Report: Patient Safety Needs Improvement

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July 17, 2001 (Washington) -- A new federal report gives healthcare officials a list of proven safety techniques that can stop errors before they start. But the authors say too often these techniques are ignored.

The massive 640 page document, titled "Making Health Care Safer: A Critical Analysis of Patient Safety Practices," is aimed at the healthcare professionals making patient care decisions.

The impetus for this analysis came from the highly publicized 1999 Institute of Medicine report indicating that between 44,000 and 98,000 Americans annually die from medical errors. While efforts at improving patient safety are nothing new, this effort, prepared by AHRQ, the Agency for Healthcare Research and Quality, is different.

"'Why aren't we doing this?' is the kind of question that a healthcare leader [reading this report] ought to be asking," says John Eisenberg, MD, director of AHRQ.

"The nation's healthcare leaders need to know what the science says about where the opportunities exist to make patient care safer right now," said Health and Human Services Secretary Tommy Thompson in a statement accompanying the report.

For this report, researchers at the University of California and Stanford University evaluated 79 patient safety practices. Of those, 73 are considered likely to improve patient safety.

Eleven techniques were singled out that are generally proven but not performed routinely. Among them:

  • Giving surgery patients antibiotics prior to their operation to prevent infections. While up to 90% of surgical patients receive antibiotics, they are improperly administered up to 50% of the time, according to the report.
  • Using ultrasound to guide intravenous lines to help prevent punctured arteries.
  • Treating surgery patients with drugs called beta-blockers, which are known to reduce the chance of heart attacks.

In addition to these patient-focused recommendations, the report suggested specific organizational changes. For instance:

  • Encouraging a "culture of safety" in institutions
  • Changing nurse staffing ratios
  • Using computerized systems to order drugs to reduce errors
  • Improving hand-washing techniques

Though it's too early to generalize, Eisenberg says that using computers to manage medications in hospitals could save billions of dollars and many lives.

One of the big questions yet to be answered is whether an increase in nurse staffing will improve patient safety.

"Changes in nurse staffing was considered to be a patient safety practice with high strength of evidence ... but not the greatest strength of evidence," said Eisenberg.

The goal is not to create cookbook medicine but rather to suggest options that will improve patient safety generally. From there, each healthcare institution will need to individualize its patient safety strategy.

"Preventing blood clots in patients that undergo surgery may be of major importance to a hospital with a large number of major orthopaedic surgeons. ... But methods for reducing ... infections [acquired while in the hospital] may be of greater interest to a small community hospital," says Gregg Meyer, MD, director of AHRQ's Center for Quality Improvement and Patient Safety.

So what can patients do to insure a safer medical experience?

One recommendation is to read back the consent form to the doctor before an operation. "Part of what gets missed is having a full comprehension of that informed consent. So some practices have been evaluated to improve full comprehension," says Kathryn McDonald, MM, the project coordinator.

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