2010 P re lim in a ry Co m p a ra tive Re s u lts : Me d ic a l Offic e
S u rve y o n P a tie n t S a fe ty Cu ltu re
Prepared for:
U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
http://www.ahrq.gov
Contract No. HHSA 290200710037
Managed and prepared by:
Westat, Rockville, MD
AHRQ Publication No. 11-0015-EF
November 2010
The authors of this report are responsible for its content. Statements in the report should not be
construed as endorsement by the Agency for Healthcare Research and Quality or the U.S.
Department of Health and Human Services.
This document is in the public domain and may be used and reprinted without permission except
those copyrighted materials noted for which further reproduction is prohibited without specific
permission of copyright holders.
Suggested Citation:
2010 Preliminary Comparative Results: Medical Office Survey on Patient Safety Culture.
(Prepared by Westat, Rockville, MD, under Contract No. HHSA 290200710037). Rockville,
MD: Agency for Healthcare Research and Quality; November 2010. AHRQ Publication No. 110015-EF.
No investigators have any affiliations or financial involvement (e.g., employment,
consultancies, honoraria, stock options, expert testimony, grants or patents received or
pending, or royalties) that conflict with material presented in this report.
ii
Contents
Purpose and Use of This Document
Report Overview
Survey Development
Survey Administration
Description of the 470 Medical Offices
Description of Medical Office Respondents
Composite-Level and Item-Level Comparative Results
Calculating Item Percent Positive Scores
Calculating Composite Percent Positive Scores
Comparative Results Using Percentiles
Composite-Level and Item-Level Results by Staff Position
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Tables
Table 1. Overall and Average Response Statistics for 470 Medical Offices
Table 2. Distribution of Medical Offices by Number of Providers and Staff
Table 3. Distribution of Medical Offices by Type of Specialty
Table 4. Number of Medical Offices by Specialty
Table 5. Distribution of Medical Offices by Number of Locations
Table 6. Distribution of Medical Offices by Majority Ownership
Table 7. Implementation Status of Electronic Tools
Table 8. Number of Patient Visits and Providers at the Medical Office
Table 9. Distribution of Respondents by Staff Category
Table 10. Distribution of Respondents by Tenure
Table 11. Distribution of Respondents by Hours Worked per Week
Table 12. Example of How To Calculate Item and Composite Percent Positive Scores
Table 13. Interpretation of Percentile Scores
Table 14. Sample Percentile Statistics
Table 15. Composite-Level Minimum, Maximum, and Percentile Results
Table 16. Item-Level Minimum, Maximum, and Percentile Results
Table 17. Overall Rating on Quality Minimum, Maximum, and Percentile Results
Table 18. Overall Rating on Patient Safety Minimum, Maximum, and Percentile Results
Table 19. Composite-Level Results by Staff Position
Table 20. Item-Level Results by Staff Position
Table 21. Overall Rating on Quality Results by Staff Position
Table 22. Overall Rating on Patient Safety Results by Staff Position
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Charts
Chart 1. Composite-Level Comparative Results From 470 Medical Offices
Chart 2. Item-Level Comparative Results From 470 Medical Offices
Chart 3. Comparative Results for Overall Ratings on Quality From 470 Medical Offices
Chart 4. Comparative Results for Overall Rating on Patient Safety From 470 Medical Offices
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Purpose and Use of This Document
Comparative results are provided for the items and patient safety culture dimensions on the
AHRQ Medical Office Survey on Patient Safety Culture to allow medical offices to compare
their survey results against the results from 470 medical offices. This number includes 292
Practice Based Research Network (PBRN) medical offices that administered the survey in 2009
and 182 medical offices that participated in a pilot test of the survey in the United States in late
2007.
The results presented here are from limited numbers of staff and medical offices and will provide
only a general indication of how your medical office compares with other medical offices in the
United States. The data summarized here were not derived from a statistically selected sample of
U.S. medical offices.
