From the November/December 2007 issue of "States in Action: A Bimonthly Look at Innovations in State Health Policy."
States' efforts to improve patient safety have grown in number and scope in recent years—prompted by rising health care budgets and evidence of the excessive costs associated with medical errors.
The Institute of Medicine's groundbreaking 1999 report, To Err Is Human, estimated that between 44,000 and 98,000 deaths are attributable to medical error in the U.S. each year—a higher death rate than for car accidents, breast cancer, or AIDS. [1] The report estimated that the total national costs of preventable adverse events in terms of lost income, lost household production, disability, and health care costs are between $17 billion and $29 billion each year, with more than half attributable to direct health costs.
This wake-up call led states, along with health care researchers and practitioners, to expand their efforts to improve patient safety and reduce "adverse events," generally defined as "injuries resulting from a medical intervention, not the underlying condition of the patient." [2] A critical first step has been surveillance, whereby hospitals and other health care institutions report harmful and/or potentially harmful events to the state. According to Jill Rosenthal, project director of the National Academy for State Health Policy, 26 states and the District of Columbia have enacted legislation, regulation, or executive orders creating reporting systems for adverse events. Similarly, states are establishing reporting systems for health facility–acquired infections. Later this month, NASHP will publish a new analysis of state adverse event reporting systems by Rosenthal and colleagues on www.nashp.org.
The initial goal of these reporting systems is to understand the scope, types, and distribution of adverse events in health care settings. Aggregating and monitoring data from multiple sources over time can reveal patterns and problem areas. This, in turn, can lead to changes in practice or health care delivery that reduce the number and severity of adverse events.
Range in State Activity
While they share common goals, states' patient safety strategies vary. Some monitor only adverse events, while others track adverse events as well as "near misses," or events or situations that did not produce patient injury, but only because of chance. Reporting may be voluntary or mandatory, and patient safety responsibility may be assigned to an independent authority or housed within state agencies. Most states are still in the collection and analysis stage, while a few leaders are working with health care providers to change their practices. Some successes from these leading states are described in the Snapshots, below.
A key challenge for states is to overcome providers' reluctance to report negative events for fear of litigation or damage to their reputation. To alleviate such fears, many states guarantee confidential reporting and strict "whistle-blower" protections. Most release data in aggregate or facility-blinded form, but a few are working toward publication of facility-specific data.
States also must find an adequate and stable funding source for their patient safety activity. Some establish dedicated funding sources, such as assessments on health facilities, while others rely on general revenues. Staffing and budgets range widely. For example, Utah has a patient safety budget of about $200,000 per year, which funds two staff members, while Pennsylvania's Patient Safety Authority, only one of the state's patient safety initiatives, has a $4 million annual budget.
Moving in the Right Direction
Despite these variations, "most states recognize the patient safety issue and are taking steps to address it," according to Rosenthal. For example, officials understand that collecting information about adverse events and health facility–acquired infections is only an initial phase. To help facilities learn from mistakes and improve patient safety, states must analyze data and feed it back to providers. They also can recommend changes in procedures and protocols, offer training, and support implementation of best practices. Eventually, states hope to hold health care providers accountable for improving patient safety.
Some states are integrating patient safety initiatives into comprehensive health policies. "States such as Pennsylvania, Vermont, Massachusetts, and Oregon are looking at how cost, quality, and access relate to each other, and are incorporating patient safety efforts into broader health reform," says Rosenthal. In this issue of States in Action, we profile Pennsylvania, Utah, and Oregon—states that are combining data collection with education, communication strategies, and/or collaboration to improve patient safety.
Pennsylvania's Patient Safety Reporting System
With Governor Ed Rendell's support, Pennsylvania is undertaking a multifaceted approach to improve both health care quality and safety. State officials are working to align initiatives led by the Pennsylvania Health Care Cost Containment Commission, departments of Health, Public Welfare, and Insurance, and an independent Patient Safety Authority (PSA). [3]
PSA does not have the authority to regulate health care organizations. Instead, it collects and analyzes data, and provides guidance and educational tools to improve patient safety. In 2004, Pennsylvania became the first state to require reporting of near misses, in addition to actual errors. Pennsylvania hospitals and other health care facilities must report "serious events" and "incidents" (i.e., near misses) to PSA on a monthly basis, using a confidential Web-based data collection system. [4] PSA reviews and evaluates the reports to identify trends and make recommendations for improvement.
The vast majority of reports (over 96%) are "near misses," providing crucial insights into how to avoid errors according to PSA executive director Michael Doering. "The press wants to know about events that cause serious harm, but it can be argued that it's even more important to know about near misses so we learn and share how errors were avoided," he says.
PSA provides detailed reports on adverse events to individual facilities and aggregates information into regional and statewide reports. In addition, they provide recommendations through Patient Safety Advisories. So far, they have published about 140 articles with recommendations on how to avoid specific types of harmful events. PSA also develops toolkits and other educational materials on patient safety principles and root cause analysis, including a CD-based training course. It communicates through its Web site and presentations at hospitals, state and national conferences, and patient safety organizations. It is working with the Health and Hospital Association of Pennsylvania to develop curricula to inform hospital board members about the importance of patient safety. PSA also distributes a "Speak Up" brochure using information developed by the Joint Commission that encourages patients to ask questions to help ensure their safety (Figure 1).
PSA receives almost 17,000 reports each month from over 400 facilities, and the numbers are rising. Authorities believe this indicates better compliance and greater desire to learn from the data, rather than an actual increase in near misses or adverse events. But according to Doering, "the ultimate success is not in the number of reports, but in how facilities and individual providers use the information fed back to them to improve patient safety."
It is difficult to quantify the impact of PSA's efforts. "When people ask how many lives did you save last year, I have to admit that I don't know," Doering says. "It's hard to assign numbers and a value to our results." According to its annual survey of patient safety officers, facilities appear to be paying attention, want to learn from the data, and are implementing a significant number of policy and procedure changes based on the guidance provided by the PSA.
One lesson from Pennsylvania's experience is that adequate, stable financing is important. PSA is funded through an assessment on facilities, with a budget of about $4 million a year—a significant commitment compared with most other states.