Coordinated Care Still Needs Some Work

While coordinated care is widely considered the best way to keep costs down and provide better patient care and is a centerpiece of the Affordable Care Act, too often care coordination isn't really happening according to a story produced by Kaiser Health News in collaboration with the Washington Post.

Kaiser Health News quotes leading health policy analyst Lucian Leape: "nobody is responsible for coordinating care." According to the story, lack of coordination is resulting in an estimated 44,000 to 98,000 deaths from medical errors annually. This, despite health care's strong response to the landmark Institute of Medicine report, To Err Is Human, published in 1999. That study was the subject of an INQRI blog carnival in 2010, featuring posts from several INQRI-funded researchers.

There is good news, however -- an article HealthLeadersMedia, published earlier this week indicates that nurses have the skills and experience provide effective and successful coordinated care. According to sources in the article, nurses' experience at the bedside - caring for multiple patients and handling their varying needs - makes them uniquely suited to understand and provide coordinated care.

Several INQRI teams have investigated how nurses' contribute to improved care coordination, especially in times of transition from hospital to home.

A Year After "Dead by Mistake" and 11 After "To Err is Human"

"Health care reform consumed the nation for the last 12 months but, despite all the talk, the country took only baby steps toward reducing medical errors that injure and kill millions of hospital patients."

In a new Times-Union article, writers Cathleen Crowley and Eric Nalder take a look back at the year following the Hearst Newspapers series, "Dead by Mistake."  With estimates of about 200,000 deaths per year caused by avoidable mistakes and hospital-acquired infections, it's clear that patients are still facing severe risks.

Click here to read the story.

The "Dead by Mistake" series debuted last year during the 10th anniversary year of the Institute of Medicine's "To Err is Human" report.  Last December, INQRI hosted a two week blog series, commemorating that anniversary. 

Click here to read the posts. 

We have also recently published a booklet of the posts.  To receive a copy, please contact Heather Kelley.

The Time is Now

INQRI researcher Linda Flynn was recently quoted in an article on Nurse.com, "The Time is Now: 'Culture of Safety' Key to Preventing Errors." This powerful article presents evidence-based tools that are effective to preventing errors, like bar codes, while also focusing on the cultural shift required to intercept errors.

Flynn's own work dealt specifically with creating a culture of safety.

In a survey of New Jersey nurses in 14 hospitals, she found nurses reduced medication errors when they asked physicians to rewrite an order that didn’t use standard wording or was unclear; questioned why a patient was receiving a particular medication; did their own medication reconciliation; and educated patients and families about medications they were receiving.

The likelihood of nurses doing these things, she says, “was predicted by the work environment,” and specifically five factors: strong frontline nursing leadership; good collaboration between physicians and nurses; adequate resources; participation in decision-making; and foundations for quality, such as good mentoring, orientation and in-service education.

Click here to read the article and check out the accompanying Checklist for Nurse Patient-Safety Advocates.

Click here to read the blog posts from INQRI's series on the 10th anniversary of the To Err is Human report... because we agree with the article: "The time is now."

Click here to watch Dr. Flynn and her collaborator Dr. Dong Suh present their findings at the 2009 INQRI annual meeting.

WSJ Health Blog: "Study Puts Cost of Medical Errors At $19.5 Billion"

In a new piece on the Wall Street Journal's Health Blog, Katherine Hobson writes about a study commissioned by the Society of Actuaries which found that medical errors cost America's economy $19.5 billion in 2008.  This estimate includes "medical costs, costs associated with increased mortality rate and lost productivity, and covers what the authors describe as a conservative estimate of 1.5 million measurable errors. The report estimates the errors caused more than 2,500 avoidable deaths and over 10 million lost days of work."

What better time to revisit 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.
 
To read Hobson's article, please click here.

