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Rather than responding to each
recommendation point by point, we discuss only those that we think
deserve specific commentary:
Congress should create a Center for Patient Safety within the Agency
for Health Care Policy and Research.
The APSF applauds the call for the establishment of a Center for
Patient Safety to be a NIH-like entity to fund research and development
projects. Research funding via this Center will be an important
vehicle for advancing knowledge and testing interventions to improve
patient safety. As in the NIH model, this agency's research support
should compliment - not replace - those offered via other Federal
agencies, by State and local governments, and through the private
sector via foundations and health care institutions themselves.
We strongly urge that the Center be devoted only to such research
inquiry and consequent education and not itself become involved
in the politics of regulating or financing health care.
A nationwide mandatory reporting system should be established that
provides for the collection of standardized information by state
governments about adverse events that result in death or serious
harm.
while we recognize the desire and importance of accountability
by practitioners for their actions, APSF has serious concerns about
the practicality, advisability and utility of the type of mandatory
reporting of serious events recommended in some detail in the IOM
report. The report itself acknowledges that the issue is extremely
complex. While it is true that some States now require some form
of reporting, there is no evidence that it has resulted in any meaningful
improvement in practice or patient outcome.
Mandatory reporting systems in general create incentives for individuals
and institutions to play a numbers game. If such reporting becomes
linked to punitive action or inappropriate public disclosure, there
is a high risk of driving reporting "underground" and
of reinforcing the cultures of silence and blame that many believe
are at the heart of the problems of medical error and patient safety.
This would be particularly true to the extent that "innocent"
providers could be unfairly accused. Health care is very different
from other high-hazard industries (e.g. transportation, nuclear
power or chemical production) in that all human beings will become
ill and all will die. Nearly all of us will die in some proximity
to medical care. The contribution of error, if any, to such events
can be difficult to identify and disentangle, and the retrospective
attribution of possible causation can be affected strongly by hindsight
bias.
We have further concerns about the nature of the bureaucracy that
would be created to manage the aggregated reports from the States.
In addition, there is the question of opportunity cost of such a
program - could the funds and effort for this component achieve
better results if used in a different way? Given the complexity
and contentiousness of mandatory reporting and its uncertain effectiveness,
is it wise to recommend at this time a specific program of mandatory
reporting?
Reasonable people and groups can and should debate these issues
widely. Thus, APSF believes that IOM recommendation 5.1 is both
premature and too specific in its content. A considerable amount
of further study and public debate will be necessary to determine
whether any form of mandatory reporting is desirable, and if so,
what form it should take.
The development of voluntary reporting efforts should be encouraged.
The APSF strongly endorses this recommendation. APSF has been working
toward this goal within anesthesiology for nearly a decade but has
been stymied by the complexity of the attendant medical and legal
issues. This makes recommendation 6.1 of particular interest to
APSF.
Congress should pass legislation to extend peer review protections
to data related to patient safety and quality improvement that are
collected and analyzed by health care organizations for internal
use or shared with others solely for purposes of improving safety
and quality.
APSF most strongly endorses recommendation 6.1 and believes that
such legislation will remove a fundamental barrier to improvements
in patient safety.
Performance standards and expectations for health professionals
should focus greater attention on patient safety. Health professional
licensing bodies should (1) implement periodic reexaminations and
re-licensing of doctors, nurses, and other key providers, based
on both competence and knowledge of safety practices; and (2) work
with certifying and credentialing organizations to develop more
effective methods to identify unsafe providers and take action.
while APSF agrees that health care workers should have appropriate
competence and knowledge of safety practices, there is no known
mechanism by which such characteristics can be measured readily.
APSF also has serious concerns about the call to develop methods
to identify and take action against "unsafe providers."
While APSF agrees that methods should be investigated for assessing
the performance ability and competence of health care providers,
this is not a simple matter and will require considerable research.
Further, the concept of "unsafe provider" and what actions
would be appropriate for such an individual are not clearly defined.
Thus, these issues require further study before specific recommendations
can be made concerning the assessment and regulation of individual
clinicians.
Professional societies should make a visible commitment to patient
safety by establishing a permanent committee dedicated to safety
improvement.
APSF strongly supports the general thrust of this portion of recommendation
7.2. Although we agree with many of the activities suggested under
this heading (e.g. information dissemination, including guidelines
on safety in practice), we believe that the specific activities
of any given professional society:
1) May not include every item on the list given;
2) Should probably include other activities that are not listed;
and
3) Should differ in their mix from discipline to discipline within
health care as appropriate.
As noted previously, one activity not mentioned on the list that
has been important to the success of APSF is that of the professional
society funding research on patient safety within a specific discipline.
In anesthesiology, not only has this generated new knowledge and
innovative ideas (e.g. patient simulation) it has generated a new
cadre of investigators committed to studying patient safety issues.
Therefore, it is important to recognize that the call for federal
funding of patient safety research through the Agency for Healthcare
Research and Quality will not eliminate the necessity of seed funding
of such research by professional societies.
Health care organizations should implement proven medication safety
practices.
In general APSF supports the call for the implementation of practices
to reduce the likelihood of medication errors. We would caution,
however, that determining the degree to which the efficacy of a
specific practice is "proven" may not be easy. Also, the
applicability of a specific "proven practice" may depend
heavily on the context in which it is used. In particular, some
practices (such as computerized drug order-entry or bar-code scanning
of the patient name-band for each administration of a drug) that
are proven to be useful in settings with low complexity and slow
pace such as outpatient clinics or hospital wards may be inapplicable,
counterproductive, or even dangerous if applied strictly in anesthesiology,
intensive care units or other high complexity, highly dynamic domains
of care. Rather than mandating specific techniques across the board,
institutions should be encouraged to adopt techniques that have
been proven successful in a specific arena of use.
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