The high rate of death and injuries among hospital patients is spurring action by industry groups.
At least 180,000 Americans die each year from the care they receive in hospitals, while another 1.1 millio n are injured, according to findings presented last week at the "Examining Errors in Health Care" conference in Rancho Mirage, Calif.
"About two-thirds of these incidents are caused by errors and are potentially preventable," said keynote speaker Lucian Leape, M.D.
Two organizations used the conference to announce new initiatives. The American Medical Association announced the formation of the National Patient Safety Foundation, which will pursue a national policy and database to enhance patient safety. And the Joint Commission on Accreditation of Healthcare Organizations added "accreditation watch" status to its oversight of hospitals. A hospital will be placed on watch if it's d etermined that a patient death or injury at the facility could have been avoided. The hospital will then have 30 days to submit to the JCAHO a plan to correct the problems that led to the error.
The conference was convened by the AM A, the JCAHO, the American Association for the Advancement of Science and the Annenberg Center for Health Sciences.
While the general tone of the gathering suggested that physicians are becoming increasingly aware of their imperfect ions, there was also wide consensus that most errors remain cloaked in secrecy and that most participants were uncertain about how to fix that situation. Self-reporting and individual accountability are still a part of most investi gations; lawsuits and intense media scrutiny often follow, so few caregivers are willing to be open. The autonomy physicians often insist on and the long hours traditionally heaped on inexperienced residents also retard the type of culture that can cut down on errors.
According to Leape, a member of the faculty of Harvard University's school of public health and Rand Corp.'s health services board, only "sentinel" events-such as Boston Globe medical reporter Betsy Lehman's death last year from a chemotherapy overdose and several highly publicized incidents at University Community Hospital in Tampa, Fla. (See "For the Record," p. 41)-have brought medical errors to the forefront of public attention.
"We have only a fragmentary idea of the problem," said Leape, who believes that as many as 90% of errors go unreported. He concluded that faults in systems, rather than individuals, should be held accountable in most cases.
Other presenters at the conference suggested that studying the techniques used to build benchmark safety records in the aviation and nuclear power industries could prove useful.
Meanwhile, there was much hand-wringing over the need for hospitals to remake themselves into error-resistant institutions. James Conway, chief operations officer of Boston's Dana-Farber Cancer Institute-which conducted Lehman's fatal chemotherapy treatments-said an open cult ure is critical.
"We should stop saying errors are rare and admit they're everywhere," Conway said. He also suggested that those who self-report be thanked instead of blamed, that system checks be simplified and that concrete erro r-reduction goals be instituted rather than tackling problems on a per-incident basis.
Those were among the ways Martin Memorial Medical Center in Stuart, Fla., dealt with the death last December of a 7-year-old boy who had been mis takenly injected with topical adrenaline rather than a local anesthetic. At first, it was reported that he'd had an allergic reaction. But the preservation of the syringe used during the procedure confirmed the error. The investiga tion was completed within three weeks, and the malpractice litigation was settled a short time later. Martin Memorial also moved to streamline its process of drawing fluid into syringes, which had caused the mixup.
At Beth Israel Ho spital in Boston, the classic issue of overworked residents overcoming fatigue has been addressed through the formation of a house staff advisory committee. Now, for instance, if the computer systems are shut down for maintenance, staff members are notified ahead of time, allowing them to pull patient records so they'll be available during downtime.