Leape, Bates Present
Patient Safety Milestones
From left: Lucian Leape and David Bates discuss patient safety milestones at a special 100th anniversary medical grand rounds held in December. |
"The cause of medical errors is not bad people, but bad
systems," said Lucian Leape, MD, at the Department of Medicine's special 100th
anniversary medical grand rounds held in the Bornstein Amphitheater last month.
"Errors are normal human behavior. This is a transforming concept; it has made
us re-examine what we do and improve our systems."
During the presentation, Leape, an adjunct professor at
Harvard School of Public Health and world leader in patient safety, shared insight from key BWH and HMS studies
related to quality of care and medical errors. One of these studies was the
1991 Harvard Medical Practice Study, which reviewed 30,000 randomly
selected acute care hospitalized cases, and found that injuries resulting from medical care occurred in 3.7 percent
of hospitalizations, with 69 percent of these cases resulting from errors.
"A tremendous amount
of research on adverse events has been conducted and has led to the development
and implementation of new safety practices," said Leape. "There is now
universal awareness of the problem of medical errors and acceptance that
improving systems is the solution. The realignment of financial incentives away
from the fee-for-service model and the recognition of the importance of
teamwork will help to create a new, safer culture for patients and families."
David Bates, MD, MSc, BWH's senior vice president for Quality and Safety and chief quality officer,
followed Leape's presentation with a discussion of the Brigham's many
contributions to patient safety research, including BWH and MGH's Adverse Drug
Event (ADE) Prevention Study. One report, authored by Bates, found that 28
percent of adverse events, or medical errors, were preventable, with the
majority of those errors (49 percent) occurring in the ordering stage. Further,
the study demonstrated that the most effective way to prevent serious
medication errors is to focus on improving systems.
"Why has BWH been so
successful regarding patient safety?" asked Bates. "I think it's our
willingness to acknowledge that there is always room for improvement, and our
willingness to try out new and unproven systems. Multi-disciplinary teams
coming together and our track record of leveraging electronic records, which
will be improved further with Partners eCare,
have also contributed to our success."
Learn more about quality and patient safety at BWH.