The Institute of Medicine brought much attention to the serious problems associated with the safety and quality of medical care in the United States through its Quality Initiative that it launched in 1996, and particularly this initiative’s associated reports, Crossing the Quality Chasm and To Err is Human: Building a Safer Health System. To Err is Human focused on how tens of thousands of Americans die each year from medical errors.The report defined "error" as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim", and noted that not all errors result in harm. Recognizing that the majority of medical errors do not result from recklessness, but rather from “basic flaws in the way the health system is organized,” To Err is Human recommended increased adoption of health information technology to reduce medication errors in prescribing, transcribing, dispensing, and administering of medications. Since the 1999 publication of To Err is Human, health care providers, policymakers, and health services researchers have worked to address the concerns identified. Policymakers have also made reducing medical errors a high priority. In February 2004, the FDA required bar codes on drugs and blood to help reduce errors. In addition, many states have instituted repositories for reporting medical errors, and as previously mentioned, in July 2005 President Bush signed S. 544, a patient safety bill encouraging the anonymous reporting of medical errors to newly created patient safety organizations.Additionally, in August 2005, the World Health Organization announced that the Joint Commission on Accreditation of Healthcare Organizations would lead an international effort to reduce medical errors. However, despite the attention given to the IOM reports, the interventions implemented and evaluated, and the recent priority policymakers have given to reducing prescribing and medication errors, the evidence still shows a higher than acceptable error rate.

Additional evidence also shows that many technologies designed to reduce errors have been abandoned due to problems with design, impact on workflow, and general dissatisfaction among the users.  Research has shown that human factor considerations must also be taken into account, in addition to theoretical knowledge about what technologies should work. [3] Strategies and technologies that have revolutionized quality, productivity, and performance in other industries can no longer be ignored as the United States strives to deliver care that is safe, effective, timely, patient-centered, efficient, and equitable.[4]

While there is much work to be done, some progress has been made.[5] Ongoing research, the high priority placed on patient safety by policymakers, and advances in the development and application of health technology hold much promise for the overall improvement of health care quality and safety in the United States. Two current HCFO projects may provide some insights to policymakers in the areas of quality and patient safety. In her HCFO-sponsored project, HCFO grantee Mary A. Pittman, Ph.D. is examining the strategic processes used to make hospital capital investment decisions in an era of patient safety and quality improvement. She hypothesizes that current capital investment needs could result in segmentation of the hospital sector in terms of the investments they are able to make in the areas of quality and patient safety. Another HCFO grantee, Randall Bovbjerg, J.D., is assessing the liability climate for safety reform and how differing theories and implementation of transparency might be improved.

Developing and achieving a national set of patient safety goals relies in large part on the continued work of health services researchers to provide evidence about what interventions work and why.It will be important for researchers to coordinate their work and disseminate their findings broadly in ways that are useful to health care providers, administrators, and policymakers as they develop new ways to use technology to improve the safety and quality of the United State’s health care system.

HCFO Funded Research:

Title: Hospital Capital Financing in the Era of Quality and Safety: Strategies and Priorities for the Future - A Survey of CEOs
Institution: Health Research and Education Trust
Time: January 2004 - June 2005
Principal Investigator: Mary A. Pittman, Ph.D.

What are the strategic processes used to make hospital capital investment decisions in an era of patient safety and quality improvement? The investigators hypothesize that current capital investment needs could result in segmentation of the hospital sector. This segmentation could create a group of hospitals that can afford improvements, a group of hospitals that will struggle to make modest improvements and a group of hospitals that will be left behind. The researchers will: 1) identify current capital positions of hospitals; 2) identify hospital-spending priorities given the competing needs of hospitals; 3) determine how capital investment decisions will be made and considerations/tradeoffs used to make these decisions; 4) identify planning processes being used at hospitals for future quality and safety infrastructure needs; and 5) identify current sources of capital financing and expected sources in the future. The objective of this study is to inform decision makers of: the array of options and best practices in hospital capital strategies; the current sources of capital financing; potential impending problems and worst case scenarios; and various approaches to quality and safety infrastructure development and financing. The researchers will conduct an extensive literature review, a nationally representative survey of hospital CEOs, an analysis of combined financial and survey data and targeted interviews.

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Title: Liability Problems and Transparent Disclosure to Patients as a Solution
Institution: The Urban Institute
Time: March 2003 - November 2004
Principal Investigator: Randall Bovbjerg, J.D.

How can the understanding of the liability climate for safety reform and of differing theories and implementation of transparency be improved? The researchers are addressing the following three questions: 1) How widespread are liability insurance problems that may threaten access to care and can heighten practitioner concerns about disclosure of problems? What evidence exists on the root causes of problems? 2) What are the shortcomings of even strong liability incentives in preventing avoidable injuries and in promoting patient safety? 3) What models of increased transparency exist, with what theoretical advantages and disadvantages? What are the opportunities and obstacles to their implementation? Has enough innovation occurred in disclosure and safety methods that an assessment is feasible and pre-testable? The objective is to assess two problems and one emerging solution: The problems are that malpractice insurance is perceived to be in crisis and that liability fears have not curbed high rates of medical injury but have undercut cooperation with patient safety initiatives. The solution is more “transparent” disclosure to patients of their injuries, to ease malpractice fears, increase fairness, and facilitate systemic improvements.

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