INQRI Blogging Events

Last December, INQRI hosted a two week blogging event to commemorate the 10th anniversary of the Institute of Medicine's "To Err is Human" report. Our blog series consisted of posts from national health care leaders, researchers and advocates who offered their perspectives on how the report changed the practice of health care in the United States and what challenges lie ahead.

These posts have been compiled into a booklet, which is now available for download as a PDF.

We have another blogging event coming up next week. INQRI is pleased to announce that we will host the next Change of Shift, a blog carnival, on February 18 at 9 p.m. ET. We are now accepting blog post submissions focused on nursing education. This theme coincides with the topic of the RWJF Initiative on the Future of Nursing, at the IOM’s final forum to be held on February 22 at 9 a.m. ET.

The Forum on the Future of Nursing: Education will be webcast live. Register for the webcast here.

Submit your posts to INQRIChangeofShift@gmail.com by 5 p.m. Wednesday, February 17.

Let’s not wait another 10 years

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.

I would like to extend a very warm thank you to everyone who participated in our two week series to commemorate the 10^th anniversary of the “To Err is Human” report.  Thank you to those who were interviewed, wrote blog entries, promoted us on your sites, followed along on Twitter, wrote comments, voted in our poll and read with us for the past two weeks. I hope you will continue to do so.

We have heard from hospital administrators, clinicians, researchers, journalists, and fellow bloggers.  We have heard what we already suspected to be true – patient safety is a team sport.  Doctors, nurses, patients and families are all part of this effort… and, though progress has been made, we still have a long way to go.

As the report said ten years ago:

“To err is human, but errors can be prevented. Safety is a crucial first step in improving quality of care…Must we wait another decade to be safe in our health system?”

Let’s not wait another 10 years.

Continue following us on our journey. Be a part of the conversation. We want to hear from you.

Patients Play Key Role In Quality Movement

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.

Teamwork has become a standard of care in many U.S. hospitals since the IOM released its landmark report on medical errors, says nurse researcher Kathleen Stevens at The University of Texas Health Science Center at San Antonio.

That team often includes nurses, doctors and other health professionals who work together to both check for errors and provide the highest standard of care, Stevens says. But she says that more and more hospitals are starting to involve patients and family members in the final effort to raise the bar on quality.

For example, nurses on a neonatal intensive care unit often provide one-on-one care for tiny babies. But the mother is often at the bedside for hours and in some cases is the first line of defense against an error or complication, Stevens says. If the mother notices the baby seems to be showing signs of distress, she can press a button on the side of the bed and call for a rapid response team.

Medical Errors in Popular Culture: Nurse Jackie

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.

In this clip from the very first episode of Showtime's Nurse Jackie, Jackie's attempt to voice her opinion to a doctor is rebuffed, with catastrophic consequences...

Ten Years Later: Look To Nurses As Champions of Patient Safety

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.

Today, Kaiser Health News featured this column by Mary Naylor and Mark Pauly, INQRI's co-directors.

Ten years ago this month, the Institute of Medicine shattered a widely held perception that American health care was safe. IOM’s finding that as many as 98,000 patients die each year in hospitals from medical errors launched an aggressive patient safety movement that continues today.

But the report also cast a spotlight on the role of the nurse in keeping patients safe, a role that will become even more important under the ongoing effort to reform the health care system.

Prior to the IOM report To Err is Human, there was little recognition among health care leaders of the contributions nurses make to improve quality and prevent medical errors. Although they are the caregivers who have the most contact with patients, nurses have typically been undervalued and have had to practice in an environment that often set them up for failure.

For example, a nurse working on an understaffed unit with lots of very sick patients might, in some cases, make a mistake. But the IOM report is credited with taking the blame off individual health care workers and shifting the focus to system-wide flaws that lead to errors.

Today, nurses are playing a central role in offering solutions that correct such flaws and advance patient safety and quality—throughout the system.

System-Wide Safety Changes Spurred by IOM

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.

INQRI in the Health Wonk Review

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.

