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Write thoughts on how the development of information essay/impact-technological-competency/”>technology has helped address the concerns about patient safety raised in the “To Err is Human” report. Summarize how informatics has assisted in improving health care safety in your organization and areas where growth is still needed.
Legal Issues
“I
’ve made a mistake.” This
simple statement, or its mere
thought, is enough to strike fear
within the most experienced and
knowledgeable of health care pro
–
fessionals. No matter how many
times a procedure has been done or
a medication administered, there is
always the likelihood of prevent
–
able error. Each year, the public
is reminded of the potential for
mistakes as the media report medical
horror stories where, for example,
unknowing patients have surgery
performed on the wrong body part,
a wrong medication administered,
or a foreign object errantly left
inside their bodies. These reports
highlight the biggest fear of health
care workers—their own fallibility.
Through carelessness, assumption,
overt act, or omission, the health
care professional can easily err
and cause harm to the patient. In
addition to the pain caused to the
patient, health care providers also
understand the devastating impact
that such errors can wreak on their
own personal and professional lives.
The purpose of this article is to
About the Authors
Mr. Plawecki is Registered Nurse,
Rehabilitation Hospital of Indiana, In
–
dianapolis, and Dr. Amrhein is Resident
Physician, Family Practice Medicine, Ball
Memorial Hospital, Muncie, Indiana.
The authors disclose that they have no
significant financial interests in any prod
–
uct or class of products discussed directly
or indirectly in this activity, including
research support.
Address correspondence to Lawrence
H. Plawecki, RN, JD, LLM, Regis
–
tered Nurse, Rehabilitation Hospital of
Indiana, 4141 Shore Drive, Indianapolis,
IN 46254; e-mail: Lawrence.plawecki@
gmail.com.
doi:10.3928/00989134-20091016-01
Clearing the Err
Reporting Serious Adverse Events and “Never Events” in Today’s Health Care System
Lawrence H. Plawecki, RN, JD, LLM; and David W. Amrhein, MD
Abstr
A
ct
Absent an infinitesimal percentage, most Americans seek health care ser
–
vices due to a legitimate health issue. Fundamental within this relationship
is the understanding that health care professionals will do everything within
their power and expertise to alleviate the suffering of each patient they
treat. Unfortunately, preventable medical errors do occur, and the in
–
nocent patient is left to suffer. In 1999, the Institute of Medicine
released
t
o
e
rr Is
h
uman:
b
uilding A
s
afer
h
ealth
s
ystem
, the
first mainstream publication calling for a change in the
culture of health care and the eradication of prevent
–
able medical errors. In the 10 years since its publica
–
tion, federal and state governments and agencies
have been proactive in attempting to meet the
recommendations originally proposed in
t
o
e
rr Is
h
uman
. This article will review what has been ac
–
complished in this time frame.
© iStockphoto.com/ Ireneusz Skorupa
JOGNonline.com
26
discuss the trend in today’s health
care systems toward the reporting
of serious adverse events or “never
events,” as well as the impact—both
impending and current—on the role
of geriatric nurses.
r
efocus
I
ng
A
nd
r
ebu
IL
d
I
ng
A
sA
fe He
AL
t
H
cA
re
s
ystem
In November 1999, the Insti
–
tute of Medicine (IOM) released a
profound call to action for everyone
involved in the health care commu
–
nity. This statement, entitled
To Err
Is Human: Building A Safer Health
System
, began with a grim statistic,
estimating that between 44,000 and
98,000 people died per year from
preventable medical errors as hospi
–
tal patients. The IOM (1999) report
defined
medical error
as the use of a
wrong plan of action to achieve an
aim or the planned action’s failure
to be completed as intended. In
economic terms, these errors were
estimated to cost between $17 billion
and $29 billion per year across the
country (IOM, 1999). These financial
estimates include the costs of lost
income, lost household productivity,
and the cost of the additional health
care necessitated by the errors (IOM,
1999). The more specific recommen
–
dations posited by the IOM (1999)
for the prevention of medical errors
are discussed below.
The IOM (1999) report recom
–
mended a four-tiered approach to
achieve a better safety record:
l
Establishing a national focus
to create leadership, research,
tools, and protocols to enhance the
knowledge base about safety.
l
Identifying and learning from
errors by developing a nationwide
public mandatory reporting system
and by encouraging health care
organizations and practitioners to
develop and participate in voluntary
reporting systems.
l
Raising performance standards
and expectations for improvements in
safety through the actions of oversight
organizations, professional groups,
and purchasers of health care.
l
Implementing safety systems
in health care organizations to ensure
safe practices at the delivery level.
As a result of these broad rec
–
ommendations, state and federal
governments, agencies, and health
care institutions were given notice
about the increased focus on the
prevention of medical errors and,
consequently, the improved safety
of the patient receiving treatment.
During the 5 years following the
IOM (1999) report, progress began
to be made.
In 2001, the U.S. Congress ap
–
propriated an annual budget of $50
million for patient safety research
(Leape & Berwick, 2005). From
this appropriation, the Agency for
Healthcare Research and Quality
(AHRQ) was codified as the federal
agency to oversee patient safety and
its improvement (Leape & Berwick,
2005). AHRQ became an important
player in the new patient safety
movement by evaluating health care
practices to determine effectiveness,
educating health care institutions
about how to best report errors and
adverse events, and creating a road
–
map of evidence-based best practices
(Leape & Berwick, 2005).
Using the roadmap created
by AHRQ, the National Qual
–
ity Forum (NQF) (2007) created a
list of 27 serious reportable events,
also referred to as
never events
,
which were offered as the basis
for a potential national reporting
system chronicling patient safety.
The serious reportable events may
be divided into six separate cat
–
egories, including surgical events,
product or device events, patient
protection events, care management
events, environmental events, and
criminal events (NQF, 2007). For
the purposes of this article, however,
the individual events will not be dis
–
cussed, as the focus is to remain on
the implementation and evolution of
patient safety standards.
In 2005, the American Medi
–
cal Association (AMA) released
a report by Leape and Berwick
detailing the effects of the origi
–
nal IOM publication. The AMA
report, while admitting there had
been little measurable effect after
the release of the IOM report and
that no comprehensive nationwide
system for monitoring had been
put into existence, discussed how
the focus of patient care had shifted
from fixing blame to implementing a
culture of safety (Leape & Berwick,
2005). This alone can be considered
an impressive feat in today’s increas
–
ingly litigious society. Furthermore,
Leape and Berwick (2005) identified
the four areas the health care system
needed to advance in the following 5
years to facilitate the transition to a
patient safety focus.
First, Leape and Berwick (2005)
recommended the implementation
of electronic medical records. It is
argued that this implementation, al
–
though a substantial initial cost, will
save the facility and pay for itself
due to the decrease in charges of ad
–
verse events and increase in efficient