FL: Preventing Medical ErrorsPage 8 of 12

6. Reducing Errors and Increasing Patient Safety

Healthcare organizations must develop a culture of safety such that an organization’s care processes and workforce are focused on improving the reliability and safety of care for patients.

Institute of Medicine [sic], 1999
To Err Is Human: Building a Safer Health System

Governments, healthcare personnel, patients, and the public must work together to create a culture of safety, decrease the effects of medical errors, and improve the safety of healthcare. Each has a role to play.

Creating a Culture of Safety

For decades, the healthcare industry, along with a myriad of agencies and stakeholders, has sought a way to curb medical errors. This has resulted in a major shift in philosophy from one of blame to one of changing cultures across the continuum of care.

Garrouste-Orgeas and colleagues (2012) wrote,

Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors . . . . Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture . . . is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures.

While the researchers were speaking in terms of the intensive care unit, the lessons can be applied to many care settings (Garrouste-Orgeas et al., 2012).

Garrouste-Orgeas and colleagues (2012) suggested that

. . . a safety culture arises from a combination of a room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. (Garrouste-Orgeas et al., 2012)

This video vignette shows a fictional scenario in which a positive culture of safety overcomes multiple commonly seen barriers to infection prevention in dialysis facilities.

Fostering a Culture of Safety [4:03]

Source: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/fosteringsafetyvid.html

Implementing Electronic Health Records (EHR)

The report that served as the clarion for efforts to prevent medical errors—IOM’s “To Err is Human”—noted that electronic systems are an “effective remedy” to combat them (IOM, 1999). The use of electronic health records (EHRs) has grown since the IOM report, bolstered by several game-changing pieces of legislation.

HIPAA, 1996

The central theme of the Health Insurance Portability and Accountability Act (HIPAA) was to protect healthcare coverage and privacy for workers and their families as they changed jobs, it also called for the development of health information systems and standards for electronic data interchange, the methodology whereby patient information is transmitted electronically (GPO, 1996).

HITECH Act, 2009

Enacted as part of the American Recovery and Reinvestment Act of 2009, it was called the Health Information Technology for Economic and Clinical Health Act (HITECH), and it authorized Medicare and Medicaid to provide incentive payments for eligible professionals, hospitals, and critical access hospitals as they adopt, implement, upgrade, or demonstrate “meaningful use” of EHR technology.

Meaningful use is defined as using certified electronic health record (EHR) technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and family; improve care coordination, and population and public health; and maintain privacy and security of patient health to improve patient care. The meaningful use incentive program has now been transitioned into the MACRA program and ONC is engaging with HITECH on a number of other programs (US HHS, 2017a; USONC, 2015; USONC, 2015a).

Affordable Care Act (ACA), 2010

Perhaps the most broad-reaching piece of healthcare legislation in American history is the Patient Protection and Affordable Care Act of 2010 (ACA). As part of the legislation’s timed roll-out, ACA mandated technologic reforms in 2012 in the use of electronic health records to improve efficiencies (US HHS, 2017). These and other accomplishments will persist despite numerous political efforts to scuttle the ACA.

Back Next