PROFESSIONAL ISSUES

Error reduction is meeting focus

A national quality conference emphasizes a culture of safety.

By Andis Robeznieks, AMNews staff. Sept. 16, 2002. Additional information

Attendees at the World Research Group's third annual Preventing Medical Errors and Improving Patient Safety conference in Chicago were told how to create a culture of safety using a combination of common sense, computer technology and leadership.

Sharon Martin, vice president for quality management at the MD Anderson Cancer Center in Houston, told how her facility worked to reduce waiting times for admission, diagnostic testing, lab results, and pharmacy services. This, she said, led to the reduction of stress and poor working conditions that, in turn, had led to errors being made. She also described other simple tips for preventing errors such as standardizing equipment and high-risk tasks.

Researchers at Chicago's Cook County Hospital showed how to link lab and pharmacy data to identify diagnostic errors such as missed hypothyroidism and unrecognized diabetes. The hospital's director of clinical quality research, Gordon Schiff, MD, predicted that performing follow-up analysis of abnormal lab tests may become "the big issue of next year."

University of Chicago Medical Center Clinical Assistant Professor Stephen Small, MD, spoke on how patient simulators can hone skills and provide continuous training.

Although he admitted that, for many institutions, hiring more nurses would provide quicker advances in patient safety, Dr. Small said patient simulators nourish a safety culture by providing high-quality team training.

For times when prevention efforts fail, Sherry Kwater, director of quality and performance improvement at St. Francis Medical Center in Peoria, Ill., said there is a difference between disclosing unexpected adverse outcomes and admitting liability.

When adverse events occur, she said patients and families look for a full explanation, an apology, and evidence that the mistake will not be repeated. Kwater recommends that physicians practice what they'll say beforehand, avoid jargon, and avoid words like "error," "mishap" and other words that suggest blame.

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Copyright 2002 American Medical Association. All rights reserved.