Improving Patient Care: A Primer for Emergency Physicians

Gregory P. Garra, DO FACEP, Clinical Assistant Professor of Emergency Medicine, Residency Program Director, Director of Medical Education, SUNY at Stony Brook

Medical error may account for as many as 98,000 in-hospital deaths per year. (As many as 98,000 people die each year in hospitals due to medical errors.) The Institute of Medicine (IOM) defined a medical error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve the aim (1). The IOM’s report is not without controversy. Although the actual number of deaths is debated, the rate likely exceeds those of motor vehicle collisions, breast cancer and AIDS. Since the report was released in 1999, a number of organizations have been producing and disseminating recommendations in an effort to reduce medical error and associated mortality. In a compendium published by the National Coalition on Health Care (NCHC) and the Institute for Healthcare Initiatives (IHI), Dr Lucian L. Leape stated that the problem of medical errors is not due to a lack of knowledge but rather inadequate dissemination and implementation of ideas and practices that are known to work. Described in this article are known practices which can be adopted by institutions to reduce medical errors and improve patient safety.

The Agency for Healthcare Research and Quality (AHRQ) instituted a project, Making Healthcare Safer: A Critical Analysis of Patient Safety Practices, designed to collect and critically review existing evidence on practices relevant to improving patient safety (2). The project identified 11 evidence-based patient safety practices that were considered strong enough to support widespread implementation.

• Giving patients antibiotics just before surgery.
• Using ultrasound to help guide the insertion of central venous lines.
• Use of maximum sterile barriers when placing central intravenous catheters.
• Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.
• Giving surgery patients beta blockers to prevent heart attacks.
• Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
• Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia.
• Use of pressure-relieving bedding materials to prevent pressure ulcers.
• Patient self-management of warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications.
• Asking patients to recall and restate what they have been told during the informed consent process.
• Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.

The Institute for Healthcare Improvement (IHI) is a not-for-profit organization with a mission to improve health by advancing the quality and value of health care. The 100,000 lives campaign (3) is an IHI initiative designed to engage US hospitals in a commitment to implement changes in care to improve patient care and prevent avoidable deaths. The 100,000 lives campaign was established to enlist thousands of hospitals across the country in a commitment to implement changes in care that have been proven to prevent avoidable deaths. The campaign goals are to implement changes in care that have been proven to prevent avoidable deaths. Six interventions have been identified:

• Deploy rapid response teams
• Deliver reliable, evidence-based medicine for acute myocardial infarction
• Prevent adverse drug events
• Prevent central line infections
• Prevent surgical site infections
• Prevent ventilator-associated pneumonia

These 6 “care bundles” are groupings of best practices that, based upon the best evidence available, are able to improve care and reduce mortality.

The Joint Commission on Allied Health Organizations’ National Patient Safety Goals are designed to promote specific, system-wide improvements in patient safety. The recommendations are derived primarily from aggregate information contained in the Sentinel Event database. An advisory panel develops, field tests and recommends new and existing goals each year to the Joint Commission Board of Commissioners. The 2006 Critical Access Hospital and Hospital National Patient Safety Goals include:

• Improve the accuracy of patient identification.
• Improve the effectiveness of communication among caregivers.
• Improve the safety of using medications.
• Reduce the risk of health care-associated infections.
• Accurately and completely reconcile medications across the continuum of care.
• Reduce the risk of patient harm resulting from falls.

Whether you believe the IOM report or not, it is inarguable that medical errors occur on a regular basis. Recommendations from multiple organizations offer simple, cost effective methods for reducing the number of medical errors. Unfortunately, the impact and global utilization of these recommendations will not be fully appreciated until well-designed studies are conducted.

1 Kohn LT, Corigan JM, Donaldson MS. To err is human: building a safer health system. Washington DC: National Academy Press, 1999.
2 Agency for Healthcare Research and Quality. Making health care safer: a critical analysis of patient safety practice. Evid R ep Technol Assess 2001;38:i-x, 1-668.
3 Institute for Healthcare Improvement Website (no date). Retrieved on September 14, 2005 from the World Wide Web: https//www.IHI.org