The patient safety story
http://www.100md.com
《英国医生杂志》
Has been told; now it is time to make practice safer
Investigating and improving patient safety in health care is now an international phenomenon. The establishment of the National Patient Safety Agency in the United Kingdom1 and of the Center for Quality Improvement and Patient Safety in the United States2 are prime examples of the prominence given to safety within the wider concept of healthcare quality. No longer can there be any doubt that the most fundamental ethical principle in medicine—first, do no harm—is being taken seriously by a wide constituency. The next step is to embed safe practice into everyday clinical behaviour.
Why is there so much interest in patient safety? Why now? Data have been available on error rates in medicine for at least a decade. Although there had been earlier work in the 1970s, the landmark Harvard Medical Practice study of hospital inpatients was published in 1991.3 Additional studies followed from Australia and other contexts.4 This research points to an adverse event rate in secondary care close to 10%. The error rate in primary care is less well studied.
What we know
The catalyst came from the United States. By 1998 some opinion leaders in health care were frustrated by the lack of attention given to addressing serious quality challenges. An extensive review of the literature on quality, conducted by RAND Health, documented shortcomings in both safety and effectiveness.5 Expert panels, one convened by the Institute of Medicine and another established by the President of the United States, recommended that improving healthcare quality should become a national priority.6 7 But despite the strong, convincing evidence and recommendations from expert panels, the "quality problem" never made it on to the national agenda.
In another effort to bring the issues to the fore-front, the Institute of Medicine established its quality of care in America committee. In late 1999 the committee's first report, To Err is Human, was released.8 Unlike previous reports on quality, which had been directed at elected representatives, healthcare leaders, and professionals, the key audience for this report was the lay public. In effect, it was direct marketing to patients about medical errors. The impact was tangible, with near saturation coverage in the media for almost three days. The United Kingdom responded with its own analysis, An Organisation with a Memory.9
There are many lessons here. Firstly, targeting the public made the issue visible and widened the debate. Secondly, and just as important, was the clarity of the message. Errors are something that everyone can understand. People are familiar with "accidents" and efforts to avoid them. There are parallels in air and road transport; indeed in these services there are institutions to protect the public. Thirdly, the report focused primarily on errors of execution—events that no one intended to happen and where there is wide agreement that something went wrong.8 This level of consensus is qualitatively different from discussions about other quality issues, such as medical effectiveness, where there is often disagreement about what constitutes evidence based practice, or the applicability of the evidence to particular patients and circumstances. Fourthly, the report made it clear that more people die as a result of medical errors than from other common causes of death including motor vehicle crashes, breast cancer, and AIDS. The case was therefore made for giving attention and resources commensurate with the scale of the problem.
The epidemiology of error
Five years have passed since To Err is Human was released, and a clearer picture of the epidemiology of error is emerging. As each new report arrives, there is a growing realisation that error in medicine is on a different scale from error tolerated elsewhere and has different consequences from error in other service sectors. Ideas about solutions are also arriving from disciplines outside medicine, including systems engineering, psychology, human factors, and informatics.
It's becoming clear that providing safe and effective care requires not only expert clinicians, but also well designed care processes and organisational supports. Industrial processes have long since developed the concept of zero tolerance for error, building quality into production. To better understand why errors occur, health care is now taking advantage of tools such as root cause analysis and failure mode effects analysis, tools already in use in fields such as aviation. Perhaps even more important, many countries are investing significant resources in electronic health record systems that provide clinicians, and hopefully patients, with improved access to relevant data and decision support. When used effectively by care teams these systems will be a powerful tool for preventing many types of errors. Equally important are efforts to promote a culture of safety: a recognition that errors are most often the result of poorly designed systems, while at the same time encouraging everyone to identify and learn from errors.10
As we entered a new millennium, we saw that medicine had arrived at a tipping point.11 The patient safety story coincided with the long awaited arrival of credible patient centred health care. Patients had, as never before, access to credible online information. Clinicians became interested in the concepts of sharing decisions and communicating risk,12 and it became obvious that medical paternalism was on borrowed time.
