Medical errors and patient safety issues made the news again in early May, when the Robert Wood Johnson Foundation reported the results of a survey in which 95 percent of physicians said they personally witnessed a serious medical error. The survey didn't define a “major mistake,” and most physicians surveyed said they had seen major errors only “infrequently.” Nevertheless, the media underscored the ongoing concern about medical errors in the US.
Indeed, patient safety has become a cause for public concern ever since the December 1999 release of “To Err is Human,” the Institute of Medicine's (IOM) troubling report that as many as 94,000 patients a year may have died from medical errors. Countless committees have formed to study the issue, institutions have incorporated new monitoring systems, and the federal government stepped up efforts to assume a watchdog role over medical quality.
DATA NEEDED FOR NEUROLOGY
As a field, neurology, too, has begun to take stock of its own performance in patient safety and health care practices. Immediately after the release of “To Err Is Human,” the AAN formed a Patient Safety Workgroup, which includes diverse constituencies within the organization and is headed by David Stumpf, MD, Professor of Neurology at Northwestern University Medical School.
At the AAN Annual Meeting in May, the group held a poster-session and distributed questionnaires to attendees. Among the key concerns identified by neurologists there were drug issues and physician communication, Dr. Stumpf said, but, he added, much more information is needed.
“We need more data to drive this process; without it, we don't know what we're dealing with. What are the errors in neurology? We don't have good data on that yet,” Dr. Stumpf said.
SAFE HARBOR FOR MISTAKES
In order to gather such data effectively, Dr. Stumpf said, a “safe harbor” is needed, where people can voluntarily report errors, near misses, and other items they think have safety implications, without fear that the reports may be discovered, brought into court, or exposed to negative publicity. “We're thinking about a role the Academy might have in creating such a safe harbor. It might well be done at a local level through hospitals and HMOs; and, of course, the government would like a role.”
Dr. Stumpf attended a national patient safety summit meeting in April and came away concerned about the federal role. “They proposed a huge database to obtain input from state agencies, hospitals, HMOs, and presumably, although they didn't go into specifics, from private physician sources as well,” he said. “But the big issue is – how is this going to be used? Most of the people at the meeting from the government side were regulators, and there's concern that this can be more of a punitive, regulatory reaction, rather than what many of us feel needs to be a more compassionate, problem-solving, non-blaming system.”
EVIDENCE ON BEST PRACTICES
How can neurologists best measure their performance then? “The whole challenge is to bring the best available evidence to bear on how people practice medicine for the purpose of improving both quality and outcomes,” said Gary Franklin, MD, a Research Professor in the Departments of Neurology and Environmental Health at the University of Washington, who spearheads the Quality Standards Subcommittee of the AAN's Committee on Practice Standards. “Not only doctors, but systems, have a huge problem in having methods to do that.”
The Quality Standards Subcommittee oversees the development of AAN practice parameters – strategies for patient management that assist physicians in clinical decision-making. Early in its existence, the Subcommittee focused on small, narrowly defined questions such as “how effective are steroids in acute optic neuritis?” Several years ago, however, they were asked to take on much larger projects to get at questions related to whole disease or disorders.
The AAN Subcommittee issued a practice parameter on ALS, for example, and completed a set of parameters in dementia, which was featured in the May 8 issue of Neurology. “This is a very comprehensive document, incorporating a huge amount of information,” Dr. Franklin said. “It's a state-of-the-art, systematic review of the best available current evidence on diagnosis, detection, and treatment.”
Work has already begun on developing parameters for epilepsy. The effort began last December at the American Epilepsy Society meeting in Los Angeles. There, four key areas of clinical importance were identified: anti-epileptic drugs, epilepsy diagnosis and management, status epilepticus, and refractory epilepsy. The work group will start by addressing epilepsy drugs and diagnosis and management. It aims to have enough people and resources to begin work on the third and fourth areas within about a year, said Jacqueline French, MD, facilitator of the epilepsy guidelines project and Associate Professor of Neurology at the University of Pennsylvania.
Dr. French said that many potential errors could be averted by a good guideline on epilepsy drugs. In the past 10 years, she noted, seven new anti-epileptic drugs have become available, more than doubling the number of drugs that physicians can prescribe for epileptic patients.
“They all have very unique characteristics and differ from previous drugs,” Dr. French said. “There's a lot of room to teach prescribing physicians about new epilepsy drugs and where their use is most appropriate – where they can benefit patients most and where they should be avoided.”
Some of the new drugs, for example, interfere with oral contraceptive agents, she said, while others don't. If a physician is unaware of the conflict, he or she could prescribe the wrong drug for a woman of childbearing age, leading to an unintended pregnancy. Such an error could be magnified by the fact that some of the drugs also have some likelihood of producing teratogenicity.
ADDING QUALITY INDICATORS
The Quality Standards Subcommittee also plans to add a new area to future parameters. “We will add what we're calling quality indicators to our practice parameters, which we have not previously used,” Dr. Franklin said. “For example, if a parameter says that anticoagulation with Coumadin® [warfarin] for nonvalvular atrial fibrillation in persons of a certain age group, to prevent future embolic strokes, is a standard, then a quality indicator might be that 80 percent of the cases that neurologists see with this condition that meet the criteria laid out in that parameter would either receive anticoagulation or a justification in the chart about why they didn't.”
Meanwhile, the Patient Safety Workgroup hopes to put together a curriculum on safety issues in neurology. “We're trying to gather input from sections of the Academy on what they consider to be the most relevant and top-burner issues,” Dr. Stumpf said. “If it's approved, we hope to make the curriculum available free in a format to which we can invite a large number of people. We'd like to open with a large informational session, then have breakout workshops, and bring participants back together at the end to have overriding decisions made.”
Defining practice parameters and quality standards represents a critical role for the AAN and other specialty societies, Dr. Franklin believes. “I think that American medicine is in a crisis. Doctors don't necessarily have a lot of control over the entire crisis, but we do have control over practicing higher quality medicine and using scientific advances to make better decisions clinically,” he pointed out. “To the extent that we can improve American medicine by translating evidence into practice parameters, that's the role we must play.”