Quality of Health Care: New Approaches
Mauro Silveira de Castro (July 2010)
The Institute of Medicine defines quality of health care as: “The degree to which
health services for individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge” (IOM, 1990). This
definition is widely accepted and used (Blumenthal, 1996), emphasizing that high quality
health care increases the probability of good outcomes. Accordingly, health services
always aim for the greatest benefit and the least possible harm, with the intention of
implementing the best practices available at the time and minimizing unexpected events,
which can happen even when professionals try their hardest.
Measurement of quality of care focuses on three different types of problems:
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Excessive care: a typical example is excessive and unnecessary X-ray
examinations.
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Lack of care: for example, when necessary vaccinations are not provided.
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Inadequate care: failures and errors in technical and interpersonal aspects of
health care; for example, failure to anticipate a preventable drug interaction.
Advances in quality measurement, as well as methodological refinements, have being
developed in recent years. Examples of measures and methods and their utilization in the
enhancement of quality programs were presented in 1996 by the IOM at the conference
Measuring the Quality of Health Care—State of the Art (IOM, 1996). One of
the aspects underscored was the need for measuring errors that occur in the organization
of work, mainly in the administration of medicines, with the recommendation that
institutions identify how each error occurred and propose measures to prevent them
(IOM, 1999a).
In June 1998, the IOM created the Quality of Health Care in America project
(IOM, 1999b), for the purpose of developing strategies that would result in improvement
in the quality of health care in the ensuing ten years. The Committee on the Quality
of Health Care in America submitted its first report in November 1999—“To Err
is Human: Building a Safer Health System”—which raised great concerns
among health professionals (Chataran, 1999; Woods, 2000) and the government. The
Committee found that at least 44,000, and possibly as many as 98,000, people die in
hospitals in the United States every year as a result of medical errors. It also found that
preventable adverse events cost between U$17 billion and U$29 billion (IOM, 1999b).
In its analysis, the IOM Committee defined error as “the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim.” Thus, errors result
from two types of failures: the original intended action is not correct (errors of planning)
or the correct action does not proceed as intended (errors of execution) (IOM, 1999b).
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Errors can occur throughout the health care process: diagnosis, prevention, and treatment.
However, these errors do not necessarily involve harm. Additionally, errors can be
regarded as presumable adverse events. Thus, error prevention mechanisms become a
first step for improvement of quality of care–patient safety (IOM, 1999b; JCAHO, 2000).
It must be demonstrated that building safety mechanisms into the care process is a more
effective method for error reduction than a policy that blames the individual when
something is done wrong. The approach needs to shift, from the past, when punishing
individuals was advocated, to the present, where future errors are prevented through
health system safety projects (IOM, 1999b; ASHP, 1993; JCAHO, 2000).
This new approach does not make individuals exempt from responsibility and does not
exclude the need to be careful, but does consider the human factor. Human beings are
susceptible to failure and, thus, any professional can make a mistake. These acts are not
intentional, but they can be prevented.
In line with the current knowledge about development of safety systems in aviation,
techniques known as human factor engineering were proposed, in which improvement in
processes is regarded as the principal factor responsible for an increase in health care
quality and safety (IOM, 1999b; Ohio State University, 2000).
The Medication Process
The patient medication process includes prescribing; order communication; product
labeling, packaging and nomenclature; compounding; dispensing; distribution;
administration; education; monitoring; and use of the drug (ASCP, 1997). Professional
practice, health products, and procedures should also be included.
A medication error is regarded as any preventable event that may cause inappropriate
medication use or patient harm, while under the control of the health care professional,
patient, or consumer (ASCP, 1997; NCC MERP, 1998-1999) as part of the medication
process.
The clinical impact of medication errors can be minimal, with little or no adverse
consequences for the patient. However, some errors can lead to severe patient morbidity
or even death (ASHP, 1993; IOM, 1999b).
The following is from a speech by Dr. Liam Donaldson, Chairman of the
World Alliance for Patient Safety. More information is available at
http:/www.who.int/patientsafety/en/.
Patient Safety: "Do No Harm"
Sir Liam Donaldson1
The maxim "First, do no harm" is attributed to Hippocrates. Scholars debate whether he
actually said it, but it endures as an elegantly simple expression of what should be the
1
Available at: http://www.paho.org/english/dd/pin/Number21_last.htm (downloaded 8 September
2010).
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cardinal rule in health care: We health care providers are called to improve patients'
health, not to make it worse by our errors.
Yet in fact, medical errors and other adverse events in health care are major contributors
to the global burden of disease and death. A 1999 study by the Institute of Medicine in
the United States found that medical errors cause as many as 98,000 U.S. deaths annually
—more than the number of deaths due to breast cancer, car accidents or AIDS. Studies in
the United Kingdom indicate that one in 10 patients suffers an adverse event while
hospitalized. Similar rates are found in New Zealand and Canada, and in Australia, the
rate is 16.6%.
Data are more difficult to come by in developing countries. But according to the World
Health Organization (WHO), half or more of medical equipment in those countries is
unsafe, and 77% of all reported cases of counterfeit and substandard drugs are in poorer
countries. There's little doubt that millions of adults and children in the developing world
suffer prolonged illnesses, permanent disabilities, or death because of unsafe vaccinations
and blood, poor-quality drugs, unsafe equipment, inadequate infection control, and
generally unreliable practices performed in ill-equipped settings.
Failures in patient safety exact an enormous human toll, but they have an important
economic impact as well. Studies have shown that individual countries lose between $6
billion and $29 billion a year as a result of prolonged hospitalizations, litigation claims,
lost income, disability, and medical expenses.
Human error is only part of the problem of lapses in patient safety. Although a more
conscientious approach by medical staff would prevent many medical errors, there are
also chronic problems with medical systems and procedures. For example, thousands of
patients every year are given the wrong drugs—sometimes with fatal results—because of
hand-written prescriptions and hospital orders that are difficult to read. Yet electronic
reporting and medical recording are widely available, though not yet standard.
New Alliance
The issue of patient safety has been a growing public concern in recent years, and a
growing number of medical practitioners, public health experts, and patient advocates
have been working to address it. In October 2004, at the headquarters of the Pan
American Health Organization, WHO launched a new World Alliance for Patient Safety
in the presence of ministers of health, senior officials, academics, and patients groups
from around the world. The goal of the new alliance is to galvanize and coordinate global
and national efforts to improve patient safety around the world.
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