INQRI was pleased to be included in this week's edition of the Health Wonk Review, which highlighted Terri Schmitt's post and provided a link to our entire "To Err is Human" series (Scroll down to the "Quality and Safety" section.).

The Health Wonk Review is a biweekly compendium of the best health policy blogs. It is a roving digest, with each issue hosted at a different participant's blog. This week's edition is being hosted at Workers Comp Insider. For more information about the Review, check out its website at http://www.healthwonkreview.com/.

Changing Hospital Cultures to Reduce Hospital-Acquired Infections

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.

This video comes from an interview with Ramanan Laxminarayan, Senior Fellow at Resources for the Future and Director of Extending the Cure, a project engaged in policy research to extend antibiotic effectiveness.

Here, Dr. Laxminarayan discusses strategies to address hospital-acquired Infections (HAIs). Certain efforts to date have been successful. For example, checklists have been associated with a significant drop in central-line bloodstream infections. The challenge is figuring out how to permanently change hospital cultures and structure incentives to reduce HAIs—because despite certain successes, there’s no conclusive evidence that overall rates of HAIs have decreased substantially in recent years. 

Patients still struggle to find their role in reducing medical errors

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.

This post is written by Nancy Shute, a contributing editor for US News & World Report, and vice president of the National Association of Science Writers. Contact her at nancy@nancyshute.com.

Last July 26 started out like a typical summer Sunday; pancakes with the family, talk about an afternoon at the neighborhood pool. Instead, I spent the day at the ER, suddenly and horribly ill with pyelonephritis and bacteremia. I was lucky; four days of IV antibiotics knocked back the bad bugs (thank you, Cipro!). But I spent those days in the hospital worrying about more than when I’d be back home cooking dinner for the family. As I watched the IV drip, hour after hour, I fretted. Was I being given the right medication? The right dose? How could I tell if there was a medication error? As a journalist who has covered health care quality for years, I knew what I should do: Check medications and doses; ask questions; recruit a family member to be my advocate. Did I do those things? Nope. Afraid that I’d be labeled a nutcase or a troublemaker by the busy nursing staff if I voiced my fears, I clammed up.

My tiny medical drama ended happily. But each year, tens of thousands of patients aren’t so lucky. Ten years after the publication of the landmark Institute of Medicine Report “To Err Is Human,” patients remain subject to errors in medical treatment that threaten their health and their lives. The federal government, hospitals, foundations, and health care providers have made concerted efforts to educate patients on their role in protecting themselves from medical errors. I’ve done my part, too, writing about successful experiments to reduce medical errors, as well as “News You Can Use” articles intended to help patients and their families advocate for safer, better care. Yet too often, patients like me still feel powerless, rather than empowered.

Modern Healthcare article: A long way to go

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.

The below comes from an article by Jean DerGurahian in Modern Healthcare this week.  The full article is available here.

In the decade since the IOM's groundbreaking study on medical errors, there's progress to report, but many of the objectives remain elusive

In the winter of 1999, one ticking time bomb appeared to be the “Y2K bug,” when it was feared that computer glitches on Jan. 1, 2000, could cause any number of annoyances and even calamities. While that fizzled, another bomb—the Institute of Medicine report To Err is Human—soon exploded in the healthcare industry.

The IOM report is still causing repercussions 10 years later.

It was not the kind of event that later leads people to ask each other: “Where were you when you heard the news?” But Helen Haskell remembers when she first heard about the IOM report. She was in her car, listening to a news report on National Public Radio, and thinking it had little to do with her life. She recalls that moment now, a decade later, after losing her son to medical errors and helping to lead patient-safety advocates in their crusade for better care in hospitals. She founded the advocacy organization Mothers Against Medical Error.

Researcher Looks At Education, Experience of Staff and Safety

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.

Nancy Donaldson is Director of the Center for Nursing Research & Innovation, a collaboration between the University of California San Francisco School of Nursing, its UCSF Medical Center, Stanford Hospital and Clinics and Lucile Salter Packard Children’s Hospital at Stanford.


