Patient-safety Expert Cites Progress in Reducing Systems Errors

WILMINGTON, Del. -- Hospitals and physicians are making slow but steady progress in reducing systems errors that affect patients' safety, according to one of the nation's leading experts in the field.

"Progress is slow. It's hard to say things are a lot safer now. I think it's so, but I can't prove it," said Dr. Lucian Leape, adjunct professor of health policy at the Harvard School of Public Health, as he accepted the 2003 Alfred I. duPont Award for Excellence in Children's Health Care on Sept. 23, 2003. Nemours, one of the nation's largest pediatric health care providers, cited Leape, a pediatric surgeon, for his leadership in focusing on medical error prevention. The award includes a $50,000 cash prize and an original Steuben Glass crystalsculpture.

Leape was a major contributor to the Institute of Medicine's 1999 report "To Err is Human" that focused national attention on patient safety issues. That study estimated that as many as 98,000 people die in hospitals each year as a result of preventable medical mistakes. In his speech, he cited several indicators that the cause he champions is having an impact. For example:

-- In 15 states, coalitions have formed that bring together a diversity of stakeholders - physicians, nurses, administrators, regulators, the insurance industry and others - to discuss patient safety issues.

-- The Joint Commission for the Accreditation of Hospitals (JCAOH) has issued a series of 11 recommendations for hospitals to follow to better ensure patient safety.

-- Organizations like the National Patient Safety Foundation have raised public awareness and helped develop a more safety-conscious culture within hospitals.

Leape, a graduate of Cornell University and Harvard Medical School, is a founding director of both the Massachusetts Coalition for the Prevention of Medical Error and the National Patient Safety Foundation.

"Human errors made in hospitals are not necessarily the result of carelessness, inadequate training or bad people," Leape said. "Careful, conscientious people make mistakes too." Rather, he said, "bad systems lead them to make mistakes" and research has demonstrated that redesigning such systems can significantly improve patient safety.

The key to continued improvement is changing the culture within hospitals to focus more on where safety breakdowns occur and how to prevent them and less on punishing the individuals involved. "In a system that punishes people who make mistakes, the only errors people report are the ones they cannot hide," he said.

Leape said pediatrics poses unique challenges to patient-safety advocates, and this is especially true in caring for newborns, whose organs are not fully developed and whose continual changes in weight require frequent adjustments in medication dosages.

In addition to campaigning for improved safety systems inside hospitals, Leape is now urging his colleagues in the healthcare professions to support a plan for tax-supported universal health insurance. He noted that 8,000 physicians earlier this year endorsed a national health insurance (NHI) proposal drafted by the Physicians' Working Group for Single-Payer National Health Insurance.

"The idea is not as far-fetched as you might think. There is a real movement to do something about it," Leape said.

According to the Physicians' Working Group, 41 million Americans have no health insurance and many more are underinsured even though the United States spends more than twice as much on health care as the average of other developed nations, all of which provide universal coverage.

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