What's the next managed care challenge? Eliminating medical mistakes

The Joint Commision's new constructive policy encourages physicians to talk about ED errors, aiming toward a new attitude on medical quality accountability.

If your emergency physicians are guilty of errors that are costing the group practice or department a fortune in wasted reimbursements, it's okay today to talk more openly about those mistakes. In fact, one of the nation's leading medical accreditation bodies, the august Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is making it easier for you.

Members of the formidable commission, whose stamp of approval is essential to most medical facilities, met quietly last year to review its policies regarding medical mistakes. There it forged key revisions in what amounted to a radical shift away from the past toward a new attitude on medical quality accountability.

The new policy, which went into effect on April 1, coaxes providers to voluntarily report incidents of medical errors and encourages them to study the causes that led to the mistake in the first place. "The aim is to take a more constructive attitude toward errors so as to eliminate future occurrences," says Paul Schyve, MD, a Joint Commission senior vice president. In the past, the practice was to point a finger of blame at an individual or facility. Providers who were accused of mishaps faced sanctions that included censure or possible loss of the hospital's accreditation.

Cost of medical mistakes is enormous

The exact cost of medical mistakes nationally is unknown. Substantive data isn't available, but the cost to providers is generally believed to be enormous stated in direct dollars, malpractice suits, and lost managed care contracts. Yet, the subject ranks among the least discussed in medical circles.

So at first, the Joint Commission's new stance seemed shocking. On the surface, the change suggested that the agency was going soft on sloppy providers. Furthermore, a worrisome message was going out that it was okay to commit clinical errors. Providers would not be held accountable for their mistakes, the standard seemed to imply.

Yet, despite the ready-made propensity for controversy, the policy-change stirred little debate. The reason, perhaps, Schyve suggests, is that the Joint Commission's new stance on medical errors is actually more effective than the old policy. Why? Because the new approach aims at the root causes within the system that gave rise to the mistake in the first place, observes Schyve. It also focuses constructively on making system changes and avoids attacking any one individual, which doesn't achieve any real results.

In emergency medicine, medical mistakes or "sentinel events," as the Joint Commission calls them, occur more often then they're reported and are rarely discussed openly, if at all by most physicians. Few hospitals voluntarily report incidents of clinical errors, and in recent years, peer review organizations have significantly scaled back efforts to call providers to task on any but headline-making mistakes.

Yet, the busy, unpredictable rhythm of emergency medicine makes it a prime setting for sentinel events, says Gregory Jay, MD, assistant professor of emergency medicine at Brown University in Providence, RI. "Most mistakes are insignificant like failing to read a chest X-ray in a minor-fracture patient or getting the name wrong on a patient's medical file. But they happen hourly," says Jay.

Watch for developing "error chains"

Providers need to talk openly about these medical mistakes before they can take steps to prevent errors from being repeated, Jay states. Researchers now know that overlooking something, no matter how minor at first, such as incorrectly spelling a medication's on a prescription, can trigger an "error chain," or series of events, that ultimately leads to a life-threatening situation. The error chain won't reveal itself sometimes for days or weeks, Jay says.

The same patient, for example, whose X-ray was merely overlooked by a nurse or physician along the way may return a month later complaining of sharp visceral pain. Meanwhile the film, which went unread, revealed a definite mass suggesting internal injury that could have been treated earlier.

Hospitals have done a good job of setting up systems such as electronic medication ordering to prevent mistakes. But the number of malpractice suits offer abundant reason for taking a more open view of medical mistakes and working on system strategies for prevention, says Jeffery Lerner, PhD, president of Emergency Care Research Institute, a non-profit Scranton, PA-based health care think tank. An inherent danger lies in thinking that only the big, sensational life-and-death cases that make it to the six o'clock news are worthy of attention, Lerner says. But there's a growing awareness in medical circles of the need to discuss systemic problems, says Schyve.

Next month, Jay and a group of colleagues will present data from an ongoing study of sentinel events in emergency medicine to the American College of Emergency Physicians (ACEP) in Irving, TX. The presentation should be an eye-opener, says Jay, whose research is believed to be the first of its kind. The financial effect of sentinel events isn't fully known. But physicians have long suspected that clinical errors take a heavy toll on both reimbursements and patient satisfaction.

In presenting their evidence to ACEP, Jay and his colleagues will show that providers pay an average of $3.45 for every patient they see at a mid-size urban hospital. The amount goes to cover the cost of a single settled malpractice suit. In other words, a hospital with 15,000 emergency department (ED) visits per month will write down about $621,000 per year just in the ED.