A new website
The World Health Organization's Patient Safety Alliance is yet another signal of this shift. In the UK not only has the National Patient Safety Agency been formed within the NHS,1 a research programme has also been established and a patient safety initiative supported by the Health Foundation. As a contribution to this activity, a new website has also been created. safer-healthcare (www.saferhealthcare.org.uk) is run by a partnership of the National Patient Safety Agency, the BMJ Publishing Group, and the Boston based Institute for Healthcare Improvement. Its aim is to be a valued source of peer reviewed tools and information to help practitioners make changes in their organisations. You are invited to register, find colleagues with similar interests, discuss, debate, and take up the offer to write about your work—in short, to be part of the patient safety story.
Glyn Elwyn, clinician editor of saferhealthcare
Centre for Health Sciences Research, School of Medicine, Cardiff University, Cardiff CF10 3AT
elwyng@cardiff.ac.uk
Janet M Corrigan, president and chief executive officer
National Committee for Quality Health Care, 1701 K St NW, Washington DC 20006, USA
This article was posted on bmj.com on 1 August 2005: http://bmj.com/cgi/doi/10.1136/bmj.38562.690104.43
Competing interests: GE is editor of saferhealthcare.
References
National Patient Safety Agency. Seven steps to patient safety. London: National Patient Safety Agency, 2003.
Center for Quality Improvement and Patient Safety. Mission statement. Washington, DC: Agency for Healthcare Research and Quality. Department of Health and Human Services, 2004.
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324: 370-6.
Thomas EJ, Brennan TA. Errors and adverse events in medicine: an overview. In: Vincent C, ed. Clinical risk management: enhancing patient safety. London: BMJ Books; 2001.
Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Quarterly 1998;76: 517-63.
President's Advisory Commission on Consumer Protection and Quality. Quality First: Better Health Care for All Americans, 1998 (www.hcqualitycommission.gov/final).
Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280: 1000-5.
Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academies Press, 2000.
Department of Health. An organisation with a memory. London: Stationery Office, 2000.
Institute of Medicine. Patient safety: achieving a new standard for care. Washington, DC: National Academy Press, 2004.
Gladwell M. The tipping point. London: Little, Brown, 2000.
Edwards A, Elwyn G, eds. Evidence based patient choice: inevitable or impossible. Oxford: Oxford University Press, 2001.
Investigating and improving patient safety in health care is now an international phenomenon. The establishment of the National Patient Safety Agency in the United Kingdom1 and of the Center for Quality Improvement and Patient Safety in the United States2 are prime examples of the prominence given to safety within the wider concept of healthcare quality. No longer can there be any doubt that the most fundamental ethical principle in medicine—first, do no harm—is being taken seriously by a wide constituency. The next step is to embed safe practice into everyday clinical behaviour.
Why is there so much interest in patient safety? Why now? Data have been available on error rates in medicine for at least a decade. Although there had been earlier work in the 1970s, the landmark Harvard Medical Practice study of hospital inpatients was published in 1991.3 Additional studies followed from Australia and other contexts.4 This research points to an adverse event rate in secondary care close to 10%. The error rate in primary care is less well studied.
What we know
The catalyst came from the United States. By 1998 some opinion leaders in health care were frustrated by the lack of attention given to addressing serious quality challenges. An extensive review of the literature on quality, conducted by RAND Health, documented shortcomings in both safety and effectiveness.5 Expert panels, one convened by the Institute of Medicine and another established by the President of the United States, recommended that improving healthcare quality should become a national priority.6 7 But despite the strong, convincing evidence and recommendations from expert panels, the "quality problem" never made it on to the national agenda.
In another effort to bring the issues to the fore-front, the Institute of Medicine established its quality of care in America committee. In late 1999 the committee's first report, To Err is Human, was released.8 Unlike previous reports on quality, which had been directed at elected representatives, healthcare leaders, and professionals, the key audience for this report was the lay public. In effect, it was direct marketing to patients about medical errors. The impact was tangible, with near saturation coverage in the media for almost three days. The United Kingdom responded with its own analysis, An Organisation with a Memory.9
There are many lessons here. Firstly, targeting the public made the issue visible and widened the debate. Secondly, and just as important, was the clarity of the message. Errors are something that everyone can understand. People are familiar with "accidents" and efforts to avoid them. There are parallels in air and road transport; indeed in these services there are institutions to protect the public. Thirdly, the report focused primarily on errors of execution—events that no one intended to happen and where there is wide agreement that something went wrong.8 This level of consensus is qualitatively different from discussions about other quality issues, such as medical effectiveness, where there is often disagreement about what constitutes evidence based practice, or the applicability of the evidence to particular patients and circumstances. Fourthly, the report made it clear that more people die as a result of medical errors than from other common causes of death including motor vehicle crashes, breast cancer, and AIDS. The case was therefore made for giving attention and resources commensurate with the scale of the problem.
