Medical Errors and
Patient Safety
Federal and State Efforts to Improve
Patient Safety
Q
Medical errors are a problem of epidemic
proportions
– 44,000 to 98,000 hospitalized patients die per
year
– Errors in outpatient and nursing home care
– Errors of ommission
– $17-29 billion from preventable errors
Jill Rosenthal, MPH
• Over 1/2 of costs are direct health care
NATI ONAL ACADE MY
– Average increased cost of medication error =
$4,700 per admission
for STATE HEALTH POLICY
National Health Policy Conference
February 7, 2006
Rosenthal
Rosenthal
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Systems Problems
Q
Q
© Feb 2006
Errors occur because of systems problems
Q
National focus on safety
– Shift focus from blaming individuals to safety
improvement
Q
Identify and learn from errors
Preventing errors means designing safer
systems of care
Rosenthal
National Academy for State Health Policy
© Feb 2006
Q
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– In all states
– Smaller number of
serious events
– Hold institutions
accountable
Rosenthal
Q
Q
– Promote existing
systems
Q
– Larger number of
near misses
Q
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– Identify system
weaknesses
© Feb 2006
Implement safety systems within health care
organizations
National Academy for State Health Policy
© Feb 2006
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Snapshot of Federal response
Voluntary
National Academy for State Health Policy
Set performance standards and expectations
for safety
Rosenthal
Identify and Learn from Errors:
Reporting Systems
Mandatory
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IOM Recommendations
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National Academy for State Health Policy
5
Patient Safety and Quality Improvement Act
of 2005
AHRQ Patient Safety Network, Web M&M,
grants, conferences
VA National Center for Patient Safety
DHHS Hospital Compare
Rosenthal
National Academy for State Health Policy
© Feb 2006
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State Reporting Systems
Snapshot of state responses
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Q
Q
Q
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Reporting systems and other
regulatory approaches
Patient safety centers
Patient safety coalitions
Purchasing for safety
Rosenthal
National Academy for State Health Policy
© Feb 2006
Q
25 states have authorized adverse event
reporting programs (Dec 2005)
Accountability
– Identification of system weaknesses and
assurance of corrective actions
Q
Facility education
– Patient safety alerts
– Identification of trends and best practices
– Web-based facility comparisons
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Rosenthal
Reporting System Improvement
Q
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Maximizing the Use of State Adverse Event
Data to Improve Patient Safety
– Data coming out is only as good as data going
in
– Anecdotal vs. epidemiological analysis
– Identification of tools, strategies, and shared
learning for system improvement
NASHP patient safety toolbox for states:
www.pstoolbox.org
National Academy for State Health Policy
© Feb 2006
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NASHP resources
Q
NASHP website: www.nashp.org
– patient safety toolbox for states
– adverse event reporting laws
– NASHP patient safety news briefs and
publications
– state resources on patient safety
Supported by The Commonwealth Fund
Rosenthal
National Academy for State Health Policy
© Feb 2006
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Rosenthal
National Academy for State Health Policy
© Feb 2006
10
Today’s speakers
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Q
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Vahe Kazandjian, Maryland Patient Safety
Center
Alan Rabinowitz, Pennsylvania Patient Safety
Authority
William Weeks, VA National Center for
Patient Safety and VA Outcomes Group
Rosenthal
National Academy for State Health Policy
© Feb 2006
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