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Study: Drastic Changes Needed to Improve Patient Safety

February 15, 2005
Health regulators are calling for far-reaching changes to improve patient safety. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) says proposals to limit medical malpractice liability should be expanded to pursue long-term changes that truly improve safety, not just limit liability.

Under the current system, fear of lawsuits chills the identification and reporting of adverse events and thus undermines opportunities for learning that could provide the basis for significant safety improvements, the commission said in a white paper.

The report urges intensified attention to patient safety and medical injury prevention by health care providers and practitioners; emphasizes the critical importance of open communication between patients and practitioners; and urges the creation of an injury compensation system that is patient-centered and serves the common good.

The call to action is set forth in the Joint Commission's newest public policy white paper, "Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury."

Any redesign of the medical liability system, the report suggests, should assure appropriate compensation for all injured patients, while also encouraging health care providers and practitioners to surface errors, learn from mistakes in the design and performance of care processes, and take action to ensure that adverse events do not recur.

"The ultimate goal is to make health care as safe as it can be, while also assuring appropriate redress for patients when this is warranted," says Dennis S. O'Leary, M.D., president, Joint Commission. "The medical liability system in place today simply falls short of this goal."

The current medical liability system, the Joint Commission suggests, fails patients because it does not effectively deter negligence, truly offer corrective justice, or provide fair compensation to those who have been injured through the care process.

It is also accurate to say that too little progress has been made in improving patient safety since the release of the Institute of Medicine's groundbreaking report on medical error five years ago, the report concedes.

Finally, it is a simple fact that a very small proportion -- two to three percent -- of injured patients receive compensation through the medical liability system, and those who do, receive highly variable recompense for similar injuries, the commission said.

"Failures in health care can have a devastating impact, and finding justice through the current legal system is almost impossible," says Sue Sheridan, a patient safety advocate who sued over medical failures that led first to brain damage to her newborn son and later to the death of her husband.

"Litigation was a 'win at all costs' blame game that we found dishonorable. Even after prevailing in court, we had no confidence that the health care system was safer because we sued." Sheridan is co-founder of Consumers Advancing Patient Safety (CAPS).

The expert roundtable assembled by the JCAHO identified the following three strategies for achieving its overall goal:

• Actively pursue patient safety initiatives that prevent medical injury. Specific recommendations address the need to encourage the creation of cultures of safety in health care organizations; to strengthen oversight and accountability mechanisms for ensuring the competency of doctors and nurses; and to provide health care researchers access to open liability claims to permit timely identification of problematic trends in care. "Pay-for-performance" programs that provide incentives for improving patient safety and health care quality must also be part of the solution.

• Promote open communication between patients and practitioners. Emphasize that patients must become members of the health care team. Ineffective communication and lack of disclosure are the most prominent complaints of patients, and their families, who are victims of medical error or negligence.

• Create a patient-centered injury compensation system. Specific recommendations emphasize the need to conduct demonstration projects of alternatives to the current medical liability system that promote patient safety and provide swift compensation to injured patients.

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