The National Patient Safety Foundation, an independent non-profit foundation founded in 1997, has been active in bringing wide visibility to the broad issues of patient safety in medicine. Strongly supported by the AMA and corporate sponsors, the NPSF Board of Directors is diverse, energetic and committed to its mission to reduce patient injuries caused by human and system failures. It is especially focused on changing the culture of blame that prevents open discussion about safety issues and human error in particular. NPSF is an educational and research organization. Last year, it conducted several successful programs to educate a wide audience about patient safety, including an inspiring conference on medical error and patient safety, sponsored jointly with the JCAHO and Veterans Administration AAAS, and the Annenberg Center for Health Sciences. The conference was held at the Annenberg Center in Rancho Mirage, CA, and was attended by 600 people representing a broad array of stakeholders and individuals involved in patient safety activities. The proceedings for the November conference entitled “Enhancing Patient Safety and Reducing Errors in Health Care” will be made available in the spring of 1999. (Order forms can be obtained from the website http://www.mederrors.org/ or by calling the NPSF at 312 464-4848.)
In December, NPSF announced its first research awards. Its research program, like the NPSF itself, takes its cues from the APSF with some differences in format. Letters of intent (LOI) were solicited via advertisement to many audiences. From the 40 LOIs, 15 full proposals were invited and 13 were received. The subjects included topics associated with medication error, incident reporting, human factors, and analysis of critical events. Four grants were awarded for a total of $350,000. These are summarized below. Three have clear applications in anesthesia and two have their roots in prior anesthesia safety research. Dr. Matthew Weinger, from UCSD, who has been supported by APSF grant funding, is conducting a project to learn how expertise is developed. He’ll be doing that in the anesthesia setting. And, Dr. Yan Xiao, from the University of Maryland, will be examining issues related to the efficacy of alarms in clinical settings.
The four newly awarded grants are described below. The principal investigator’s name and institution are in parentheses.
“Quantitative Measurement of the Progression of Clinical Expertise”
This project – the recipient of the James Todd grant – will study how physicians acquire clinical expertise, using anesthesia as the domain of study. This is a potentially widely applicable, somewhat basic, research project that gets at the underlying mechanisms of how clinicians learn how to do the right thing at the right time. The work will involve real time observations in clinical settings and analysis of videotapes of clinician performance. Domain experts will generate a cognitive map of one clinical process. That will be used to compare the decision-making processes of providers of different levels of training and experience. The methods get to the heart of what Dr. David Woods of The Ohio State University calls “understanding technical work,” which is a critical precursor to improving patient safety. (Matthew B. Weinger, MD, of the University of California at San Diego)
“Auditory Warning Signals in Critical Care Settings”
A team of researchers from the University of Maryland and the University of Illinois will examine the fundamental question of the value of audio alarms as information-providing technologies. While audio alarms may seem to have inherent value, they are known to be problematic in clinical settings. The utility of audio alarms is not really well understood. This project will examine how clinicians actually use alarms, what information alarms provide and how can they be better designed. The team will use cognitive engineering techniques to examine how providers use the information in audio alarms and will develop new design principles, re-evaluating the role of audio alarms in acute care settings. (Yan Xiao, PhD of the University of Maryland)
“Theory and Methods for Minimizing Name Confusion Errors”
The two-year project will focus on what are called Look-Alike-Sound-Alike (LASA) drug names. One primary objective is to create an improved computer algorithm to identify drug names that look and sound alike when new drug names are being assigned. There are now rudimentary searches for names that are similar. Using psycholinguistic theory and practice, this project will produce a more systematic approach to identify LASA names, prevent new similar names from being introduced, and thus help prevent the errors associated with drugs that have similar names. (Bruce L. Lambert, PhD, of the University of Illinois at Chicago)
“Looking for Trouble in All the Right Places: Electronic Decision Support for Error Reduction in a Large HMO”
The objective of this project is to develop a computer program that will search clinical information systems to identify cases that should be more carefully examined for errors and system problems. Using a database of obstetrical cases, investigators will seek “signatures” of cases that should be more carefully examined. This would greatly improve the identification of such cases, which now are found mainly by manual chart reviews without correlation with other hospital data. The methodology should be widely applicable to other patient cohorts. This is another two-year project involving a multi-disciplinary team, including co-investigators from Cornell University. (Gabriel J. Escobar, MD, of the Kaiser Permanente Medical Care Program)
See the NPSF web site for more information about its mission and activities. Portions of this report are reprinted from the NPSF Jan. 11, 1999, News Brief. To subscribe to News Brief, which is available via email, send the email message “SUBSCRIBE” to [email protected]. To receive the NPSF quarterly newsletter, Focus on Patient Safety, contact the foundation at [email protected] or 312-464-4848.
Dr. Cooper, member of the APSF Executive Committee and Chairman of the APSF Research Committee, is the Chairperson of the NPSF Research Program.