state departments of health, which establish the terms under which they may operate.

One way in which federal and state quality oversight requirements have historically been met is through reliance on private-sector accrediting bodies, termed deemed status. In most circumstances, deemed status arrangements allow a facility to meet government standards either through accreditation or directly through the government agency or through accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic Association.

A brief review of widely implemented safety programs in health care facilities, then, is grounded in the state licensing or, more likely, the voluntary accreditation standards of accrediting bodies such as the JCAHO. The JCAHO's standards for hospital accreditation,1 for example, include several facility-wide safety systems intended to ensure patients' physical safety and protection from environmental hazards and risks, accidents, and injuries including, for example, life safety; infectious disease surveillance, prevention,

Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 267

and control; and the handling and use of blood and blood products. Other traditional approaches to learning about error and how it might be prevented include morbidity and mortality conferences and autopsy.

Life Safety

Life safety refers to a set of standards for the construction and operation of buildings and the protection of patients from fire and smoke. These standards are based on the Life Safety Code, promulgated by the National Fire Prevention Association. Life safety standards that require fire alarm and detection systems are monitored and serviced routinely, that fire and smoke containment systems are in place, and that systems for transmitting alarms to the local fire department are functional. Facilities typically participate in fire and other disaster drills that help them identify weaknesses in their systems. By analogy, many other kinds of delivery-related simulations can probably help groups with differing disciplinary backgrounds learn to work cooperatively and effectively in, for example, the intensive care unit, emergency department, or operating room. The recent development of highly sophisticated operating room simulators has demonstrated their value both in teaching and for practitioners to practice recovering from crises.

Infectious Disease Surveillance, Prevention, and Control

Today, infection control covers a broad range of processes throughout the hospital. It requires epidemiological expertise and includes attention to medical devices (e.g., intravascular and alimentation devices, ventilators, equipment used for examination); the physical environment (e.g., air ducts, surfaces); surgical wound management; and carriage by employees and other health professionals.

Such infection control processes are managed by individuals who are assigned the responsibility of surveillance, reporting, and investigating outbreaks of nosocomial infections (infections acquired while in health care that are unrelated to the original condition), and putting in place and monitoring the results of processes to prevent or reduce the risk of infectious transmission. In the best systems, data from many sources within the hospital—infection control committee surveillance, length-of-stay outlier reports, operating room logs, bacteriology and pathology reports, morbidity and

Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 268

mortality (M&M) conferences and so forth—can be brought to bear to identify trends and sources of infectious disease.

Despite major efforts to decrease transmission, infection control remains a challenge to health care facilities. Indeed, in some ways it is more difficult now than in the past. Like other advances in patient care, the advent of antibiotics has dramatically improved patient care, but the emergence of antibiotic resistance means that new efforts of surveillance and prevention must be implemented in order to make progress against infection, and continuing efforts are needed to maintain earlier achievements.

According to the Centers for Disease Control (CDC), nosocomial infections affect approximately 2 million patients annually in acute care facilities in the United States at an estimated direct patient care cost of approximately $3.5 billion per year (NCID/CDC&P). In long-term care facilities including nursing homes, CDC estimates that more than 1.5 million cases of nosocomial infection occur each year, an average of one infection per patient per year.2 Epidemiological studies have estimated that one-third of nosocomial infections can be prevented by well-organized infection control programs, yet only six to nine percent are actually prevented.

Recognition of the danger of transmission of infection in the health care setting is credited to the insight of a Viennese obstetrician Ignaz Phillip Semmelweis in 1847. Semmelweis correctly identified the cause of an epidemic of childbed fever (puerperal sepsis) among maternity patients as originating from physicians who had previously done autopsies and then transferred bacteria (later found to be Streptococcus pyogenes) on their hands when they examined their patients. After Semmelweis introduced the practice of hand washing with a solution of chloride of lime (an antiseptic) before examination, maternal mortality decreased from 18 percent to 2.4 percent in the first month.3,4 According to CDC, even today, ''handwashing is the single most important means of preventing the spread of infection." Yet, repeated studies indicate that after more than 150 years of experience, lack of or improper handwashing still contributes significantly to disease transmission in health care settings5,6,7,8,9,10,11 Exhortations to personnel have not been effective, and some organizations have begun to look at system barriers to handwashing (e.g., the time required as well as the chapping and irritation caused by frequent handwashing) and ways to eliminate these problems by designing better hand hygiene processes.

Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 269

Morbidity and Mortality Conferences

Morbidity and mortality (M&M) conferences began early in the twentieth century (1917) as a standardized case report system to investigate the reasons and responsibility for adverse outcomes of care. Mandated in 1983 by the Accreditation Council for Graduate Medical Education, M&M is a weekly conference at which, under the moderation of a faculty member, medical and surgical residents and attendings present cases of all complications and deaths. The value of the M&M conference is highly dependent on how the department chair uses it, but a recent national survey on attitudes and opinions of the value of M&M conferences found that 43 percent of residents and 47 percent of surgical faculty believed that the conference was an important and powerful educational tool.12 Lower rankings were given to its value in reducing error and improving care.

M&M conferences are case-by-case reviews, with an emphasis on learning what might have been done differently in a given case rather than punishment, but they stress the value of knowledge, skill, and alertness to anticipate problems.13 They tend not to address systemic issues. Their value in improving the quality of care could be substantially increased if ongoing data are kept to identify repeated complications and time trends and if information from the M&M conferences is integrated with information from other available sources within the hospital.