The epidemiology of error
Five years have passed since To Err is Human was released, and a clearer picture of the epidemiology of error is emerging. As each new report arrives, there is a growing realisation that error in medicine is on a different scale from error tolerated elsewhere and has different consequences from error in other service sectors. Ideas about solutions are also arriving from disciplines outside medicine, including systems engineering, psychology, human factors, and informatics.
It's becoming clear that providing safe and effective care requires not only expert clinicians, but also well designed care processes and organisational supports. Industrial processes have long since developed the concept of zero tolerance for error, building quality into production. To better understand why errors occur, health care is now taking advantage of tools such as root cause analysis and failure mode effects analysis, tools already in use in fields such as aviation. Perhaps even more important, many countries are investing significant resources in electronic health record systems that provide clinicians, and hopefully patients, with improved access to relevant data and decision support. When used effectively by care teams these systems will be a powerful tool for preventing many types of errors. Equally important are efforts to promote a culture of safety: a recognition that errors are most often the result of poorly designed systems, while at the same time encouraging everyone to identify and learn from errors.10
As we entered a new millennium, we saw that medicine had arrived at a tipping point.11 The patient safety story coincided with the long awaited arrival of credible patient centred health care. Patients had, as never before, access to credible online information. Clinicians became interested in the concepts of sharing decisions and communicating risk,12 and it became obvious that medical paternalism was on borrowed time.
A new website
The World Health Organization's Patient Safety Alliance is yet another signal of this shift. In the UK not only has the National Patient Safety Agency been formed within the NHS,1 a research programme has also been established and a patient safety initiative supported by the Health Foundation. As a contribution to this activity, a new website has also been created. safer-healthcare (www.saferhealthcare.org.uk) is run by a partnership of the National Patient Safety Agency, the BMJ Publishing Group, and the Boston based Institute for Healthcare Improvement. Its aim is to be a valued source of peer reviewed tools and information to help practitioners make changes in their organisations. You are invited to register, find colleagues with similar interests, discuss, debate, and take up the offer to write about your work—in short, to be part of the patient safety story.
Glyn Elwyn, clinician editor of saferhealthcare
Centre for Health Sciences Research, School of Medicine, Cardiff University, Cardiff CF10 3AT
elwyng@cardiff.ac.uk
Janet M Corrigan, president and chief executive officer
National Committee for Quality Health Care, 1701 K St NW, Washington DC 20006, USA
This article was posted on bmj.com on 1 August 2005: http://bmj.com/cgi/doi/10.1136/bmj.38562.690104.43
Competing interests: GE is editor of saferhealthcare.
References
National Patient Safety Agency. Seven steps to patient safety. London: National Patient Safety Agency, 2003.
Center for Quality Improvement and Patient Safety. Mission statement. Washington, DC: Agency for Healthcare Research and Quality. Department of Health and Human Services, 2004.
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324: 370-6.
Thomas EJ, Brennan TA. Errors and adverse events in medicine: an overview. In: Vincent C, ed. Clinical risk management: enhancing patient safety. London: BMJ Books; 2001.
Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Quarterly 1998;76: 517-63.
President's Advisory Commission on Consumer Protection and Quality. Quality First: Better Health Care for All Americans, 1998 (www.hcqualitycommission.gov/final).
Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280: 1000-5.
Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academies Press, 2000.
Department of Health. An organisation with a memory. London: Stationery Office, 2000.
Institute of Medicine. Patient safety: achieving a new standard for care. Washington, DC: National Academy Press, 2004.
Gladwell M. The tipping point. London: Little, Brown, 2000.
Edwards A, Elwyn G, eds. Evidence based patient choice: inevitable or impossible. Oxford: Oxford University Press, 2001.