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Where Are We Now?
Albert Wu, MD, MPH
Johns Hopkins University
Five Ten Years Later

Lucian L. Leape and Donald M. Berwick’s Five Years after “To Err Is
Human”: What Have We Learned?*
*Leape, Lucian L., and Berwick, Donald M. (2005, May 18). Five years
after “To err is human”: What have we learned? Journal of the
American Medical Association, 293, 19, 2384–2390.
3
What Have We Accomplished?

Wider recognition in health care that medical errors are a serious
problem

Engagement of important stakeholders
-  Federal government
-  Veterans Health Administration
-  Joint Commission

Understanding that the most effective method to improve safety
and quality is to change systems

Accelerated implementation of safe care practices
4
Clinical Effectiveness of Safe Practices: Isolated Evidence

CPOE
-  81% reduction in medication errors
  Bates, 2003, NEJM

Protocol enforcement
-  95% reduction in central venous line infections
  Pronovost, 2005

Team training in labor and delivery
  Sachs, 2005
5
Limited Improvement

Fewer deaths from concentrated KCl

Fewer complications from warfarin

Fewer hospital-acquired infections
6
In the UK

Reduction in mortality
-  Overall hospital standardized mortality ratios
  1996–1997: 114
  2006–2007: 82
-  Reduction in cardiac surgery mortality
  1997–1998: 2.4%
  2004–2005: 1.8%

MRSA bacteremia rates rose steadily until 2002, now falling

BUT, 7 of 9 safety indicators show an increase (probably reflecting
better coding)
7
Payment Incentives?

Centers for Medicare and Medicaid Services (CMS)
-  Reward hospitals and physicians that achieve high levels of
safety?
  Central line infections, ventilator-associated pneumonia,
surgical-site infections
-  New policy of not paying for specific complications
8
So Is Health Care Safer?

Overall, not much
9
Health Care Has Become Complex

Technological and medical progress

A specialized, complex environment

Inpatients are seen by dozens of providers each day

Outpatients may see a dozen different physicians
10
Why Is It So Difficult?

Why is it so difficult to implement practices and policies to deliver
safe health care?
-  Culture of medicine
  Autonomy
  Professional fragmentation
  Positivism/progress via research
-  Lack of leadership
-  Fear
11
Backlash
“It’s the system”
vs.
“The major cause of bad care is bad doctors and nurses”
12
Information

Despite numerous initiatives to improve patient safety, we have
little idea whether they have worked

Lack of good measures

No comprehensive national monitoring system for patient safety
13
The End of the Beginning—A Long Way to Go
The End Of The Beginning:
Patient Safety Five Years After
‘To Err Is Human’*
Amid signs of progress, there is still a long way to go."
By Robert M. Wachter!
*Health Affairs. (2004).
14
How Are We Doing – Half full or half empty?
Photo by Rob Hayes. Creative Commons BY-NC-SA.
15
Give It a Grade

Regulations

Reporting systems

Clinical information technology

Malpractice and other vehicles for accountability

Workforce and training
16
Regulation: A
JC with stronger, more specific
regulations

In an individualistic culture with
the absence of financial
incentives, regulation is a first
step

“Sign your site”

But next steps are harder
Image source: American Academy of Orthopaedic Surgeons.
17
Reporting Systems: C

Reports can be powerful tools

Many organizations lack any programs to follow up reports and make
meaningful changes
18
Information Technology: B
Wider implementation with some notable successes

High up-front costs

Unintended consequences
19
Malpractice System: D

The malpractice system is broken

Both negative and positive impacts on safety overrated?

Lack of accountability: a continuing problem
20
Workforce and Training: B

New care models are promising: hospitalists, intensivists

Work-hour limits are sensible

Data link nurse-force issues with safety

Training and simulation: promising but underused
21
Overall Grade

Overall patient safety five years after the IOM report:
C+
22
Goals

Change in consciousness and culture

Ubiquitous education about safety

Reformed system of compensation for injury

A major effort to develop safety measures

Expanding evidence base for safe, high-quality care

Positive incentives for quality
23
Assess Trends in Safety Issues?

Annual review of medical records to monitor trends in adverse
events

Screening program for drug errors of a sample of patients

Clinician coding to identify proportion of patient admissions due to
adverse drug events
24
This Is Not the End
“This is not the end. It is not even the beginning of the
end. But it is, perhaps, the end of the beginning.”
— Winston Churchill
At the Lord Mayor’s Luncheon
November 10, 1942
25
Where Are We Now?
26