Re-engineering how care is delivered to provide safer, more compassionate care
One of the most pressing issues in health care today is the quality and safety of care that people receive. Each year, millions of people suffer from medical errors and tens of thousands die from these errors. Medical errors are numerous and varied – from infections to misdiagnoses – and their causes equally diverse.
For years, major efforts to improve the safety of care have focused on the inpatient, or hospital setting. Yet more and more health care is being delivered in the outpatient, or community-based settings. So, it makes sense that the focus of safety work move in this direction too.
The community setting is prone to problems and errors that include missed and delayed diagnosis, delay of proper treatment or preventive services, and medication error and adverse drug events. A recent review of studies published from 1980 to 2014 finds that patient safety incidents are relatively common in primary care, with roughly two to three incidents per 100 consultations. Of these, an estimated four percent result in harm, with the most severe cases of harm commonly associated with diagnostic or prescribing errors.
Shifting safety work to community-based settings, such as outpatient clinics, rehabilitation centers or in people’s homes, presents an important opportunity to increase collaboration and coordination of care within these different settings to address avoidable harms and errors, and improve patient experiences and outcomes. As the next wave of patient safety efforts move in this direction, we will explore how our resources can best be applied to improve the safety of the care people receive.
Currently we are exploring two areas that need improvement: diagnostic and medication errors. Each year, approximately 12 million adults in the U.S. experience a diagnostic error as part of an outpatient office visit – that’s one in 20 people. The National Academy of Medicine defines a diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” The Academy also reports that more than 1.5 million medication errors occur in the U.S. annually. According to their report, “errors are common at every stage, from prescription and administration of a drug to monitoring of the patient's response.”
In addition to a focus on diagnostic and medication errors, we are exploring ways to improve safety practices with health information technology. While the rapid pace of adopting new health IT offers great promise to improve safety, it also comes with unintended consequences. For example, copy and paste practices in electronic health records may cause harm to patients by replicating inaccurate information; excessive use of alerts may lead to alert fatigue, where clinicians fail to pay attention to the alerts that really matter; and poorly designed screens may result in inappropriate orders.
Our focus on patient safety originates from our co-founder, Betty Irene Moore. Based on her personal experience in the hospital, and in caring for family members who have been hospitalized, she saw an opportunity to improve the quality and safety of care throughout the San Francisco Bay Area in adult acute care hospitals. Through the Betty Irene Moore Nursing Initiative (2003-2015), quality and safety throughout the Bay Area and the greater Sacramento region was significantly improved. Building on the regional success, the foundation created the Patient Care Program in 2012 to improve the experience and outcomes of patient care nationally.
From 2012 to 2016, our efforts focused on quality improvement projects in critical care. We selected the intensive care unit because it is one of the most complex and costly settings in health care and it is a place where there is significant risk of experiencing harm. Our ICU work was a partnership with four academic medical centers: Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Johns Hopkins Medical Center and University of California, San Francisco Medical Center. Each center focused on eliminating some of the more prevalent, and preventable, medical harms experienced in the ICU. They also focused on addressing non-medical harms, specifically ensuring patients are treated with dignity and respect. As this work comes to a close, we are preparing to share learnings from this work with others.