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Patient
Safety at the Clinical Interface
Holiday
Inn O'Hare International, Rosemont, Illinois
Thursday, November
30, 2000 (8:00 a.m. - 4:30 p.m.)
Research
Agenda (Printable Version)
In response
to the Institute of Medicines report on medical errors, To
Err is Human: Building a Safer Health System, President Clinton
asked the Quality Interagency Coordination Task Force (QuIC) to
draft a response that outlines the Federal governments existing
programs and plans to address the issues of medical errors and
patient safety. Among the actions proposed in the QuICs response,
Doing What Counts for Patient Safety: Federal Actions to Reduce
Medical Errors and Their Impact, was a National Summit on
Medical Errors and Patient Safety Research. This 1-day meeting
was held in Washington, DC, on September 11, 2000, to solicit
responses from the users of patient safety research about their
pressing needs, and to highlight specific research questions related
to those needs. Twenty-four users of medical errors/patient safety
research were invited to testify orally about their research questions,
and about 35 other users submitted written testimony. Many
of those testifying or submitting written testimony represented
leading professional organizations, patient advocacy groups, institutional
providers, and health care purchasers.
To insure
that the users input led to a coordinated privatepublic action
plan by funders of patient safety research, representatives from
14 public- and private-sector organizations that fund patient
safety research were asked to listen to the oral statements on
September 11 and to read the written testimony. After receiving
this input from the users, the representatives met to develop
an integrated, coordinated, user-driven, patient-focused, system-based
patient safety research agenda for all 14 organizations. Although
each of the funding organizations may have a different focus of
interest within the overarching agenda and may prioritize their
individual research agendas differently, all agreed that the overall
issues for patient safety research were captured in the outlined
research agenda. Given the extent of both the users comments
as well as of the patient safety field, the research agenda is
rather broad in scope. Future discussions and meetings will be
scheduled to provide more detail for the current research framework.
In trying
to organize the research issues as we strive for the safest possible
health care system, it became clear to the funders that the most
logical structure was based on the timing and priority of the
various research objectives. Therefore, each of the specific research
aims was separated into one of three categories: short- (6 months
to 2 years), medium- (just over 2 years to 5 years), and long-term
(over 5 years). The short-term projects are those for which the
users expressed their most pressing needs, and address issues
that are currently inhibiting their ability to move forward. Such
research projects may extend past the outlined time period, but
the main objective would be to begin those projects immediately.
Medium-term projects may require some initial funding for planning
and start-up, but the full benefit of the research results will
require the use of information from some of the short-term projects.
The objectives of the long-term projects will be met only if the
results of a few preliminary short- and medium-term projects are
used to develop the long-term research plans.
This patient
safety research agenda is only a research agenda. As a research
agenda, it is not meant to capture other aspects of the patient
safety issues (e.g., legislative and legal issues) that should
also be addressed to allow the patient safety effort to move forward.
The research agenda could help formulate proper responses to obvious
policy dilemmas, but it is intended to be a part of, not the complete
solution to, patient safety issues.
Please feel free to comment on these
research objectives by writing to:
Nancy Foster
Quality Interagency Coordination Task Force
c/o Agency for Healthcare Research and Quality
2101 East Jefferson
Rockville, MD 20852
National
Summit on Medical Error Research:
Draft Research Agenda
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Short-Term
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Medium-Term
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Long-Term
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Epidemiology of Errors
What are the barriers,
opportunities, and incentives to studying errors in non-hospital
settings and what are the best strategies to address such
barriers?
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Epidemiology of Errors
What are the types of errors?
(e.g., failure to diagnose, human/machine interaction,
medication-related)
Are there differences in
the types or rates of errors in settings other than acute
care?
Who are at risk for particular
kinds of errors? [Suggested groups for study include patients
who are terminally ill; mentally ill; are diagnosed with
chronic diseases or disabling conditions; are children
(particularly newborns under 5 kg); have limited English
proficiency and low health literacy; are women, low income
individuals, members of minority groups, individuals requiring
end-of-life care, or urban/rural residents.]
What is the relationship
of the health of workers to patient safety?
What are particular system
vulnerabilities that lead to an increased occurrence of
medical errors?
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Epidemiology of Errors
How do we know which outcomes
are caused by error, rather than by underlying disease
or disabling conditions?
What human factors lead
to error?
What are typical clinicianpatient
interaction problems?
How can human/technology
interaction be made safer?
How do system complexities
affect the ability to improve safety?
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Infrastructure to Improve
Patient Safety
What are the proper roles
for different interest groups in promoting patient safety?
Point of care (Patients
and providers who have direct interaction with each
other are the initial research dyad.)
Environment or context
in which care is delivered (Purchasers, legislatures,
organization leaders, oversight bodies such as accreditors
and boards, State programs, courts, licensure and accrediting
bodies)
How can the efforts of
disparate parties involved with patient safety be coordinated?
What should be the common
vocabulary (errors, adverse events definitions, typology,
data standards)?
