Improving Patient Care
The Family Physician's Role in Reducing Medical Errors
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By educating patients, adopting the latest technology and creating “no-fault” environments, family physicians can be part of the solution.
Fam Pract Manag. 2000 Feb;7(2):45.
"As to diseases, make a habit of two things – to help or at least to do no harm." – Hippocrates, Epidemics
U.S. health care is touted as the best in the world, and every day millions of Americans receive high-quality medical services delivered in a timely fashion. However, few would argue that our system is flawless. There are major disparities in access as well as outcomes, and throughout the system mistakes are made.
In health care, even a small number of mistakes made by individuals, groups of individuals or organizations can have serious, costly or fatal consequences. Such injuries can result in increased disability, lost productivity, lost wages, additional health expenses and death. These outcomes and costs are borne not only by the individuals harmed, but also by their families, the health care system and society as a whole.
Evidence of medical errors
Medical errors can range from a simple miscommunication about a drug's name during a telephone call between a doctor and a nurse to the erroneous programming of a complex medical device at the end of a busy hospital night shift. They include wrong diagnoses due to mislabeled blood tubes, mistaken treatments because of poorly labeled drugs, improper dosing because of faulty calculations and a simple lack of communication as a patient gets passed from one provider to the next.
Studies estimating the number of Americans injured in the course of treatment have primarily focused on inpatient or hospital settings:
Extrapolations to the national population from the benchmark study conducted by Harvard University for the state of New York suggests that 1.3 million people are injured annually in hospitals, 180,000 of whom will die from those injuries. The study concluded that most adverse events were preventable.1
More recent studies are coming in with higher estimates. Three studies published in the Journal of the American Medical Association indicate that as many as 140,000 people may be dying from adverse drug events alone, that 50 percent of these are preventable, and that three-fourths of those that are preventable could have been caught by computerized systems, which hospitals have been slow to install.2
Rather than relying on what physicians and nurses write down in the medical record — as most error studies have done — a 1997 study used trained observers to monitor care at an urban teaching hospital. Based on what physicians and nurses discussed in clinical meetings, the observers identified one serious adverse event — ranging from temporary physical disability to death — in about 18 percent of the patients.3 The more seriously ill the patient, the more likely that patient was to suffer some sort of treatment-caused harm.
A new study released in December 1999 by the Institute of Medicine (IOM) estimated that as many as 98,000 Americans die unnecessarily every year from medical mistakes made by physicians, pharmacists and other health care professionals, costing the nation as much as $29 billion a year.4 The IOM lists medical errors as the fifth leading cause of death in the United States, behind heart disease, cancer, stroke and lung disease.
What can family physicians do?
Although efforts to date have been concentrated primarily in inpatient and nursing home settings, family physicians can take several steps to help reduce medical errors and improve patient safety.
Family physicians can help promote the development and application of new knowledge about preventing errors and can support initiatives by providers, hospital administrators and researchers in their practice areas.
Family physicians can use the latest technology, such as new hand-held electronic prescription pads that could reduce medication errors and make prescription writing easier. These portable devices check for adverse drug interactions and allergies when physicians enter prescriptions. Prescriptions are then e-mailed to a pharmacy, eliminating the possibility of handwriting errors or lost prescriptions.
Family physicians can help to assure medication compliance by providing patients with appropriate knowledge about their drug therapy management and encouraging patients to ask questions and participate in their own care plans.
Family physicians can use physician-generated computerized protocols to aid in making treatment decisions. These protocols do not replace decision making that is based on the specific needs of patients but can assist clinicians in identifying what works best for groups of patients under varying circumstances.
Family physicians can use computer-generated reminders to ensure that follow-up testing is performed on time. For example, studies have found that a small number of repeat tests were actually done too early to yield useful results. A computerized physician-reminder system would help prevent patients from being subjected to unnecessary repeat testing and would reduce the risk of harm to the patient.
Family physicians can chronicle innovative efforts to reduce medical errors and improve patient safety and report these initiatives to medical societies and researchers so they can be replicated by other family practices.
Family physicians, through their state and local specialty societies, can work with other interested parties to support the development of reporting systems to identify medical errors and prevent their recurrence. The reporting process does not have to be punitive but should be viewed as a learning opportunity for the medical community.
Despite their disturbing number, treatment-related injuries until recently have not been perceived as a major problem in American medicine. Experts attribute that to several factors, including the scattered nature of adverse events, the fact that many errors do not lead to serious injury, and the culture of medical practice that encourages many practitioners to deny or conceal errors. Health care professionals are trained to strive for error-free practice and often view errors as a failure of character.
In turn, corrective efforts generally focus on the individual practitioner rather than systemic causes, which means underlying causes are seldom examined. By focusing on organizational systems changes in a “no-fault” environment, the medical profession can achieve better results for patients and can live up to its title as the best in all the world.
National initiatives to reduce medical errors
Faced with a growing awareness that medical errors contribute to serious problems as well as a decline in public confidence in the health care system, a number of high-profile organizations have committed significant resources to finding ways to reduce errors and to increase patient safety.
The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that provides education about adverse drug events and their prevention through the ISMP Medication Safety Alert and other publications, educational programs and consultation with health care organizations.
The National Patient Safety Foundation is a nonprofit organization founded by the AMA. The foundation has co-sponsored a series of conferences bringing safety experts from health care together with experts from other industries, such as aviation and nuclear power, to pool experience.
The United States Pharmacopoeia (USP) is a private, not-for-profit public service organization that develops standards and disseminates information for health care professionals, patients and consumers about the use of medicines and other health care technologies. The USP has created an anonymous database designed to help hospitals and other health care organizations document, track and prevent medication errors.
The National Coalition on Health Care and the Institute for Healthcare Improvement have launched the “Accelerating Change Today (ACT) — For America's Health” initiative, which aims to identify “best practices” and breakthrough innovations in health care and to accelerate their adoption by hospitals, physicians and other health care providers. The first report on best practices, which is due to be released early this year, will profile initiatives undertaken by hospitals to reduce medical errors and improve patient safety. The organizations are also planning to hold a series of forums with medical specialty societies and other groups to present the findings from the best practice reports.
Joel Miller is the director of policy for the Washington, D.C.-based National Coalition on Health Care, a nonprofit, nonpartisan organization that brings together large and small businesses, labor unions, consumer groups, religious groups and primary care physicians in initiatives to improve the quality of health care and to make it more affordable.
1. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard medical practice study I. N Engl J Med.1991;324(6):370–376.
2. Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. JAMA. 1997;277(4):301–306; Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277(4):307–311; Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA.1997;277(4):312–317.
3. Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet.1997;349(9048):309–313.
4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Institute of Medicine. Washington, DC: National Academy Press; 1999.
Copyright © 2000 by the American Academy of Family Physicians.
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