In response to the Institute of Medicine's report on medical errors, To Err is Human: Building a Safer Health System, President Clinton asked the Quality Interagency Coordination Task Force (QuIC) to draft a response that outlines the Federal government's existing programs and plans to address the issues of medical errors and patient safety.
Among the actions proposed in the QuIC's response, Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact, was a National Summit on Medical Errors and Patient Safety Research. The research agenda from the summit follows.
Introduction
The National Summit was a 1-day meeting held in Washington, DC, on September 11, 2000. It solicited responses from the users of patient safety research about their pressing needs, and to highlight specific research questions related to those needs. Twenty-four users of medical errors/patient safety research were invited to testify orally about their research questions, and about 35 other users submitted written testimony. Many of those testifying or submitting written testimony represented leading professional organizations, patient advocacy groups, institutional providers, and health care purchasers.
To ensure that the users' input led to a coordinated private-public action plan by funders of patient safety research, representatives from 14 public- and private-sector organizations that fund patient safety research were asked to listen to the oral statements on September 11 and to read the written testimony. After receiving this input from the users, the representatives met to develop an integrated, coordinated, user-driven, patient-focused, system-based patient safety research agenda for all 14 organizations. Although each of the funding organizations may have a different focus of interest within the overarching agenda and may prioritize their individual research agendas differently, all agreed that the overall issues for patient safety research were captured in the outlined research agenda.
Given the extent of both the users' comments as well as of the patient safety field, the research agenda is rather broad in scope. Future discussions and meetings will be scheduled to provide more detail for the current research framework.
In trying to organize the research issues as we strive for the safest possible healthcare system, it became clear to the funders that the most logical structure was based on the timing and priority of the various research objectives. Therefore, each of the specific research aims was separated into one of three categories: short- (6 months to 2 years), medium- (just over 2 years to 5 years), and long-term (over 5 years).
Short-term projects are those for which the users expressed their most pressing needs, and address issues that are currently inhibiting their ability to move forward. Such research projects may extend past the outlined time period, but the main objective would be to begin those projects immediately. Medium-term projects may require some initial funding for planning and start-up, but the full benefit of the research results will require the use of information from some of the short-term projects. The objectives of the long-term projects will be met only if the results of a few preliminary short- and medium-term projects are used to develop the long-term research plans.
This patient safety research agenda is only a research agenda. As a research agenda, it is not meant to capture other aspects of the patient safety issue (e.g., legislative and legal issues) that should also be addressed to allow the patient safety effort to move forward. The research agenda could help formulate proper responses to obvious policy dilemmas, but it is intended to be a part of, not the complete solution to, patient safety issues.
Please feel free to comment concerning these research objectives by writing to:
Nancy Foster
Quality Interagency Coordination Task Force
c/o Agency for Healthcare Research and Quality
2101 East Jefferson
Rockville, MD 20852
The QuIC plans to convene other meetings to allow for input into and guidance concerning these research priorities.
Research Agenda
Contents
Epidemiology of Errors
Infrastructure to Improve Patient Safety
Information Systems
Knowing Which Interventions Should Be Adopted
Adoption Issues
Using the Information
Transition Issues
Ongoing Issues
Mechanisms
Epidemiology of Errors
Short Term:
- What are the barriers, opportunities, and incentives to studying errors in nonhospital settings and what are the best strategies to address such barriers?
Medium Term:
- What are the types of errors? (e.g., failure to diagnose, human/machine interaction, medication-related)
- Are there differences in the types or rates of errors in settings other than acute care?
- Who are at risk for particular kinds of errors? [Suggested groups for study include patients who are terminally ill; mentally ill; diagnosed with chronic diseases or disabling conditions; are children (particularly newborns under 5 lbs.); have limited English proficiency and low health literacy; are women, low income individuals, members of minority groups, individuals requiring end-of-life care, or urban/rural residents.]
- What is the relationship of the health of workers to patient safety?
- What are particular system vulnerabilities that lead to an increased occurrence of medical errors?
Long Term:
- How do we know which outcomes are caused by error, rather than by underlying disease or disabling condition?
- What human factors lead to error?
- What are typical clinician-patient interaction problems?
- How can human / technology interaction be made safer?
- How do system complexities effect the ability to improve safety?
Return to Agenda Contents
Infrastructure to Improve Patient Safety
Short Term:
- What are the proper roles for different interest groups in promoting patient safety?
- —Point of care (Patients and providers who have direct interaction with each other are the initial research dyad.)
- —Environment or context in which care is delivered (Purchasers, legislatures, organization leaders, oversight bodies such as accreditors and boards, State programs, courts, licensure and accrediting bodies)
- How can the efforts of disparate parties involved with patient safety be coordinated?
- What should be the common vocabulary (errors, adverse events definitions, typology, data standards)?
Medium Term:
- What analytic capacity needs to be developed?
- What infrastructure is needed?
- How can data be integrated?
- How can we best develop talent to perform analysis and interventions?
