WASHINGTON, DC—The World Health Organization (WHO) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have launched an international partnership aimed at slashing health care errors, which are estimated to cause serious harm to one in every 10 patients around the globe.
WHO has designated the JCAHO and the Joint Commission International (JCI)—which together launched the Joint Commission International Center for Patient Safety earlier this year—as the world's first WHO-collaborating center focused solely on patient safety. JCI is a not-for-profit affiliate of JCAHO dedicated to improving health care globally.
Worldwide inequalities in access to health care have received much publicity, and the Population Reference Bureau estimates that more than half the world lives on less than $2 a day. But the new international partnership is necessary because reducing harm from health care is as important as access, said speakers at a news briefing at the National Press Club here.
The new patient safety partnership will identify best practices to reduce medical errors globally, and will coordinate worldwide efforts to disseminate these best practices as broadly as possible, working through ministries of health, patient safety agencies and experts, health care professional societies, and consumer groups.
Sir Liam Donaldson, MD, Chair of WHO's World Alliance for Patient Safety and Chief Medical Officer of the United Kingdom's Department of Health, emphasized that medical errors are committed in all corners of the world and occur because—no matter how conscientious and dedicated physicians and nurses may be—medicine is inherently a high-risk industry subject to human error (see box).
Example of 18-Year-Old Leukemia Patient Who Erroneously Received Intrathecal Vincristine
To dramatize the concept that medical errors occur globally because of systems failures, not those of individuals, Dr. Donaldson related the story of Wayne Jowett, an acute leukemia patient who died at age 18 in January 2001 in a hospital in Nottingham, UK, because he erroneously received vincristine intrathecally, which is contraindicated.
“He was the victim of a simple mistake,” Dr. Donaldson said. Wayne was to receive two drugs from two different syringes, both containing a clear fluid, one to be injected intravenously and one intrathecally. The chemotherapy error occurred despite the fact that the vincristine syringe was labeled “not for intrathecal use.”
When the mistake was discovered, an attempt was made to flush the intrathecal vincristine from Wayne's body in the operating room, but this effort unfortunately failed and he died.
A root-cause analysis of the tragic mistake after the fact revealed several weak links in the medical system. Wayne, who had some reluctance about his treatment, had dropped in unexpectedly out of his appointment sequence with his grandmother. The medical staff was eager to accommodate him and treat him.
As Dr. Donaldson noted, the chemotherapy protocol called for injecting the two drugs on two different days (which would have reduced the chance of a mix-up to near zero), but out of good intentions it had become the custom to give patients the two drugs on the same day for their convenience so they would not have to make two different trips to the hospital on separate days.
Two junior physicians carried out the procedure; one gave the injection, while one assisted. They were supposed to have been supervised by a senior physician, but due to a miscommunication, the senior physician was not there, Dr. Donaldson added.
In medicine, “human error is inevitable,” Dr. Donaldson said. But, he noted, steps can be taken to reduce the likelihood of human error.
“Training is very important; supervision is very important,” he continued. In Wayne Jowett's case, “the supervision in that particular situation was inadequate.”
“This incident is not an isolated incident. There have been other vincristine mix-ups. It's an example of something that, if it happens, is absolutely catastrophic.”
Dr. Donaldson noted that a badly written protocol (or one that is not followed) creates a set-up for a “potentially fatal incident.” And he also stressed that it is not just the patient and the patient's family who suffer—“Let's not forget the trauma to our clinical teams. The anguish of that moment [of error] is frozen in time” for the medical staff as well as the loved ones left behind.
Dr. Donaldson emphasized that in order to reduce medical error, it is not enough just to urge health professionals to take care, because achieving patient safety requires a strong systems approach.
Unfortunately, he said, improving systems to reduce medical errors is not ensured.
“Learning [from patient errors] is sometimes not even transmitted within the same hospital…let alone across the world,” he noted.
Following the death of Wayne Jowett, Dr. Donaldson said the UK's Department of Health published and distributed a set of standards for intrathecal chemotherapy guidance. But Dr. Donaldson decried the slow adoption of these standards—identified on audits—and the fact that some hospital staffs said they were compliant with the new standards when they were not.
“Providing safe care is not always convenient,” Dr. Donaldson said. “Sometimes safe care requires us to make things a little inconvenient.”