At this time, there is no central repository for medical offices to submit data for comparative
purposes. However, similar to the AHRQ Hospital Survey on Patient Safety Culture
Comparative Database (www.ahrq.gov/qual/patientsafetyculture), AHRQ plans to support a U.S.
comparative database for the medical office survey that will provide more extensive comparative
data. More details will be forthcoming from AHRQ about when data submission will begin and
when updated comparative results will be available.
Report Overview
•
•
•
•
Comparative results are provided for the survey items and patient safety culture
dimensions based on data from 10,567 staff from 470 medical offices.
The data were obtained from two survey administrations: 6,463 staff from 292 PBRN
medical offices surveyed in 2009 and 4,174 staff from 182 pilot test medical offices
surveyed in late 2007.
Basic descriptive data are provided about the respondents and medical offices.
A description of how composite scores on the Medical Office Survey on Patient Safety
Culture were calculated is also provided.
Survey Development
The Medical Office Survey on Patient Safety Culture is an expansion of the Agency for
Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture, which
was pilot tested and made available to the public in November 2004
(http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm). The Medical Office Survey
on Patient Safety Culture was specifically designed to measure the culture of patient safety in
medical offices from the perspectives of providers and staff.
Safety culture can be defined as the set of values, beliefs, and norms about what is important,
how to behave, and what attitudes are appropriate when it comes to patient safety in a workgroup
or organization. The Medical Office Survey on Patient Safety Culture is intended to help a
medical office assess the extent to which its organization’s culture emphasizes the importance of
patient safety, facilitates teamwork and open discussion about mistakes, and creates an
atmosphere of continuous learning and improvement.
1
The survey design team reviewed the literature on patient safety problems and issues in medical
offices, interviewed more than two dozen experts and researchers on patient safety in medical
offices, asked many medical office providers and staff to identify appropriate survey topics, and
drafted sets of survey dimensions and items for review by experts. The draft survey was
pretested with medical office providers and staff to ensure that the questions were easy to
understand and answer and that the items were relevant. The pilot test survey was then
administered in 2007 in a total of 182 medical offices, the data were analyzed to examine the
survey’s psychometric properties (reliability and factor structure), and the length was shortened
by dropping items.
The final survey includes 52 survey items that measure the following 12 areas of organizational
culture pertaining to patient safety:
1. Communication About Error
2. Communication Openness
3. Information Exchange With Other Settings
4. Office Processes and Standardization
5. Organizational Learning
6. Overall Perceptions of Patient Safety and Quality
7. Owner/Managing Partner/Leadership Support for Patient Safety
8. Patient Care Tracking/Followup
9. Patient Safety and Quality Issues
10. Staff Training
11. Teamwork
12. Work Pressure and Pace
The survey uses 6-point frequency scales (“Daily” to “Not in the past 12 months”), 5-point
frequency scales (“Never” to “Always”), or 5-point scales of agreement (“Strongly disagree” to
“Strongly agree”). Most items include a “Does not apply or Don’t know” option.
The survey also includes overall ratings questions that ask respondents to rate their medical
office in five areas of health care quality (patient centered, effective, timely, efficient, equitable)
and to provide an overall rating on patient safety.
Survey Administration
In 2007, a pilot administration was conducted with 182 medical offices and 4,174 staff across 21
States. The pilot survey was designed to contain a diverse sample of medical offices, although
participation was voluntary and therefore may not statistically represent all medical offices in the
United States. In 2009, 11 PBRNs collected data from 292 medical offices and 6,463 staff across
17 States.
The data from the 182 pilot test medical offices were combined with the data from the 292
PBRN medical offices, yielding a total of 474 medical offices. Four medical offices were
dropped because they had participated in both data collections, resulting in a final combined
dataset of 470 medical offices.
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Description of the 470 Medical Offices
Completed responses from the 470 medical offices came from 33 States. However, the medical
offices that voluntarily participated in these data collection efforts may not be representative of
all medical offices in the United States. Overall response results for the participating medical
offices are summarized in Table 1.