- How can we best develop an organizational culture of safety?
Return to Agenda Contents
Information Systems
Short Term:
- What makes a reporting system successful?
- What useful data sources exist?
- What can we learn from existing systems?
- What data should be collected and how?
- Can we develop a common definition of a "reporting system" or what data is most useful for which purposes? For example, should reports primarily focus on errors, injuries, "incidents," risk factors, or safety practices? Who should submit those reports? Should it be providers, hospitals or organizations, patients, manufacturing companies, and/or administrative bodies? How should the data be collected? Should it be by compiling routinely collected surveillance data on indicators of possible errors, performing a medical record review, or conducting surveys? How should be classify the types of errors (commission, omission, severity)?
- How can privacy/confidentiality be assured?
- What legislation facilitates/hinders reporting?
- What infrastructure is needed to support data collection, analysis and use?
Medium Term:
- How does one collect information on omissions of care?
- How can data be clustered to facilitate analysis?
- How do we measure success of the reporting systems?
- In providing information to potential users, how can confidentiality and the need to inform be balanced?
- How can we best develop infrastructure to support data collection, analysis, and use?
Long Term:
- How do we measure overall success of the reporting systems?
- How can more complete data be collected?
Return to Agenda Contents
Knowing Which Interventions Should Be Adopted
Short Term:
- What level of evidence is required?
- How should the effectiveness of safety improvement efforts be measured?
- How will we measure unintended consequences?
- Can we catalogue evidence-based successful interventions?
- How can we best get leadership and governance involved in promoting and prioritizing safety?
- What can we learn from other industries?
Medium Term:
- What interventions increase safety? How should these interventions be evaluated?
- What effect does training have on safety?
- What technologies are effective in improving safety?
- What procedural redesigns are effective in improving safety?
- How can technologies, drugs, and procedures be designed and tested to improve safe use prior to general marketing?
- How is simulation useful in training and premarket testing?
- How do we know if interventions are realistic and applicable in routine practice environments?
- How can we best foster education of both professionals and nonprofessionals (e.g., through formal education, continuing health education, in-service training)?
- What working conditions improve or detract from patient safety, (e.g., how do staffing ratios, the mix of skills among staff, and work/rest cycles influence patient safety?)?
- How can research on safety improvement be integrated into training promptly?
Long Term:
- What are the organizational changes or characteristics that affect safety?
- How does trust among health care professionals and between professionals and patients influence the culture of safety?
- What cultural, organizational, and leadership factors promote safety improvement?
- What factors foster or hinder reporting?
- How does an organization create a nonpunitive environment for improvement?
- What is the effect of design and structure on safety?
Return to Agenda Contents
Adoption Issues
Short Term:
- How can we create a business case for safety in provider organizations?
- How can we determine the cost of doing the wrong thing to the wrong patient at the wrong time?
- How can we engage the public in the patient safety issue? What type of information is important to the public?
Medium Term:
- Research on adoption: Why are interventions adopted and why not?
- How can we create a business case for safety among purchasers and policymakers?
- How can we determine the cost of poor quality?
Long Term:
- Why do some organizations adopt safety practices quickly while others resist the adoption? Why are certain adopted safety processes more successful in some organizations compared with others?
Return to Agenda Contents
Using the Information
Short Term:
- How can useful information be provided effectively to those who can act (e.g., consumers, providers and provider organizations, purchasers, States, and oversight organizations)?
Medium Term:
- How can we encourage adoption and use of safety information?
- Can purchasers assist consumers in identifying risks from care?
Return to Agenda Contents
Transition Issues
Short Term:
- How can we collect data that follows patients across transitions in care?
Medium Term:
- How can we foster communication among health professionals?
- What are the underlying causes of breakdowns in communication?
Return to Agenda Contents
Ongoing Issues
- How do various cultural issues affect patient safety?
- When is international collaboration beneficial? What can we learn from other countries who are dealing with patient safety issues?
- How can we effectively use different methodologies (qualitative and quantitative, use of narrative, syntheses) when researching patient safety questions
?
- How can we maintain a patient-centered focus in research and priority-setting?
- How can we move past thinking about errors and instead discuss the risks to patients and vulnerabilities of systems, which manifest themselves as mistakes?
- What is the best method for diffusion of successful approaches?
- How can we coordinate our efforts?
Return to Agenda Contents
Mechanisms
- How can we develop a vision of a safe health care environment?
- How can we form successful partnerships between users, doers, and funders?
- How can we take advantage of natural experiments?
- How should we engage the legal community in patient safety research?
- How can we develop more research capacity?
- How can we begin to focus on underlying causes?
- What is the best method for developing tools to facilitate adoption of successful interventions, including self-assessment?
- How do we form/maintain a multidisciplinary approach to research?
Return to Agenda Contents
Current as of October 2000
Internet Citation:
Research Agenda: Medical Errors and Patient Safety. National Summit on Medical Errors and Patient Safety Research. October 2000. http://www.quic.gov/summit/resagenda.htm
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