250 words with both perspectives 1. Go to the website of the report on Medical Errors by the Institute of Medicine called “To Err is Human.”  Reflect on the report, how does the report reflect...

250 words with both perspectives

1. Go to the website of the report on Medical Errors by the Institute of Medicine called “To Err is Human.”  Reflect on the report, how does the report reflect your practice or experiences, think about the report from the point of view of the consumer. 

2.  Read “Crossing the Quality Chasm”. Reflect on the report from the perspective of a nurse.

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kipling2448 | (Level 3) Educator Emeritus

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The two reports to which the question refers constitute a series commissioned, funded and executed under a common sponsor. As the second of these two reports notes in its preface: 

“This is the second and final report of the Committee on the Quality of Health Care in America, which was appointed in 1998 to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. The committee’s first report, To Err Is Human: Building a Safer Health System, was released in 1999 and focused on a specific quality concern—patient safety. This second report focuses more broadly on how the health care delivery system can be designed to innovate and improve care.”

As such, the reports represent a continuum, with the first report, To Err is Human:  Building a Safer Health System, laying the groundwork for the more difficult task covered in the second report, Crossing the Quality Chasm:  A New Health System for the 21st Century. Before responding further, however, it is important to note that questions such as this require a representation of the views of the individual student based upon his or her own experiences and observations.  What follows, therefore, is a more general approach to the issue of medical errors.

Medical errors, as To Err is Human points out, are discouragingly common. The report estimates that the total number of Americans killed annually as a result of such errors could reach as high as 98,000, more, the report’s authors point out, than are killed annually by motor vehicle accidents, AIDS, or myriad other higher profile causes of death.  From a colder practical sense, the report notes, the costs to the nation of these deaths:

“Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors result-ing in injury) are estimated to be between $17 billion and $29 billion, of which health care costs represent over one-half.”

Unsurprisingly given the scale of the problem, the causes of this state of affairs are multiple, and the requisite fixes time intensive and contentious. Each element of the health care system carries some measure of responsibility for the problem, with the legal ramifications of medical malpractice playing an important role. As the authors write: “Providers also perceive the medical liability system as a serious impediment to systematic efforts to uncover and learn from errors.”  Additionally, consumers and the insurance industry – “third party payers – are culpable in creating an environment in which incentives to improve the current system are minimal:

“. . .the context in which health care is purchased further exacerbates these problems. Group purchasers have made few demands for improvements in safety. Most third party payment systems provide little incentive for a health care organization to improve safety, nor do they recognize and reward safety or quality.”

A culture accepting of substandard practices and procedures exists, according to this report, and the authors suggest that the requisite measures, while politically onerous, could result in considerable reductions in the number of medical errors made each year:

“The combined goal of the recommendations is for the external environment to create sufficient pressure to make errors costly to health care organizations and providers, so they are compelled to take action to improve safety. At the same time, there is a need to enhance knowledge and tools to improve safety and break down legal and cultural barriers that impede safety improvement. Given current knowledge about the magnitude of the problem, the committee believes it would be irresponsible to expect anything less than a 50 percent reduction in errors over five years.”

Anyone who has a great deal of interaction with the health care community, or who has close family or friends who have experienced major health problems, has probably witnessed or been exposed to some measure of ineptitude, if only fleetingly.  This educator’s father was trained in medicine and was far more knowledgeable than most patients when he was diagnosed with a particularly pernicious form of leukemia. He was, consequently, more mentally attuned to the procedures to which he was subjected.  It was not, therefore, surprising when he “caught” a member of the hospital staff, during the middle of the night, when even medical staff are tired and operating under less-than-advantageous conditions (e.g., dimmed lighting), inadvertently preparing to inject the wrong substance into my father’s IV line – a mistake that would have proven fatal if not caught. Had my father not been knowledgeable about medicine and medical procedures, and had he not routinely inquired of the attending physician as to the nature of the substance about to be injected into his blood, he would have died then and there, and his family would have only been notified that he died during the night. 

The lessons here are that informed consumers are an essential component of the systemic fixes to which these reports are addressed, and that medical errors can occur at any time, under any conditions, and may never be acknowledged or reported.  My purpose, then, in relating this story is to illuminate the relevancy of the report’s recommendations, which include addressing the legal environment in which medical care is administered to allow for acknowledgement of errors while providing a dual-track system for reporting such errors. One track would officially acknowledge the mistake so that the affected patients and/or their families would know the truth; the other track would remain confidential so that medical personnel can examine the causes of the mistake in an atmosphere free of legal ramifications. As the title of the first volume notes, “to err is human.”  Mistakes will be made – far fewer following implementation of the study’s recommendations, according to the authors – irrespective of systemic fixes to the current system. Doctors and nurses are only human, after all.  The cultural impediments to minimizing those mistakes cannot be adequately addressed if the environment is not conducive to an open and comprehensive examination of medical errors. 

Which brings us to the second volume, Crossing the Chasm.  Whereas To Err is Human covered the myriad deficiencies in the existing health care system, and provided recommendations for how to improve that system, Crossing the Chasm focused more heavily on cultural factors, particularly relationships among the various components of the system, mainly patients and medical providers (“how patients and their clinicians should relate, and how care processes can be designed to optimize responsiveness to patient needs”). As this volume also states, though:

“Change is also required in the structures and processes of the environment in which those organizations and professionals function. Such change includes setting national priorities for improvement, creating better methods for disseminating and applying knowledge to practice, fostering the use of information technology in clinical care, creating payment policies that encourage innovation and reward improvement in performance, and enhancing educational programs to strengthen the health care workforce.”

The cultural changes that must occur involve creating an atmosphere in which quality of medical care is paramount – one would assume that is the case, anyway – with patient care the highest priority.  Government has role to play in passing legislation intended to address deficiencies in the broader “system,” including the aforementioned “third-party payers,” but also demands from the public and its political representatives to improve safety inside health care organizations. And, to reiterate, the inevitability of some medical errors must be acknowledged so that medical personnel can learn from those mistakes.  As the first report stated,

“identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts, both with the aim of making sure the system continues to be made safer for patients”

From the nurse’s perspective, the relationship between physician and nurse has to change to allow greater latitude for the latter to report errors, whether observed of others, or perpetrated by him- or herself. They must, as the report acknowledged, be held accountable, but, to the extent the error was a product of systemic deficiencies, it is that system that bears the greatest burden of accountability. The problem with Crossing the Chasm, though, from the nurse’s perspective, is its platitudinous recommendations that lack “teeth.”  The report appropriately recognizes disconnects among and between components of the health care system, and may even legitimately address broader flaws in the approach to medical care when discussing the distinctions between acute and chronic impairments.  The practical, everyday realities of medical care, though, simply do not allow for such distinctions.  The American public, the focus of this attention on medical care, is not in a position to approach its health care from this kind of macro perspective.  It is fine to suggest, as the report’s authors do, that “Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case.” Addressing those deficiencies, however, requires a level of effort, and the dismantling of certain bureaucracies, that is antithetical to many of the very same medical practitioners who would otherwise advance such recommendations.  Forcing the issue through governmental mandate, such as was the point behind the Affordable Care Act, can cause as many problems as it fixes.

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