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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

  


 

A culture of safety

To err is human, but to report is no longer "divine" – it's expected. The AMA is working to reduce medical errors and improve reporting protocol

One of the driving forces behind the National Patient Safety Foundation (NSPF) is the Hippocratic Oath, which commands physicians "Above all, do not harm."

Now read that sentence again. There are two errors: one is fairly obvious to the average physician, the other more elusive* (see end of article for answers.) The point of this exercise: everyone makes mistakes, even doctors. But how should we handle errors when they are not easily remedied with a stroke of the “delete” key? The answer, according to AMA Trustee Timothy T Flaherty, MD, “is to acknowledge errors when they do occur, and use the opportunity to figure out how not to let them happen again.”

According to a recent study from the national standards-setting organization U.S. Pharmacopeia, while U.S. hospitals and health care systems have improved their track record of reporting medication errors, they continue to make the same mistakes over and over. The most common mistakes reported: omission errors.

 


And though less than one percent of reported errors result in patient death, the AMA believes that any error that harms a patient is one error too many. In keeping with this belief, we have pioneered the effort to reduce health care system errors and ensure that patients receive safe, quality health care.

In 1996, the AMA partnered with other organizations to convene an inaugural multidisciplinary conference on errors in health care, spawning numerous patient safety initiatives at both the state and national level. In 1997, with the help of CNA HealthPro, 3M and the Schering-Plough Corporation, the AMA established the National Patient Safety Foundation (NPSF), an independent, non-profit organization representing clinicians, consumer advocates, health product manufacturers, policymakers and more, with the ultimate goal of promoting patient safety to the nation’s top priority.

“The sort of first commandment for doctors is ‘First, do no harm,’” explained Tom Houston, MD, director of Science and Community Health Advocacy for the AMA. “The major thrust of what physicians do springs from that. Whatever physicians can do, and whatever the systems within which physicians work can do to improve and maintain patient safety as a cornerstone of medical care, the AMA wants to accomplish.” Dr. Houston added that cooperation from the health community at large is essential. Hospitals, physicians, nurses, pharmacists, drug and device manufacturers, nursing homes, and others must unite to identify, study, and solve system-wide problems that could cause errors or adverse outcomes.

Towards this end, in 2000 the AMA joined with more than 20 other national health care organizations to form a coalition to develop a set of General Principles for Patient Safety Reporting Systems that underscore the point that, for error reporting systems to be successful, they must be constructed in a non-punitive manner that provide appropriate confidentiality protections. Congress can help create a “culture of safety” by encouraging medical professionals to convene to discuss patient safety problems and potential solutions without having their discussions, findings, or recommendations become the basis for class action or other lawsuits. The AMA strongly believes that a confidential, non-retaliatory, evidence-based system for reporting health care errors will improve care and prevent future oversights. “With so much attention being paid today to professional liability reform, any one of us might hesitate to admit that we have ever committed a medical error,” Dr. Flaherty said. The focus must remain on widespread system reform, rather than individual punishment.

 


Such strategies, Dr. Houston said, are “integral to making sure patient safety is enforced throughout the health care environment, from the pharmacy to the operating room, from legibility of medical records and prescriptions to safe anesthesiology procedures.”

The latest effort to cut down on medical errors: the Patient Safety and Quality Improvement Act introduced in the Senate early this summer, under which medical professionals would be able to report mistakes confidentially. Reporting would be made to private "patient safety organizations," or PSOs – groups authorized to collect and analyze patient safety information on a confidential basis, and deed the data back to health care organizations. The NPSF would be one such group.

Ensuring confidentiality and protection from lawsuits is critical to encouraging more health care providers to volunteer information about patient safety, Sen. James Jeffords (I, Vt.), one of the bill's sponsors, told AMNews. “If you don't get the information, you can't address the problems.” Similar legislation has been introduced in the House.

The AMA is committed to continuing and redoubling our efforts to work with Congress and our partners in the health care system to achieve an environment in which patients are assured of safe, quality health care.

* The National Patient Safety Foundation is NPSF, and the Hippocratic oath says "Above all, do no harm."