As an example of learning from a medical mistake, he cited and commended Boston's Dana-Farber Cancer Institute for instituting and following strict protocols after the 1994 death of Boston Globe health news reporter Betsy Lehman. Ms. Lehman, a breast cancer patient, died from an accidental chemotherapy overdose.
He also cited the patient's role in helping prevent medical errors. Dr. O'Leary said the JCAHO's “Speak Up Program” urges patients to get involved in their care and to ask questions.
For example, the Speak Up Program urges a patient to ask the physician to mark the area to be operated on in advance, so there will be no confusion in the operating room.
The program also urges the patient to speak up if she believes she is being confused with another patient, or is about to receive the wrong medication.
Dr. O'Leary said JCAHO priorities for patient safety include wrong-site and wrong-person surgery, use of nasogastric tubes, and look-alike drugs. “The pool of opportunities is very deep,” he said.
‘Normalization of Deviant Behavior’
Peter Angood, MD, a surgeon who is Chief Patient Safety Officer of the JCI's Center for Patient Safety, said a change in medicine is needed because “a normalization of deviant behavior” has been pervasive in health care for a long time.
Following standardized protocols is one way to reduce that deviant behavior and improve patient safety, he said.
Mirta Roses Periago, MD, Director of the Pan American Health Organization, stressed that medical errors and adverse events are a major part of “the global burden of disease, disability, and death.” She urged a re-evaluation of the increased use of medical technology, to make sure that this increased use is not inadvertently causing increased medical errors.
Marty Hatlie, JD, President of the Partnership for Patient Safety, a consumer group, said that many US hospitals up until now have not been forthright with patients about telling them what happened when something goes wrong, judging from the calls his center receives. Often, he said, the caller will say something such as, “The hospital told me they did a complete analysis, but they didn't talk to the patient or the family.”
But Mr. Hatlie also said there has been a recent “growth spurt” in US patient safety efforts.
The new WHO-JCAHO global collaboration is an important step, said Carolyn M. Clancy, MD, Director of the federal Agency for Healthcare Research and Quality (AHRQ), which funds research aimed at improving patient safety efforts in the United States.
“Congratulations—this is a very exciting opportunity,” said Dr. Clancy, who attended the news briefing. “The opportunities to do harm in health care don't know any national borders.”
Dr. Clancy added that patient safety is a “team sport.” Recent AHRQ-funded patient safety research has shown that: adverse drug events occur frequently in long-term care facilities, and that nearly half of them are preventable; linking laboratory and pharmacy databases can help identify patients who don't undergo follow-up for abnormal tests; and a new Web-based intensive care unit safety reporting system may have the potential to reduce medical errors at ICUs across the country.
William R. Steiger, PhD, Special Assistant to the Secretary for International Affairs of the US Department of Health and Human Services, praised the efforts of the UK's Dr. Donaldson in leading the global patient safety effort: “We owe a lot to Sir Liam; we've learned a lot from the UK,” said Dr. Steiger, who also attended the news briefing.
“We are very supportive of all patient safety efforts; all health is global,” commented Rita Munley Gallagher, PhD, RN-C, Senior Policy Fellow in the Department of Nursing Practice at the American Nurses Association, who was also at the briefing.
Global Data on Medical Errors
▪ Medical errors cause between 44,000 and 98,000 deaths every year in US hospitals, according to the Institute of Medicine's 1999 report.
▪ Almost every tenth patient in hospitals in Europe suffers from preventable harm and adverse events related to his or her care (2000 report from Hospitals for Europe).
▪ Adverse events harm an estimated 10% of patients admitted to national health service hospitals in England—at a rate of more than 850,000 per year (2000 report from the Department of Health, UK).
▪ An estimated 16.6% of Australian hospital patients—230,000 people—experienced a preventable adverse event in 1992. Up to 14,000 preventable deaths would have occurred (1995 article in The Medical Journal of Australia).
▪ An estimated 7.5% of patients admitted to Canadian hospitals in 2000 experienced one or more adverse events. One third of these events were considered highly preventable (2004 article in Journal de l'Association medicale canadienne).
▪ An estimated 12.9% of public hospital admissions in New Zealand were associated with an adverse event (2002 article in The New Zealand Medical Journal).