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Feigin:
Patient safety is the right thing to do. |
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Institute of Medicine report
underscores
the importance of safety
By Ralph D. Feigin, M.D.
To Err is Human: Building a Safer Health System was
published in 1999 by the Institute of Medicine of the National
Academy of Sciences. The report was the result of deliberations
by a blue-ribbon committee that looked at safety in health care.
It pointed out that human beings in all lines of work make
mistakes, but that errors can be prevented by designing systems
that make it difficult for people to do the wrong thing and easy
for people to do the correct thing. It also said building a
safer system means designing processes of care to ensure
patients are safe from accidental injury.
The report pointed to several
high-profile cases publicized in the lay press as examples of
egregious errors that resulted in deaths of a number of
patients. It also referred to more extensive studies – such as
those conducted in Colorado, Utah and New York – that found
adverse events occurred in 2.9 to 3.7 percent of
hospitalizations. In Colorado and Utah hospitals, 6.6 percent of
adverse events led to death, whereas in New York hospitals 13.6
percent of adverse events led to death of the patients.
Medical errors are a serious problem in
the U.S.
In both of these studies, more than
half the adverse events resulted from medical errors that could
have been prevented if appropriate systems were in place. When
extrapolated to the more than 33.6 million admissions in U.S.
hospitals in 1997, the results of these studies imply that
44,000 Americans die each year as a result of medical errors.
The number could be as high as 98,000 if New York state data
were extrapolated to the nation as a whole. This means more
people die each year as a result of medical errors than from
motor-vehicle accidents, breast cancer or AIDS.
This report has provoked extensive action and reaction. The
Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has mandated that for a hospital to be accredited, it
must employ an extensive patient-safety program. Although Texas
Children’s Hospital and its physicians have focused on safety as
part of excellence in patient care for many years, a formal
safety officer (Dr. Joan Shook) was appointed in 2004 and a
formalized safety program put into place a little more than a
year ago. At Texas Children’s, as in many institutions, adverse
events sometimes occur, including errors in the use of
appropriate medications, the dose of medication written for a
given patient, and the like. We continue to work diligently to
create systems to eliminate these kinds of events.
Building a safer system
I know with certainty that our
medical staff believes that when a course of medical treatment
has been agreed upon, patients should have the assurance it will
proceed correctly and safely. This means building a safer system
by designing processes of care to ensure patients are safe from
accidental injury.
There are considerable external
pressures being put into place to make errors costly to health
care organizations and providers and to compel us to take action
to improve safety. Such an environmental change shouldn’t be
necessary to ensure we subscribe to appropriate patient safety
goals. I know that all the physicians with whom I have worked in
this organization are committed to patient safety because it is
the right thing to do. I thank you for joining me in
enthusiastically endorsing our patient-safety program and
recommitting to ensuring the safest and best possible outcomes
for our patients.
Ralph D. Feigin, M.D., is physician-in-chief at Texas
Children’s Hospital and professor and chairman of the Department
of Pediatrics at Baylor College of Medicine.
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