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Public, government demand action on old problem
The recent report from the Institute of Medicine on medical errors did not initially raise nearly as much interest among health care risk managers as it did among the public, government leaders, and the general media because risk managers already knew about this serious problem and were working hard to reduce the errors.
Nearly everyone else, on the other hand, responded to the IOM report with shock and outrage. There was immediate support for the formation of an entirely new government agency to monitor and reduce medical errors, even though many risk managers express doubt that such an agency would accomplish anything positive. The result, say some risk managers, is that the profession is now being pressured to do something — preferably something big — about a problem they have spent their careers working on.
On the whole, the IOM report is a good devel opment for risk managers, says Fay Rozovsky, JD, MPH, DFASHRM, a risk management consultant in Richmond, VA. Rozovsky, president of the Amer i can Society for Healthcare Risk Manage ment in Chicago, has been chair of the ASHRM Sentinel Event Task Force and the ASHRM representative on the Joint Commission-American Hospital Asso ciation National Legal Task Force that has been addressing risk managers’ concerns about the sentinel event policy. She has significant concerns about how government and health care leaders will react to some parts of the report, but in an overall sense, Rozovsky says, it probably is good for the public to be informed about a problem that risk managers spend every day trying to correct. She would like the public to understand what measures already are being taken to address medical errors, but she fears the report will denigrate hospitals unnecessarily.
"I don’t know if it’s good to draw all the attention to this, but it has raised the awareness of an important part of health care," she says. "How the report will be used is another question. It can be used to frighten people unnecessarily, or it can be used to make positive changes. I think it’s good to get it on the table and discuss it."
Unanswered questions for risk managers
Rozovsky says she was impressed by the depth of the IOM report and its apparent accuracy. Although the report addresses risk management concerns, she says she is not surprised that health care risk managers haven’t responded immediately with a sense of alarm.
"There is a lot there in the report that affirms what risk managers have believed and espoused for a long time," she says. "I think something definitely is going to come out of this report and all of this concern. We should sit down and review what’s going on and how we can make something positive from this report. We should consider the synergies that are in place with this, the support of the president and other stakeholders, and see how we can set differences aside and create some positive changes."
Risk managers may see the report as a vindication of all their past work, suggests Leilani Kicklighter, RN, ARM, MBA, DASHRM, assistant administrator for safety and risk management with the North Broward (FL) Hospital District. Kicklighter, a past president of ASHRM, says the report has "raised the level of visibility of a very important issue to the forefront. I think that down the road some good things for patient care will come out of this just because of the high visibility the report has given the issue."
One immediate concern is the report’s proposal for a new government agency to monitor and reduce medical errors. That sounds to some risk managers like a knee-jerk reaction to the sudden discovery of a long-term problem. Rozovsky expresses particular concern about how such an agency would be set up and what it would do. After all, what risk manager really wants to deal with yet another government agency?
"I really wonder about that. I have some major worries about that, but I’m trying to stay open-minded," she says. "What benefit would such an agency do for health care and particularly for the consumer? How would it relate to the agencies already present, and would it duplicate their efforts, or would it be able to streamline things?"
There are so many unanswered questions about the proposed agency that it is difficult to do more than wonder about the possibilities, both good and bad, Rozovsky says. Other questions concern what information will be collected, how it will be collected, how it will be used, and who will pay the expense of all this proposed data collection, she says. The basic purpose of the agency must be refined beyond just trying to reduce medication errors, she says. "We don’t want to embark on something that will be punitive in nature. We want a positive, quality-driven approach. How we get there, whether it’s through an agency or otherwise, remains to be seen."
Grena Porto, RN, ARM, DFASHRM, director of clinical risk management and loss prevention services at VHA Inc. in Berwyn, PA, and past president of ASHRM, says the IOM report can be a tremendous step forward for patient safety efforts as long as it is not used punitively.
"Our challenge is to define and demonstrate accountability without punishing individuals for their human failings," says Porto, who also is on the board of directors for the National Patient Safety Foundation. "This means working on solutions and being committed to prevention. Medical errors cannot simply be legislated away; it is not a legal problem. It is a human condition that we have to learn more about and deal with in a constructive and collaborative way."
Kicklighter says the enormous political response to the IOM report leaves her a bit uneasy. It could represent an opportunity to focus political power on a longstanding risk management problem, she says, or it could portend a messy government intervention that accomplishes little.
"Back with the sentinel event issue, I said that if reporting of untoward outcomes makes for better health care, then Florida should have perfect health care because it has required reporting since the mid-80s," she says. "So reporting in and of itself does not improve health care. It’s what you do with what’s reported."
Rozovsky notes, however, that a new agency requiring health care providers to report medical errors may not be as troublesome as it first seems. She compares the possible reporting requirement to the introduction of the Joint Commission’s sentinel event policy but says risk managers should not assume it would be as difficult. The sentinel event reporting requirement was a major head ache for risk managers until the Joint Commis sion clarified the rules to make it only a moderate head ache, and Rozovsky says that experience will be useful for any new agency.
"We now have a whole history behind us, and we know that some states have changed laws to accommodate sentinel event reporting, and we can learn from that rich history," she says. "If the same kind of reporting flows from this, I don’t think it will be as traumatic as setting up the sentinel event system. We know how to make it work."
o Fay Rozovsky, 12317 Pleasant Lake Terrace, Richmond, VA 23233. Telephone: (804) 364-2956.
o Leilani Kicklighter, Safety and Risk Management, North Broward Hospital District, 303 S.E. 17th St., Ft. Lauderdale, FL 33316. Telephone: (954) 355-4993. E-mail: Lkicklighter@NBHD.org.
o Grena Porto, VHA, 200 Berwyn Park, Suite 202, Berwyn, PA. Telephone: (610) 296-2558.