ROCKVILLE, MD—Could 11 fairly simple practices markedly improve your patients’ safety while in the hospital? A new federal report says yes.

Two years ago, in its alarming report on patient safety, the Institute of Medicine estimated that medical errors annually cause 44,000 to 98,000 deaths in US hospitals.[1] Since its release, many experts have debated the accuracy of its conclusions. But that report—and media coverage of individual fatalities due to medical errors—prompted a number of patient safety initiatives, including new evidence-based recommendations from the Agency for Healthcare Research and Quality (AHRQ).[2]

The recommendations address 79 patient safety practices identified through an extensive literature search. “All 79 have at least some evidence that they can improve patient safety,” related Nancy Foster, the AHRQ’s Coordinator for Quality Activities.

Rodney A. Hayward, MD, endorses the recommendations. “They are just what we need to address quality improvement,” he told RESPIRATORY REVIEWS. Dr. Hayward, a Professor of Health Management and Policy at the University of Michigan in Ann Arbor, is one of the authors of a recent study suggesting that the role of medical errors in patient deaths has been exaggerated (see sidebar). Nevertheless, he strongly supports the AHRQ report.

The AHRQ formulated its recommendations with help from the University of California at San Francisco–Stanford University Evidence-Based Practice Center (EPC). The EPC reviewed the scientific literature for patient-safety data, focusing on inpatients for two reasons: Hospitalization is associated with significant risks, and the best data on improving safety relate to the hospital setting.

The EPC defined a patient safety practice as “a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures.” This definition reflects current thinking that changing the health care system will be far more effective in reducing medical errors than will punishing individual providers, Ms. Foster said.

The 79 patient safety practices were rated on a 1-to-10 scale based on the strength of the evidence for their effectiveness and clinical judgment of their probable impact on adverse events. The EPC chose not to consider the difficulty or cost of implementation when rating each practice.

Eleven of the practices received especially high ratings. They are listed, in descending order, in Table 1.

This list may be a good starting point for those who wish to get started quickly on improving patient safety without analyzing the entire 79-item list, Ms. Foster suggested. “However, we strongly encourage going back over the whole list to identify the items that would be most beneficial for each health care system,” she told RESPIRATORY REVIEWS.

FUTURE RESEARCH PRIORITIES

Because patient safety is a relatively new field, better evidence is needed to support many patient safety practices. According to the AHRQ, researchers should give 12 practices top priority. In addition to items 1, 4, and 10 on the list of 11 highly rated patient safety practices, these include:
• Improved perioperative glucose control to decrease perioperative infections.
• Localizing specific surgeries and procedures to high-volume centers.
• Supplemental perioperative oxygen use to decrease perioperative infections.
• Changes in nursing staff to decrease overall hospital morbidity and mortality.
• Use of silver alloy-coated urinary catheters to prevent urinary tract infections.
• Computerized physician-order entry with computerized decision support systems to decrease medication errors and adverse events.
• Limiting antibiotic use in order to prevent hospital-acquired infections with resistant organisms.
• Use of analgesics for acute abdominal pain without compromising the accuracy of diagnoses.
• Improved hand-washing compliance through education and behavior change, sink technology and placement, and/or the use of antimicrobial washing products.

 

Stats on Fatal Medical Errors: Eye-catching but Misleading

ANN ARBOR, MICH—Physicians should not put much stock in the statistics on medical error–related deaths that have gotten so much publicity. They are probably unreliable, a new study suggests.[1] “Hospitals have been portrayed as dangerous places, and I think that is the wrong portrayal,” stated lead author Rodney A. Hayward, MD. Dr. Hayward and coauthor Timothy P. Hofer, MD, supervised a retrospective review of 111 deaths at seven Veterans Affairs medical centers from 1995 to 1996. The medical records for these cases were evaluated by 14 board-certified internists, who rated each death on a 1-to-5 scale from “definitely” to “definitely not” preventable with optimal care. They also estimated the patient’s chances, had care been optimal, of surviving to discharge and of living at least three months post-discharge with good cognitive function. Patients with hospital-acquired renal failure, hyperkalemia, hyponatremia, or digoxin toxicity were intentionally over-sampled because previous research has suggested that patients with fluid and electrolyte imbalances and drug toxicities have higher preventable death rates. Terminally ill patients receiving end-of-life comfort care were excluded. Because many of the cases were evaluated multiple times, 383 reviews were completed. As in previous studies, nearly a quarter (22.7%) of the deaths seemed to have at least some degree of preventability with optimal care. However, only 6% were rated as probably or definitely preventable. In other words, just 6% of the patients would have survived to discharge had care been optimal. Furthermore, only 0.5% of the patients would have lived at least three months with good cognitive function after discharge, the reviewers estimated. —Timothy Begany

Reference 1. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286:415-420.

—Timothy Begany