Working together to improve patient safety

Working together to improve patient safety

Last month, the Agency for Healthcare Research and Quality finally released its long-awaited proposed rule to implement the Patient Safety and Quality Improvement Act of 2005. The AMA had been pressing the U.S. Department of Health and Human Services to issue the rule since this legislation was signed into law in July 2005.

The proposed rule establishes a process through which health care providers can voluntarily report medical errors without fear of legal prosecution. Under the proposal, patient safety organizations would be established to collect and analyze medical data confidentially, and breaches of confidentiality would be subject to civil monetary penalties. The AMA played a leading role in securing passage of the law three years ago, and we're reviewing this proposal to provide comments on it by the April 14 deadline.

AMA advocacy for this law only scratches the surface of our leadership in improving the safety of America's patients. Through the Quality of Care Campaign for Patient Safety, the AMA offers numerous tools to enhance teamwork, communication, and systems improvement to help institute a culture of safety in all settings of care.

A significant part of this campaign is the Making Strides in Safety^® initiative, through which the AMA has developed numerous model programs and resources. These include toolkits on participation, (PDF, 256KB) implementation, (PDF, 353KB) and health delivery systems improvement, (PDF, 310KB) as well as a tip sheet on communication effectiveness. (PDF, 92KB) Meanwhile, Doctor-to-Doctor resources (PDF, 203KB) feature advice from physician leaders on patient safety interventions and hospitals' implementation strategies.

Earlier this week the AMA released a new toolkit, "Working together to improve care and prevent harm," (PDF, 513KB) which includes quality measures that, for example, can help physicians deliver reliable, evidence-based care for heart failure. This toolkit also includes a new strategy that details how to reduce harm from high-alert medications such as sedatives, narcotics, and insulin. The AMA, as a strategic partner in the ongoing efforts of the Institute for Healthcare Improvement (IHI) to improve patient care, created this toolkit to help widen adoption of the IHI's 12 proven interventions in care.

The AMA created a booklet, "The Physician's Role in Medication Reconciliation," that details issues, strategies, and safety principles to optimize the safe and effective use of medications. The booklet, which will be available online later this year, includes a medication tip card that physicians can share with their patients.

The AMA timed its announcement about the availability of these new resources to coincide with National Patient Safety Awareness Week, which is observed through Saturday, March 8. The theme is "Patient Safety—A Road Taken Together," and earlier this week the AMA offered patients a list of easy tips (PDF, 563KB) to help them be active partners in their own health care, starting with a check of items in their own medicine cabinets.

Launched in 2002 and celebrated each year during the first week of March, National Patient Safety Awareness Week honors John M. Eisenberg, MD, (PDF, 16KB) a patient safety leader whose commitment to patient safety and health care quality is memorialized by an award bearing his name. The annual John M. Eisenberg Patient Safety Awards are presented by the National Quality Forum and The Joint Commission to recognize individuals and health care organizations that significantly contribute to improving patient safety. One of the most recent winners is AMA member Darrell A. Campbell Jr., MD, a surgeon at the University of Michigan Hospitals and Health Centers.

Another significant aspect of the AMA's Quality of Care Campaign for Patient Safety is the Physician Consortium for Performance Improvement (PCPI), which focuses on clinical quality improvement and patient safety through the development, testing, and maintenance of evidence-based clinical performance measures and measurement resources for physicians. I wrote a column about the PCPI in October.

In a separate column about the rising costs of health care, one subject I didn't mention is health literacy—the degree to which people have the capacity to obtain, process, and understand basic health information. According to a recent report from the University of Connecticut, low health literacy costs the U.S. economy as much as $236 billion annually.

In 1998, the AMA became the first national organization to adopt policy recognizing that low health literacy negatively affects medical diagnosis and treatment. Since then, the AMA Foundation has developed an educational toolkit, patient safety monographs, and patient safety tip cards to help physicians and other health care professionals approach this issue with their patients. In addition, the AMA supports legislation designed to help the 90 million adults who have limited comprehension of essential health information.

The AMA-established National Patient Safety Foundation (NPSF) recently partnered with the World Health Organization (WHO) to focus on improving health literacy by translating its Ask Me 3 program, an initiative designed to assist with communication between patients and providers, into the six official languages of the WHO to spread word of the program worldwide. This partnership is one of many ways the NPSF is making a difference in improving the safety of patients. The AMA established the NPSF in 1996, donating more than $7 million to it and remaining actively involved in its governance.

The road to improving patient safety is best traveled together. By working in concert, we can continue to ensure that our patients receive safe, effective, and timely care.

The lighter side

Patient safety is a top priority in the real world of medicine. But this subject has also found its way into the entertainment media, with the depiction of medical errors in serious drama as well as comedy.

Medical mishaps and ethical lapses occur often in the medical shows on television that are now the rage. But Hollywood too has portrayed medicine as risky business.

A "classic" movie about medical misadventure was "The Hospital" (1971), starring George C. Scott and Diana Rigg. It did for hospitals what "Jaws" did a few years later for beaches. According to the outline of the plot on the Internet Movie Database, "People in the wrong beds are given wrong medicines, sent to operating theaters for incorrect surgery, and found in waiting rooms dead of natural causes."

Recently I came across "Men in Black," the 1934 film starring The Three Stooges (which bears no resemblance to the 1997 comedy sci-fi flick using the same title). The movie shows Larry, Curly, and Moe causing chaos in Los Arms Hospital, where—as Columbia Pictures puts it—"they dispense unorthodox advice, flirt with the nurses and battle a babbling intercom system."

"Men in Black," as described in Wikipedia, "consists of a series of skits in which the Stooges go from one patient to the next, making mistakes ranging from drinking a patient's medicine to sewing their tools inside a man on the operating table." The film was nominated for an Academy Award for Best Short Subject—Comedy.

And here's a trivial personal connection between me and "Men in Black": The film pauses several times on the "Loud Speaker Call" box on the wall, the PA system used to page doctors. Sixteen doctors are listed on the wall unit, and "Dr. Davis" is one of them. (Ironically, "Dr. Scott" (George C. Scott?) is another.)

Do you remember any particularly striking portrayals of medical errors on television or in film?

Please send comments, questions, and replies to amaprez@ama-assn.org.