Re-engineering how care is delivered to provide safer care for patients

One of the most pressing issues in health care today is the quality and safety of care that people receive. Each year, millions of people suffer from medical errors and tens of thousands die from these errors. Medical errors are numerous and varied – from misdiagnoses to medication mishaps – and their causes equally diverse.

Diagnostic Excellence

Diagnostic errors, a form of medical error, represent a major public health problem likely to affect each of us in our lifetime. It has been called the number one issue in patient safety. Each year, approximately 12 million adults in the U.S. experience a diagnostic error as part of an outpatient office visit – that’s one in 20 people. And, diagnostic errors contribute to at least 70,000 deaths per year.

The National Academy of Medicine defines a diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”

“Improving the diagnostic process is not only possible, it also represents a moral, professional and public health imperative”

-National Academy of Medicine report: Improving Diagnosis in Health Care

Diagnostic errors occur because of cognitive mistakes and system failures. With the explosion of medical knowledge, the complexity of human physiology, and the limited attention of clinicians in a busy community clinic or hospital emergency room, errors in cognition are inevitable. We see an opportunity to improve this by moving to a state of diagnostic excellence, where methods to detect and measure diagnostic errors are established and practices that are likely to reduce errors are deployed. Currently, health care systems are unable to systematically measure diagnostic errors and existing systems to surface errors are ad-hoc and informal.

Through our work, we hope to reduce errors in diagnoses by establishing and improving measurement of diagnostic performance, facilitating the role of technology in improving diagnosis, and focusing on prevalent health conditions in which delayed or inaccurate diagnoses occur frequently and where errors have severe consequences.

Medication Safety in the Community

More than 1.5 million medication errors occur in the U.S. annually. In a report from the National Academy of Medicine, Improving Diagnosis in Health Care, “errors are common at every stage, from prescription and administration of a drug to monitoring of the patient's response.” The risk of harm begins with the high number of medications used, most of which are prescribed in community settings (e.g., outpatient clinics, rehabilitation centers,  people’s homes). Nearly one third of U.S. adults take five or more medications and each additional medication causes a 10 percent increase in the likelihood of medication harm.

The problem is expected to grow as the U.S. population ages. Adults over 65 have been shown to experience the highest rate of adverse drug events – injury from taking a medication. One underlying driver for this is the prevalence of chronic conditions among the elderly population, who require medications for treatment. The rate of preventable harm is also exacerbated by the lack of well-functioning safety systems in community settings (physician practices, community pharmacies and patient homes). Much medication safety improvement work has been done in hospitals but comparative progress in the community lags. As more and more health care is being delivered in community settings, it makes sense that the focus on medication safety move in this direction too.

Currently, we are exploring how to improve medication safety in community settings, with an emphasis on patients with complex, chronic health conditions and functional limitations. We look forward to sharing what we learn and what we identify as the best opportunity for us to make a difference.

Roots in patient safety

Patient safety has been a central focus of our work in patient care since 2003. Our previous work includes the 12-year Betty Irene Moore Nursing Initiative, which focused on improving the quality of care delivered throughout the Bay Area and greater Sacramento. We also spent four years exploring quality improvement projects in critical care. Work in this area was a partnership with four academic medical centersBeth Israel Deaconess Medical CenterBrigham and Women’s HospitalJohns Hopkins Medical Center and University of California, San Francisco Medical Center. Lessons from this work are shared in a report from the Evaluation Sciences Unit at Stanford School of Medicine.


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