Spiraling malpractice premiums have fueled interest in medical tort reform while at the same time quality assurance initiatives among physician practices and hospitals have taken center stage in risk management debates. "Curiously, however, the problem of medical injury (stemming from clinical errors) has received comparatively little attention from either perspective," writes Lucian L. Leape, MD, an authority on sentinel events and a faculty member in the department of health policy and management at the Harvard School of Public Health in Boston.1

Patient satisfaction scores can drop

But aside from malpractice expenses, complications that result from medical errors play a significant role in lowered patient satisfaction scores, says Schyve. Managed care organizations (MCOs) have become increasingly sensitive to patient satisfaction trends in determining provider contracts. And errors have an indisputable correlation to increased lengths of inpatient stays and frequent repeat outpatient visits, Schyve adds.

Health plans also are keenly aware whenever providers make mistakes that prove financially costly. Unfortunately, they hear about them mostly through malpractice suits, says Robert Bitterman, MD, JD, director of risk management and managed care at Carolinas Medical Center in Charlotte, NC.

Jay and his fellow researchers believe they have found the Achilles heel in past efforts at preventing sentinel events. In almost 80% of malpractice suits involving clinical errors, teamwork failure was directly responsible for the errors, Jay says, citing from his research. In his view, an absence of teamwork is a leading cause of most system failures and is directly related to clinical errors, especially in the ED.

Although his argument may be debatable, Jay believes emergency personnel aren't formally trained to work in a team structure. Physicians, nurses, and assistants normally operate independently and only collaborate when the need arises and then only within the scope of clearly defined responsibilities, he says.

In addition, medicine traditionally has been an authoritarian field in which a physician's orders are seldom challenged by nurses, and crucial life-or-death decisions are made by a handful of designated individuals. "Something is wrong with that model. It implies that certain individuals are invulnerable to making mistakes," says Jay.

Furthermore, not all sentinel events are alike, according to Jay. There are slips (a provider forgets the correct spelling of the ordered medication), mishaps (the patient gets overlooked in a crowded triage area or suffers an unpredictable adverse drug reaction), and mistakes (the surgeon or nurse forgets to extract a gauze before closing a wound).

Borrowing heavily from military aviation experiences, Jay's researchers have developed what he acknowledged may be a radical approach to changing traditional job roles in the ED. Technology-transfer from the military to health care is a growing trend. But in this case, adapting sets of role-playing behaviors used by airplane cockpit crews for use in emergency medicine may be considered a stretch by some.

"Not necessarily," counters Jay, who has coined the term MedTeam to describe the new approach to emergency medical care. In both situations-the airplane cockpit and the ED-the teams are playing a high-stakes game in which verbal communication is essential. In the ED, the biggest sore point with Jay is that people don't talk to each other. "They communicate mainly through the patient's medical chart. That in itself reinforces a probable error chain," he adds.

Researchers are pitching their ideas to ACEP

Over a four-year period, the MedTeam researchers have developed a 10-hour course and training manual designed to teach workers in the ED, including nurses and physicians, in how to break down system-wide barriers that cause sentinel events. The course requires that physicians and other personnel take the training together. The MedTeam researchers hope to present the course material to ACEP this year for adoption in the continuing education curricula. (For details about the MedTeam course, see the article on p. 49.)

But is teamwork enough to guard against medical mistakes in the ED? Based on Leape's work at Harvard, drug complications were the most common type of adverse events in hospitalized patients. Leape defines an adverse event as "an unintended injury that was caused by medical management that resulted in measurable disability." An adverse event isn't the same as negligence, which legally is defined as "a failure to meet the standard of practice of an average qualified physician" in the given specialty.1 (For more on drug-related complications, see the chart on this page.)

But these adverse events, according to Leape, covered a broad spectrum-from those that were unpredictable and unpreventable, such as an unforeseen allergic reaction, to those that were avoidable. This fact is significant because Leape's researchers found that a patient's age plays a role in sentinel events. Patients over the age of 64, according to the Leape study, had adverse events at rates more than double the rate of patients under the age of 45. And although only 27% of the hospitalized population in New York, where the study was conducted, were over 64, they accounted for all adverse events.1

Then again, physicians and nurses are bound to commit errors. "Studies in other areas of human endeavor confirm that some degree of error is inherent in all human activity," Leape and his co-authors wrote. "However, most adverse events are preventable," they concluded. Education, training, and causal research can play important roles in prevention, the researchers concluded.

Can physicians learn to reduce sentinel events in the ED through research and learning? "That's what we hope to eventually determine with this work," says Jay about the MedTeam project.


    1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:384.