I have observed a transformational revolution in health care during the 10 years that have passed since the IOM released its landmark report, To Err Is Human. That report estimated that as many as 98,000 Americans die in hospitals each year as a result of preventable medical errors. It also casts a harsh light on delays or lapses in care that can threaten patient safety and challenges all health care providers to examine the quality, safety and outcomes of their care.

Checking the Right Boxes, but Failing the Patient

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.


Dena Rifkin, M.D., recently published a piece in the New York Times Health section with her reflections on the care delivered to patients in the ten years following the release of "To Err is Human." While she acknowledges the need for adherence to best practices and understands the importance of newer interventions (i.e. pay-for-performance and electronic prescription systems), she also believes that there is a large problem in our current health care system: "a change in focus from treating the patient toward satisfying the system."

"The effects of focusing physicians’ attention on benchmarks and check boxes are not, I think, to the patient’s advantage. "

Click here to read more.

Nursing Research Helps Drive Safety

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.

Ten years after the IOM reported on medical errors, research funded by INQRI has been adding crucial information to the ongoing debate on quality of care. So says Laura Caramanica, Senior Vice President and Chief Nursing Officer for Westchester Medical Center in Valhalla, New York.

She should know. Caramanica is also a member of INQRI’s National Advisory Committee. She says INQRI grantees have been hard at work generating data that’s already being used by policymakers and health care leaders to enact changes aimed at making the U.S. health care system safer for patients.

For example, INQRI funded studies have been investigating the role that nurse staffing levels have on the quality of care that patients receive in hospitals and other health care settings.

“Nurses make a tremendous difference in the provision of high-quality care and often step in and prevent medical errors,” Caramanica says.

Advocates of a safe staffing level suggest that when the number of registered nurses dips too low, the quality of the care can suffer. But INQRI research suggests that the safe staffing question is more complicated than just counting the number of registered nurses. They’re finding that the skill mix and staffing levels for non-nursing positions can also make a difference: For example, nurses on units that don’t have enough staff, including secretarial staff, can end up being pulled away from direct bedside care, Caramanica says.

What Do YOU Think?

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.

During this series, we are hearing from researchers, clinicians and journalists about their views on patient safety in the ten years following the release of To Err is Human. Now, we want to hear from you. On the top right corner of this page, we have posted a one question poll about patient safety. Please take a moment to cast your vote and then comment on this post to explain your thoughts.

Hospital Error Rates - Still a Long Way to Go

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.

"In hospitals, high error rates with serious consequences are most likely in intensive care units, operating rooms and emergency departments…" — To Err is Human, p.36

We'd all like to think that, 10 years after the publication of To Err is Human, the problems and conflicts it described have been examined and improved. But a new study published Dec. 2 in the Journal of the American Medical Association underlines how very far we have to go.

The study, informally named EPIC, was a prospective point-prevalence survey — essentially, an intense single-day snapshot — of infections in 1,265 ICUs in 75 countries on May 8, 2007. It found that 51% of the critically ill patients in those ICUs (7,087 of 13,796 adults) were experiencing infections on that day, and 71% (9,084 of 13,796) were receiving antibiotics.

Those percentages are dismaying enough. But here's the really bad news: This iteration was EPIC II; its predecessor study, EPIC I, was conducted 15 years earlier, on April 29, 1992. And over those 15 years, the ratios of infected patients and antibiotic therapy worsened: In 1992, they were respectively 45% and 62%.

Medical Mistakes, 10 Years Post-Op

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.

To commemorate the 10th year anniversary of "To Err is Human," The Hospitalist caught up with two of the committee's original members: Donald Berwick, MD, MPP, FRCP, president and CEO of the Institute for Healthcare Improvement (IHI) and Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM) to discuss the advances made in medicine since November, 1999 and what still needs to be accomplished. They discuss the report's legacy and the impact it has had on medicine and the patient safety agenda.

Click here to read the interview.