Thursday, December 10, 2009

System-Wide Safety Changes Spurred by IOM

To Err Is Human Blog Series Logo

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

By Tracey Yap and Susan Kennerly

Ten years ago the IOM report issued this challenge to health care leaders:

“The status quo is not acceptable and cannot be tolerated any longer. Despite the cost pressures, liability constraints, resistance to change and other seemingly insurmountable barriers it is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing and comfort.”

Today, we believe the health care system is safer, although we still have a long way to go. Part of the revolution in the way that care is delivered has to do with a change driven by the IOM, which noted that faulty systems or procedures are often responsible for common medical errors. Rather than put blame on the individual, the IOM report shifted the focus so that hospitals now try to create a culture of safety.

What we’ve noticed in the decade after IOM is that hospitals and other health facilities take a broader view of quality and instead of homing in on one mistake and one individual, they look at systems to try to figure out how they can make the whole process of providing care more safely. Here are some ways:

Diffusing technology. Increasingly, hospitals now rely on technology, such as computerized prescribing systems to prevent drug errors. In the past, a doctor ordering a drug might write out the prescription by hand and the nurse trying to read the script might get the drug name wrong. Now, hospitals that use computerized systems have the doctor type the drug prescription right into the computer. Such systems eliminate errors that resulted from hard-to-read handwritten prescriptions.

That’s an example of a technology fix that’s made a big difference in errors.

Improving Systems. Another big picture change we’ve noticed is this: In the past, people who made mistakes might have focused on the error and pledged to change their ways. But in many cases, the IOM report pointed out that the error was not caused by a “bad apple” but by a faulty system.

Now, we believe that the entire health care industry has started to look for ways to improve quality on that system-wide level. One key change is that hospitals and other facilities have put teams in charge of patient care, a move that spreads responsibility for safety throughout the entire team. For example, doctors, nurses, therapists, and others might all work together to provide the highest standard of care.

Focusing on Staff Needs. In addition, hospital administrators are looking closely at staffing levels. They might put higher numbers of experienced staff, including nurses, on a unit, like an intensive care unit, that requires one-on-one care.

Promoting Accountability. We’ve also seen a revolution in accountability: Health care workers from housekeeping right up to the nurses and doctors are much more likely to speak up and draw attention to an error if they think some part of care has gone awry.

Research by INQRI and other private and public organizations has been driving a lot of the changes in quality that we now see in the health care system. Today there is more funding for such research and more attention is paid to the results, which can be used by policymakers to craft laws or regulations aimed at making health care even safer.

Are patients safer today than they were 10 years ago? Yes. But we believe that we still can make a lot of improvements in the system in the next 5-10 years.

Tracey Yap and Susan Kennerly are INQRI researchers at the University of Cincinnati.

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