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Distance Education -> Prevention of Medical Errors for the Massage Therapist -> Chapter: 04
Recommendations for Improving Patient Safety
In June 1998 the Institute of Medicine Quality of Health Care in America Committee was formed to develop a strategy for quality improvement in health care. Their report, To Err Is Human: Building a Safer Health System, addressed patient safety issues, quality-related health care concerns, and laid out a national agenda for reducing medical errors and improving patient safety in the health care system. The strategy was planned and implemented over the next ten years.
The committee concluded that the major force for improving patient safety is to motivate health care providers who are grounded by professional ethics, and expectations. The committee feels these specific health care providers have the knowledge and tools to make patient safety the norm, and would provide strong and visible leadership within a health care culture. This action would encourage recognition and learning from medical errors, and create an effective patient safety program. 8
Other recommendations for reducing medical errors include improving system protocols within health care organizations. These include:
• Designing systems that take into account patient safety. This point would include a healthcare provider's work hours and workload. The healthcare organization should have enough qualified workers in the system to enable balanced workloads, and staff rotation. This would reduce the tendency for overwork, there by reducing the possibility of medical errors happening as a result of distractions and fatigue.
• Avoiding reliance on memory. A Study by the Agency for Healthcare Research and Quality (AHRQ) found that a patient chart review completed by a qualified worker was more accurate than computer tracking, and voluntary reporting, for identifying adverse drug events. But, it required five times more personnel time. The Study concluded that computerized methods for tracking drug errors were more efficient.
• Avoiding reliance on vigilance. Another AHRQ study found that a computerized reminder system to alert physicians to the proper timing of repeat tests reduced the number of patients being unnecessarily retested. The AHRQ went on to report that automatic alerting systems for communicating critical lab results reduced the waiting time for appropriate treatment.
• Standardize work processes. The AHRQ concluded in another study that standardizing health care protocols could decrease the incident of medical errors. For example, they found that patients in intensive care units with severe respiratory disease showed a four-fold increase in survival rate with the use of computerized treatment protocols.
The Agency for Healthcare Research and Quality continues to research ways to improve the delivery of quality healthcare through identifying high-risk patients or patient groups, high-risk providers, and high-risk health care processes and settings. In addition, the AHRQ continues to develop generalizable methods for error reduction. 9
Our healthcare system is becoming increasingly complex. And, while research continues to find ways to improve the delivery of healthcare, and the reduction of medical errors, one of the most important keys to the problem may be the simplest. That key is communication. Medical errors happen when doctors and patients have trouble communicating. The Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not effectively communicate with their patients in order to help them make informed decisions about their health care. As a result, patients tend to be less involved and less informed about their health care choices, less likely to accept the doctor's choice of treatment, and less likely to follow through with treatment. The single most important way a person can help prevent medical errors from happening is to be an active member of their healthcare team. 10
PRACTICE QUESTIONS FOR CHAPTERS 4.
Please complete the following questions:
1. While patient chart review was found to be more accurate when identifying adverse drug events, it required five times more personnel time. A major study concluded that computerized methods for tracking drug errors were more efficient. This was a recommendation for improving which system protocol?
a. Avoiding reliance on vigilance.
b. Standardized work processes.
c. Avoiding reliance on memory.
2. Balancing of a healthcare provider's work hours and workload, is a recommendation for improving which system protocol?
a. Avoiding reliance on vigilance.
b. Designing systems that take in into account patient safety.
c. Avoiding reliance on memory.
3. In our increasingly complex healthcare system, which choice is one of the most important keys to reducing medical errors?
a. Designing systems that take in into account patient safety
b. Communication
c. Avoiding reliance on paperwork
8 Kohn, Linda T., Corrigan, Janet M., Donaldson, Molla S., Editors, To Err Is Human Building a Safer Health System, Washington D. C., National Academy Press, 1999.
9 Internet Citation: Reducing Errors in Health Care, Translating Research into Practice , Rockville, MD, AHRQ Publication No.00-PO58. April 2000.
10 Internet Citation: 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publications
No. 00-PO38, February 2000 Agency for Healthcare Research and Quality, Rockville, MD.
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