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Having Zero Adverse Events In Hospitals Is Now A Realistic Goal, Lucian Leape Says In Health Affairs Interview

Patient Safety Pioneer Cites Exciting Developments In The Field, But Gives Low Grades To Hospital CEOs And Government

Bethesda MD -- It is now feasible to talk about completely eliminating adverse events for hospital patients, one of leading figures in the field of patient safety states in a Health Affairs interview published today. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.6.w687

“The most exciting thing that has happened recently in patient safety -- something that has truly changed our agenda -- is that it is now apparent that we can use perfection as a benchmark,” says Lucian Leape, an adjunct professor of health policy at Harvard School of Public Health. Leape points to “convincing demonstrations” at places such as the Johns Hopkins intensive care unit that “we can actually eliminate certain adverse events,” such as central-line infections and ventilator-assisted pneumonia. “There is no reason to think that this cannot be expanded to the whole universe of adverse events,” he declares.

In a January 2007 discussion with Peter Buerhaus, who heads the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University, Leape points to several other important patient safety developments. They include:

Team Training Using Simulations. “Everyone likes the idea of doctors, nurses, and anesthesiologists experiencing their first crisis on a plastic patient,” Leape says. Simulation is expensive, but it “is sweeping the country,” bringing with it “a new emphasis on and increased sophistication in team training.”

Better Ways Of Identifying Adverse Events. A “trigger tool” developed by the Institute for Healthcare Improvement (IHI) “has proved very effective,” Leape says. “This is a list of approximately fifty elements that can be found in the patient record, many of them laboratory tests or simple clinical observations. . . . You identify abnormal findings and investigate whether a patient has suffered an adverse event.” Hospitals that have used the IHI trigger tool have found that 40 percent of admitted patients will experience some sort of injury -- ten times more than indicated by a seminal 1991 study.

A National Effort To Ensure Physician Competency. All of the major stakeholders are working toward requiring “continuing assessment of competency . . . rather than merely having a physician take a board examination on one occasion.”

Acknowledgement Of The Need For Disclosing Mistakes. Liability insurance carriers and hospital counsels have “perpetuated the myth that informing the patient [of a mistake] will increase the likelihood of being sued,” Leape says. Fortunately, new evidence is proving “just the opposite,” finding “that full disclosure and early compensation have led to substantial reductions in the number of suits filed and in the total payouts.”

Hospital CEOs And Government
Hinder Progress On Patient Safety

The “single most disappointing aspect of the safety movement for me” has been “the difficulty in getting CEOs of hospitals and health care systems to make safety a priority,” Leape says. “CEOs are a ‘sea anchor’ on progress, and that has to change. . . . No organization can make the significant changes that are necessary to develop a culture of safety without vigorous leadership at the top.”

Leape also criticizes the record of federal and state governments on patient safety issues: “Although there was some increase in funding for research early on after the 1999 IOM report [To Err Is Human], since then the federal government has not done much to provide incentives, financial or other, to improve safety. Some states have established reporting systems, but most of us do not think that those are very effective as incentives.”

The media get better reviews from Leape, who says that news outlets “have treated us very well.” He praises a Newsweek special issue in particular for focusing on what hospitals are doing to improve safety. “From time to time there are sensationalized reports, but nothing like they have experienced in Great Britain,” he says.

Leape criticizes the current payment system that compensates hospitals and physicians for treating the consequences of their own mistakes, and he praises payers who have refused to pay for 27 egregious events -- such as a surgeon removing the wrong leg -- that have been dubbed “never events” by the National Quality Forum because they should never occur. (Leape has also praised the August announcement, which occurred after this interview, that Medicare would no longer pay hospitals for treating certain preventable conditions that occur in the facilities.)

Leape is ambivalent about pay-for-performance, however; he worries, for example, that paying for outcomes could “devalue and direct attention away from the ‘soft stuff’ that means so much to patients: time spent listening to them, caring about them, communicating with them.”

ABOUT HEALTH AFFAIRS:

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.

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©2007 Project HOPE–The People-to-People Health Foundation, Inc.