Home Q&A Six years after the IOM report, is patient safety lagging at hospitals?

Six years after the IOM report, is patient safety lagging at hospitals?

March 2006

In the six-plus years since the Institute of Medicine released its landmark report on inpatient errors, patient safety has been transformed from a small movement to a multimillion-dollar industry. But if a study released late last year is correct, all of the attention ” and money “being put into patient safety may be having only a minimal impact.

The study, which was published in the Dec. 14, 2005, issue of the Journal of the American Medical Association, found that even with some of the most popular patient safety strategies, there appears to be little progress among a number of hospitals.

Researchers sent out two surveys “one in 2002 and another 18 months later “to acute care hospitals in Missouri and Utah. They asked how the hospitals implemented dozens of patient safety programs, procedures and technologies, from the use of a hospital approved set of medication abbreviations to the establishment of near-miss reviews.

The study revealed that hospitals are making some progress with safety systems, but not much. While surveyed hospitals did show some improvement in several areas, their rate of improvement “was only in the single digits,” according to lead author Daniel R. Longo, ScD, professor of family and community medicine at the University of Missouri, Columbia.

And while researchers found some improvement in the use of technology “including computerization of lab results “investigators found little overall change in two key areas of patient safety: drug storage, administration and safety procedures; and the implementation of high-tech approaches like physician order-entry systems, computerized test results, and assessment of adverse events.

“We’re not moving ahead as quickly as we need to,” Dr. Longo explained in an interview with Today’s Hospitalist. During that conversation, he used his study’s findings to give a state of the union on patient safety efforts in U.S. hospitals.

How representative are the data in this study? Aren’t the acute care hospitals in Missouri and Utah smaller and more rural than the national average?

When you look at the number of beds and the type of hospitals in the study, the data are very representative of hospitals nationally. Because the data are generalizable, it gives us some indication of what’s going on nationwide.

What was the most surprising result from the study?

I was amazed there wasn’t more computerization, given how much we hear about computerization in our everyday lives, and the fact that hospitals in Utah are known for their work in computerization. I suspect we hear more about hospitals that acquire technology as opposed to ones that don’t, so we think everyone must be computerized. That’s not the case.

But the real disappointment was the rate of change. The IOM report received extensive attention, and we have had a great deal of professional literature dedicated to patient safety since that report came out. We anticipated far more change than what we saw, but the statistically significant changes are just not there.

A number of other articles have focused on the topic in the five years since the report, all using different data sets and coming to the same conclusion: Progress is modest.

Why do you think the pace of change is so slow?

Funding is certainly one issue, although there is a lot of money in the health care system that could be more effectively used to put safety systems into place.

There’s also the complexity of hospitals themselves. Because of the bureaucracy and time involved in putting these things in place, you don’t fl ip a switch and make everything change. This takes time. But even taking that into account, we’re not seeing a lot of change.

Your surveys found that patient safety procedures related to surgery had improved more significantly than programs related to medical safety. Why is that?

In part, I suspect it’s because surgical outcomes “did the patient die, did the surgeon remove the right organ? “are much easier to measure than medical outcomes. And due to the obvious nature of surgical outcomes, hospitals got their act together more quickly in this area.

With all the recent attention paid to medication errors, why do you think the study didn’t find more progress related to preventing drug errors?

That was very surprising. The hospitals in our study weren’t even doing that well on simple components of medication safety, such as implementing systems to prevent mix-ups in look-alike and sound-alike drugs.

We also found that less than half of all hospitals made sure that all of their practitioners involved in the medication process “such as pharmacists “were off duty for more than 10 hours between shifts. That tells me that people are being overworked, despite all the evidence that long shifts produce cognitive difficulties.

The findings point to a lot of inertia and highlight the fact that, when it comes to dispensing medications, hospitals have antiquated systems, or very complicated systems that are very hard to change.

Did the study find any good news?

Hospitals have formed more patient safety committees, which is one of the fundamentals. Another interesting element was the growth of patient safety rounds. That refl ects the fact that hospital administrators are taking this seriously.

Other groups have looked at the relationship between hospital culture “whether you can highlight problems without being reprimanded or if you have to hide problems ” and patient safety. They have found that culture is a big predictor.

Another positive result is that more hospitals have established a patient safety program budget, but many still do not have a separate budget for safety programs. As someone in one of our focus groups said, “A lot of hospitals aren’t putting their money where their mouth is.” They say patient safety is important, but you need resources to do these things.

The study claims that a much more aggressive national agenda is needed to accelerate the rate of change in patient safety. What types of drivers do you have in mind?

Patients need to become much better consumers when it comes to patient safety. They need to know, for example, what patient safety systems are in place in each of their local hospitals so they can decide in advance which hospital they prefer to go to.

After the study was published, someone wrote me to point out that there won’t be significant change in this area without regulatory change that is based either on licensure or accreditation. We also need a much bigger push from legislators who are already spending a lot of federal or state funds to support hospitals.

Those are external changes, but internal changes are needed as well, both from the top down and the bottom up. We need boards of trustees to ask administrators, “What are we doing in patient safety?” They need to demand accountability, just as they would demand a balanced budget.

I would also like to know how many compensation packages of hospital CEOs and executives include quality or patient safety measures. In the vast majority of cases, I suspect the answer is not many.

And then the people in the trenches “hospitalists fit into that category “need to speak up and say, “We have a problem.” If you say you have a problem and some kind of retribution is made, you know that’s not the kind of place you want to work.