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Infrastructure to Improve
Patient Safety
What analytic capacity
needs to be developed?
What infrastructure is
needed?
How can data be integrated?
How can we best develop
talent to perform analysis and interventions?
How can we best develop
an organizational culture of safety?
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Information Systems
What makes a reporting
system successful?
What useful data sources
exist?
What can we learn from
existing systems?
What data should be collected
and how?
Can we develop a common
definition of a "reporting system" or what data is most
useful for which purposes? For example, should reports
primarily focus on errors, injuries, "incidents," risk
factors, or safety practices? Who should submit those
reports? Should it be providers, hospitals or organizations,
patients, manufacturing companies, and/or administrative
bodies? How should the data be collected? Should it be
by compiling routinely collected surveillance data on
indicators of possible errors, performing a medical record
review, or conducting surveys? How should we classify
the types of errors (commission, omission, severity)?
How can privacy/confidentiality
be assured?
What legislation facilitates/hinders
reporting?
What infrastructure is
needed to support data collection, analysis and use?
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Information Systems
How does one collect information
on omissions of care?
How can data be clustered
to facilitate analysis?
How do we measure success
of the reporting systems?
In providing information
to potential users, how can confidentiality and the need
to inform be balanced?
How can we best develop
an infrastructure to support data collection, analysis,
and use?
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Information Systems
How do we measure overall
success of the reporting systems?
How can more complete data
be collected?
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Knowing Which Interventions
Should Be Adopted
What level of evidence
is required?
How should the effectiveness
of safety improvement efforts be measured?
How will we measure unintended
consequences?
Can we catalogue evidence-based
successful interventions?
How can we best get leadership
and governance involved in promoting and prioritizing
safety?
What can we learn from
other industries?
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Knowing Which Interventions
Should Be Adopted
What interventions increase
safety? How should these interventions be evaluated?
What effect does training
have on safety?
What technologies are effective
in improving safety?
What procedural redesigns
are effective in improving safety?
How can technologies, drugs,
and procedures be designed and tested to improve safe
use prior to general marketing?
How is simulation useful
in training and premarket testing?
How do we know if interventions
are realistic and applicable in routine practice environments?
How can we best foster
education of both professionals and nonprofessionals (e.g.,
through formal education, continuing health education,
in-service training)?
What working conditions
improve or detract from patient safety, (e.g., how do
staffing ratios, the mix of skills among staff, and work/rest
cycles influence patient safety)?
How can research on safety
improvement be integrated into training promptly?
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Knowing Which Interventions
Should Be Adopted
What are the organizational
changes or characteristics that affect safety?
How does trust among health
care professionals and between professionals and patients
influence the culture of safety?
What cultural, organizational,
and leadership factors promote safety improvement?
What factors foster or
hinder reporting?
How does an organization
create a nonpunitive environment for improvement?
What is the effect of design
and structure on safety?
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Adoption Issues
How can we create a business
case for safety in provider organizations?
How can we determine the
cost of doing the wrong thing to the wrong patient at
the wrong time?
How can we engage the public
in the patient safety issue? What type of information
is important to the public?
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Adoption Issues
Research on adoption: Why
are interventions adopted and why not?
How can we create a business
case for safety among purchasers and policymakers?
How can we determine the
cost of poor quality?
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Adoption Issues
Why do some organizations
adopt safety practices quickly while others resist the
adoption? Why are certain adopted safety processes more
successful in some organizations compared with others?
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Using the Information
How can useful information
be provided effectively to those who can act (e.g., consumers,
providers and provider organizations, purchasers, States,
and oversight organizations)?
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Using the Information
How can we encourage adoption
and use of safety information?
Can purchasers assist consumers
in identifying risks from care?
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Transition Issues
How can we collect data
that follows patients across transitions in care?
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Transition Issues
How can we foster communication
among health professionals?
What are the underlying
causes of breakdowns in communication?
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Ongoing Issues:
How do various cultural
issues affect patient safety?
When is international collaboration
beneficial? What can we learn from other countries who
are dealing with patient safety issues?
How can we effectively
use different methodologies (qualitative and quantitative,
use of narrative, syntheses) when researching patient
safety questions?
How can we maintain a patient-centered
focus in research and priority-setting?
How can we move past thinking
about errors and instead discuss the risks to patients
and vulnerabilities of systems, which manifest themselves
as mistakes?
What is the best method
for diffusion of successful approaches?
How can we coordinate our
efforts?
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Mechanisms:
How can we develop a vision
of a safe health care environment?
How can we form successful
partnerships between users, doers, and funders?
How can we take advantage
of natural experiments?
How should we engage the
legal community in patient safety research?
How can we develop more
research capacity?
How can we begin to focus
on underlying causes?
What is the best method
for developing tools to facilitate adoption of successful
interventions, including self-assessment?
How do we form/maintain
a multidisciplinary approach to research?
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Last Updated on Wednesday, November 1, 2000 4:15 PM
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