Strategies for Minimizing Preventable Medical Errors

0

Prevent medical errors with the following strategies

An estimated 440,000 patients die annually in U.S. hospitals as a result of medical errors, according to the Journal of Patient Safety. The implications of this statistic for individuals and our healthcare system are staggering. In fact, it represents the equivalent of eight fully loaded Boeing 737 jets crashing each day with loss of life of everyone on board.

When errors occur, it is essential for hospital systems to understand why they occurred and learn from these errors to prevent future deaths or serious injuries. Medical data analytics that help organizations to monitor, manage and report errors and adverse events now play a central role in realizing the delivery of safer, higher quality care.

Industry purveyors who design useful and usable solutions for this purpose will best position themselves to effectively meet the expectations of both providers and payers if they can provide a unique blend of functionality that centers on three fundamental areas:

  1. Safety Risk Management and Surveillance
  2. Pay-for-Value Reporting
  3. Performance Analytics

As part of this offering, the combination of SaaS-based solutions and information services should be made available, either on a standalone or fully integrated basis, to more effectively monitor and measure clinical and financial performance with precision and conviction.

If It Matters, It Must Be Measured

While there is no price tag on the loss of human life or personal injury to patients, there is the reality of medical errors impacting hospital budgets. As payments become increasingly and explicitly linked to a complex myriad of performance measurements, non-performing providers will face greater financial risk. Hospital systems should aim to optimize their day-to-day operations. In order to unlock value in healthcare and see improvements in quality and safety, there must also be a commitment to standardizing their approach to the treatment of major medical conditions and measuring their outcomes.

The key is to unlock all of the benefits of value-based healthcare, keeping in mind that this requires a clear commitment to measuring a minimum set of outcomes for every major medical condition, and standardizing them. Information technology vendors must take the lead in embedding standardized order sets and clinical processes into electronic medical records, and in creating software solutions that automate and aggregate outcomes-data collection. A data platform that allows provider benchmarking based upon resource utilization and condition-by-condition clinical outcomes should be included as a critical component.

Choosing the Right Solution

With the widespread use of healthcare information technology (HIT), data that providers need to track patient care is now readily available. This is significant, considering that episode of care analysis, where the complexity of measurement is most evident, requires a sophisticated system for tracking and measuring data.

Fortunately, episode evaluation systems exist that can span the entire continuum of patient care. Unlike traditional encounter-based systems, these have the capacity to capture all clinically related encounters and assign them to a single episode of illness regardless of care setting, allowing providers and purchasers to accurately compare the total cost and utilization of medical services against local peer groups, national norms and generally accepted best practices. This gives providers the power to measure what matters using meaningful and reliable information for assessing the integrated delivery of cost-effective care.

Building a Better Incident Reporting System

Incident reporting systems are architected to capture the systematic measurement of safety. These systems, which are capable of aggregating, monitoring and analyzing performance attributes in real-time, are already deployed in one form or another in nearly every health facility in the country. Unlike EHRs, Incident Reporting Systems were conceived as modern rapid-capture devices on the front-end and dynamic intelligence-gathering data-marts on the back-end.

Capturing an adverse event, a near miss hazard or a procedural gap in care requires little or no training, minimal time away from patient care, and can be completed in as little as two minutes. When appropriately designed, these systems enable front line staff and patients alike to instantaneously record both errors of commission and omission, as well as adverse events, without neglecting patient needs.

When combined with an effective strategic approach to performance improvement, clinical leaders and patient safety experts can derive the sophisticated analytical insights they need to drive tangible, measurable improvements.

Modern incident reporting systems can also pinpoint procedural safety gaps in care. Safe practices that mitigate certain safety risks have already been defined, are well established, and have been recognized as evidence-based within a growing cadre of tools.

Compliance with evidence-based practices necessitates instant recall at the point of care by those tasked with following such practices. Data suggests that barriers to compliance with best practices often stem from caregivers who don’t know or can’t recall what they should be doing, often under a growing set of increasingly complex clinical conditions.

Smart integration of Incident Reporting Systems with EHRs can aid in the proactive identification of high-risk conditions and patients, with the intent of mitigating preventable harm. Matching risk profiles from Incident Reporting Systems with patient data from EHRs can direct decisions on when, and in what manner, to enable precise application and documentation of care in the spirit of real-time decision-support.

Capturing provider performance for high-risk or error-prone conditions and patients will accelerate the identification of where both individual and system failure modes lie, and present clear, unambiguous targets for focused improvement efforts.

Incident Reporting Systems were built to identify and categorize errors and adverse events so that appropriate improvement efforts can be undertaken, but are still only fulfilling a small fraction of their potential. Modern technology can deliver the way to cost-effectively systematize and measure adherence to evidence-based practices.

The time has come for healthcare to affirm the intelligent, efficient and systematic capture of actions that constitute performance in every facet of care by way of precisely defined safety standards. Doing so will accelerate the ability to proactively monitor hazards in real-time and mitigate risks to both patients and providers.

Share.

About Author

Frank Mazza, MD
Frank Mazza, MD

Frank Mazza, MD, chief medical officer, Quantros, is a physician by training (pulmonary, critical care and sleep disorders), and still practices medicine part-time. Prior to joining Quantros, he held several executive positions within the Seton Healthcare Family in Austin, Texas, including system-level chief patient safety officer and associate chief medical officer, as well as vice president of medical affairs at Seton Medical Center, Austin.

Leave A Reply

Log in or register to comment on this article.