Autopsy

Unexpected findings at autopsy are an excellent way to refine clinical judgment and identify misdiagnosis. Lundberg cites a 40 percent discrepancy between antemortem and postmortem diagnoses.14 Nevertheless, autopsy rates have declined greatly in recent years from 50 percent in the 1940s to only 14 percent in 1985.15,16 Autopsy rates in nonteaching hospitals are now less than 9 percent.

When autopsies are completed, their value in improving care depends on reports reaching clinicians in a timely manner. Yet, many hospitals report long delays (several weeks or more) before clinicians receive autopsy reports. In general, rapid improvement requires shortening the cycle time between investigation and feedback to caregivers and managers, and timeliness in autopsy reporting is representative of all data gathering activities intended for quality improvement and reduction of errors.

Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 270

Risk Management Programs

Originating with the increase in liability risk in the mid-1970s, hospital risk management programs have long been associated with the reduction of institutional liability and financial loss control.17,18 Controlling loss has focused historically on preserving the institution's financial (and human) resources. Risk management includes identification of risk and education of staff, identifying and containing risk after an event, education of staff and patients, and risk transfer. Educational efforts tend to focus on such topics as review of state statutes on informed consent, presentations by the hospital's defense counsel, and programs on medical and legal topics for physicians.

Although effort has been made to move toward "primary" risk management that would focus on preventing adverse events from occurring, risk management is still focused largely on loss control. Although incident reporting systems are intended to include major events such as surgical mishaps, incidents have traditionally been greatly underreported and the reports that are fried have involved largely slips, falls, and medication errors that may have little consequence.19,20 The American College of Surgeons estimated in 1985 that only 5–30 percent of major mishaps are reported on traditional incident forms.21 Cullen et al. (1995) found that of 54 adverse drug events identified in their study, only six percent had a corresponding incident report submitted to the hospital's quality assurance program or the pharmacy hotline.

Although risk management committees include a member of the medical staff, risk management has not been embraced at the organizational leadership level in its broadest sense of patient safety—protecting patients from any accidental injury. Risk managers interact when necessary with the administrator or chief executive officer, medical director or chief of staff, nursing director, medical records director, and chief financial officer, but the function of improved patient safety is not, typically, represented through risk managers on the governing board's executive committee or at corporate headquarters.

References

1. Joint Commission on Accreditation of Healthcare Organizations. 1998 Hospital Accreditation Standards. Oakbrook, IL: Joint Commission, 1998.

2. From "Hospital Infections Program." www.cdc.gov/ncidod/publications/brochures/hip.htm 4/29/99. "Hospital Infections Program"

Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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3. "Ignaz Philipp Semmelweis." www.knight.org/advent/cathen/1312a.htm (Catholic Encyclopedia) 4/29/99.

4. From "Etiology of Childbed Fever." www.obgyn.net/women/med-chest/med41105.htm 4/29/99.

5. Pittet, D.; Mourouga, P.; Perneger, T.V., et al. Compliance with Handwashing in a Teaching Hospital. Annals of Internal Medicine. 130:126–155, 1999.

6. Steere, A.C., and Mallison, G.F. Handwashing Practices for the Prevention of Nosocomial Infections. Annals of Internal Medicine. 83:683–690, 1975.

7. Sproat, L.J., and Inglis, T.J. A Multicentre Survey of Hand Hygiene Practices in Intensive Care Units. Journal of Hospital Infections. 26:137–148, 1994.

8. Albert, R.K., and Condie, F. Hand-washing Patterns in Medical Intensive-Care Units New England Journal of Medicine. 24:1465–1466, 1981.

9. Larson, E. Compliance with Isolation Technique. American Journal of Infection Control. 11:221–225, 1983.

10. Meengs, M.R.; Giles, B.K.; Chisholm, C.D., et al. Hand Washing Frequency in an Emergency Department. Journal of Emergency Nursing. 20:183–188, 1994.

11. Thompson, B.L.; Dwyer, D.M.; Ussery, X.T., et al. Handwashing and Glove Use in a Long-Term-Care Facility. Infection Control and Hospital Epidemiology. 18:97–103, 1997

12. Harbison, S.P., and Regehr, G. Faculty and Resident Opinions Regarding the Role of Morbidity and Mortality Conference. American Journal of Surgery. 177:136–139, 1999.

13. Gawande, A. When Doctors Make Mistakes. The New Yorker. 74(41):40–52, 1999.

14. Lundberg, G.D. Low-Tech Autopsies in the Era of High-Tech Medicine. JAMA. 280:1273–1274, 1998.

15. Geller, S.A. Autopsy. Scientific American. 248(3):124–129, 132, 135–136, 1983.

16. Leads from the MMWR. Autopsy Frequency—United States, 1980–1985. JAMA. 259:2357–2362, 1988.

17. Troyer, G.T., and Salman, S.L. Handbook of Health Care Risk Management. Rockville, MD: Aspen, 1986.

18. Monagle, J.F. Risk Management: A Guide for Health Care Professionals. Rockville, MD: Aspen, 1985.

19. Institute of Medicine. Medicare: A Strategy for Quality Assurance, Volume II. Washington, D.C.: National Academy Press, 1990.

20. Cullen, David J.; Bates, David W.; Small, Stephen D., et al. The Incident Reporting System Does Not Detect Adverse Drug Events: A Problem in Quality Assurance. Joint Commission Journal on Quality Improvement. 21:541–548, 1995.

21. Leape, Lucian, L.; Woods, David D.; Hatlie, Martin, J., et al. Promoting Patient Safety and Preventing Medical Error. JAMA. 280:1444–1447, 1998.

Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

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Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 266
Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 267
Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 268
Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 269
Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 270
Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 271
Suggested Citation:"E Safety Activities in Health Care Organizations." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 272
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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?"

Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves.

First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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