Transcript Slide 1

Patient Safety Matters
How Does The Patient Safety Research Center See
and deal with these matters
and why are others, such as, Interested in our work
AHRQ
Resource Center
WONCA
San Antonio 2005
11th European Forum
2006. Prague.
?
2006
Our Vision
International Champion of Patient safety
SAR-AIMER
Systematic Appraisal of Risk And Its Management for Error Reduction
We are about
Placing Patient Safety at
the
of Medical
Education
and
Practice
CONTENT OF THIS AND THE OTHER THREE
PRESENTATIONS
•Our Mission, Driving principles,
Premises, and Implications
•The Burden of Lack of Safety on the Nation
Covered in the other three presentations
•The Opportunity
•Our approach to lightening the Burden
Main Areas of our Activity
Education/training
Safety Practice Enhancement
Mission
Pursuit of excellence in patient safety
in the various domains of healthcare
by applying systems-safety science,
systems-engineering principles
and systems-management strategies
for building adaptive learning practices
with self-empowered teams
providing care with
highest professionalism and integrity
Driving Principles
Natures way of creating wholesto
that are
more than
Not
succumbing
the
Holism the sum of the parts through creative evolution
prevailing
“Hegemony”
and
This
is the inspiration
behind Systems Approach
and complexity science
“Greedy Reductionism”
Aristotle
Cybernetics
Singh 1987
Science of observed systems
SoArt
that we can broaden
the
+
Of
Science of observing systems
view of EBM
1940
Goals
Predictions
Actions
Feedback
Response
Berwick
Supremacy of Relevance over Rigor
Reductionism gives rigorous answers, but to wrong questions
Better an approximate answer to a right question Singh 1987
Aristotle 300.. BC & GS 1976
Patient Safety
Is
“freedom from accidental injury
due to medical care or medical
error”
(US IOM)
UN: WHO is working towards
declaring it a Basic HUMAN
RIGHT
There is already a “London Declaration” by WHO
Singh: April 2005
Safety is a fundamental
system property.
Without safety there can
be no quality of care IOM
© Gurdev Singh 2007
Patient Safety
Is
“freedom from accidental injury
due to medical care or medical
error”
The Burden
Singh: April 2005
This constitutes nearly 50% of the surgical “Never Events”
Wrong body part :
Wrong procedure :
Wrong patient:
30%
16%
4%
CMS press release 2006 (Minnesota Study)
The National Burden of Systemic Errors in the
Health Care
(US)
In ambulatory
7.75
Morbidity
care
million
of‘n’
and
just
office
mortality
Medicare
visits
as
patientsthe
athe
result
More
than
Jumbo
jetsby
of
One
There
of
is
the
little
costlier
or
no
outcomes
understanding
of
drug
Geriatrics
carry
the
over halfIn
a2001
elderly
million
of
drug-related
resulted
preventable
in
problems
the
ADE’s
prescribing
in
the
of
there
were
4.3
million
Care Industry
drop
related
ofHealth
the incidence
morbidity
rates,
is hospitalization.
costsout
andof
due to errors
at
ambulatory
least
of
commission
one
medication
settings
may
from
Gurwitz
cost
the
et.almore
2003
list
Gurwitz
1995
ambulatory
visits
for !alone
treating
maximum
share
of
the
sky
every
day
(Analogy
after Leape: the
prevention
strategies
of
medication
Safety Guru of USA) Cooper 1996
59%
of
than
20
aredrugs
$177
preventable
Billion/yr
judged potentially
Cooper
Adverse
Drug
Events
Zhan et al 2005
this
1996 burden
errors
IOM 2006
inappropriate in the elderly Aparasu 1997
1.5 Million/year
Incidents of Harm
IHI/IOM
1.5 million medication errors occur in hospitals each year .
One in five elderly patients is given medicines that may
not be good for them
Clancy 2007
1.7 million infections per year in US hospitals
i.e. 4.5 infections for every 100 admissions
And then there are other adverse Events!!
© Gurdev Singh 2007
International Rankings and National
Health Expenditure (Through Patient’s Lens)
AUS CAN GER NZ
UK USA
Overall Ranking
4
5
1
2
3
6
Patient Safety
Effectiveness
4
5
2
3
1
4
2
3
6
5
6
1 ?
Patient-centeredness
3
5
1
2
4
6
Timeliness
4
6
1
2
5
3
Efficiency
4
5
1
2
3
6
Equity
2
4
5
3
1
6
$2903
3003
2996
1886
Health Expend./Capita
Source: The Commonwealth Fund : 2006.
2231 $5,635
$7600
Jan. 2008
Commonwealth Fund
reveals interesting picture of effectiveness
“Amenable mortality - deaths from certain
causes before age 75 that are potentially
preventable with timely and effective
health care”
Healthcare Safety Comparison
with Civil Aviation
Adverse Events Per
Million Opportunities
1.000,000
MEDICATION
100,000
IOM
10,000
1000
100
10
aviation
1
1
3
2
σ
SIGMA
4
5
6
σ
Not a fair but a telling comparison
© Gurdev Singh 2003-7
2007 Adapted
from Robert Galvin (GE, MOTOROLA)
Hazard Comparisons (rough)
(AHRQ)
Dangerous More
than 1 in a thousand
Lives Lost per year
100,000
Health
Care
Driving
10,000
1000
Scheduled
Flights
100
10
1
Bungee
Jumping
10
Nuclear
Power
Chartered
Flights
100
1,000
10,000
100,000
1,000,000 Very Safe
Less
than 1 in 1000 thousand
10,000,000
Encounters (opportunities) for Each Fatality
After AHRQ
A R G Singh: 2004/7
Split of $2.3 trillion US National Budget
of a fragmented and decentralized HC System
R and G Singh
Payers of $2.3 trillion US HC Costs
Please see this in the context of the fact that
every 30 seconds
an American is driven to bankruptcy
due to health care costs
30 - 40% of the huge Health Budget is wasted
pitalization
Cost of Hos
31%
es s
lud ting nts !
ie
Inc et
% er s o pat
t
-40 th
30 of o arm
h
sts of
co osts
dC
an
30 - 4
0%
is the
of Ad
min.
Wasta
ge
>> $700 Billion/yr!
Cost
35% of $2.3 trillion HB
R and G Singh
The chasm
between
what is done and
what can be done
is about 50%
© Gurdev Singh 2007
If this is not a MAJOR National Disaster
our name is not Singh !
Congressional Budget Office Head, Peter Orszag: Times Nov 08
The total cost of medical injury in
the health care system is
estimated to be $200 billion per
year which is about one fifth of
the national health budget.
(AARP 1998 Research Report)
Singh: April 2005
Take Home:
We must create and ride a health
machine that will “change the
world”
We want a
“Toyota of Health Care”
We can all play a role in making this a reality
R & G Singh: Aug. 2002
AARP Sep.2007
AARP Sep.2007
Importance of Patient Safety
Formidable and Compelling Pressures:
Federal Government
Institute of Medicine (IOM)
Professional Bodies
Accreditation Authorities
If we do not heed they will make errors
“expensive for us”
A R G Singh: 2002/7
Importance of Patient Safety
In year 2000
Inst. Of Medicine was seeking 50%
reduction in errors
by 2005 !!!!!!
Progress so far has been only modest
and highly variable!
A R G Singh: 2003/7
Medicare says it
won’t cover
hospital errors
“Never Events” Aug 2007
A R G Singh: 2003/7
Patient Safety Improvements
are
Likely to provide the biggest
FOR
About 2 trillion