In all tables, column percent totals may not add to exactly 100 percent because of rounding.
Table 1. Overall and Average Response Statistics for 470 Medical Offices
Overall Response Rate Information
Statistic
10,567
14,558
Number of respondents
Number of surveys administered
Overall response rate
Average Response Rate Information
Average number of respondents per medical office (range: 5 to 192)
Average number of surveys administered per medical office (range: 5 to 376)
Overall average medical office response rate (range: 21% to 100%)
73%
Statistic
22
31
78%
Medical office characteristics were obtained from a designated point of contact in each medical
office. Tables 2 through 4 show the distribution of medical offices by total number of providers
and staff, type of specialty, and number of medical offices by specialty.
The vast majority of medical offices (77%) had 40 or fewer providers and staff.
Table 2. Distribution of Medical Offices by Number of Providers and Staff
All Medical Offices
Number
Percent
84
140
90
47
Total Number of Providers and Staff
5–10
11–20
21–30
31–40
41–50
51–60
61–70
More than 70
Total
40
22
11
36
470
3
18%
30%
19%
10%
9%
5%
2%
8%
100%
As shown in Table 3, more than half of medical offices (56%) were single specialty.
Table 3. Distribution of Medical Offices by Type of Specialty
All Medical Offices
Number
Percent
263
56%
Type of Specialty
Single specialty
Multispecialty with primary care only (e.g., family medicine, internal
medicine, pediatrics, OB/GYN, general practice)
114
24%
Multispecialty with primary care and specialty care
Multispecialty with specialty care only
Total
Missing
81
11
469
1
17%
2%
100%
0
The 470 medical offices represent a wide range of specialties, with most categorized as family
practice/family medicine (291 offices)(Table 4).
Table 4. Number of Medical Offices by Specialty
Specialty
Allergy/immunology
Anesthesiology
Cardiology
Number of
Medical Offices
15
2
22
Child and adolescent psychiatry
Dermatology
Diagnostic radiology
Emergency medicine
6
11
8
7
Endocrinology/metabolism
Family practice/family medicine
22
291
Forensic pathology
Gastroenterology
1
11
General practice
General preventive medicine
16
7
General surgery
Geriatrics
Hematology/oncology
Internal medicine
Medical genetics
Nephrology
21
14
12
102
2
9
Specialty
Neurology
Nuclear medicine
OB/GYN or GYN
Number of
Medical Offices
11
2
63
Ophthalmology
Orthopedics
Otolaryngology
Pathology –
anatomic/clinical
Pediatrics
Physical medicine and
rehabilitation
Psychiatry
Public health and
rehabilitation
Pulmonary medicine
Radiology
15
23
12
1
Rheumatology
Surgery (all)
Urology
Vascular medicine
Other specialty
11
11
12
3
47
95
9
26
2
9
6
Note: The total number of medical offices will not necessarily sum to 470 as some medical offices may categorize
themselves as more than one type of specialty.
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Table 5 shows the distribution of medical offices by number of locations. Approximately twothirds of medical offices (67%) had a single location, while the rest (33%) had multiple
locations. Medical offices with more than one location had an average of 9 locations (ranging
from 2 to 40 locations). Of the 152 medical offices with multiple locations, 48 indicated they
were the primary/parent location and 104 indicated they were a satellite location.
Table 5. Distribution of Medical Offices by Number of Locations
All Medical Offices
Number of Locations
Number
One location
Multiple locations
Total
Missing
Percent
310
152
462
8
67%
33%
100%
Table 6 shows that almost half of medical offices (47%) were owned by a hospital or health
system.
Table 6. Distribution of Medical Offices by Majority Ownership
All Medical Offices
Number
Percent
134
29%
Majority Ownership
Providers and/or Physicians
Managed care or health maintenance organization
University or medical school or academic medical institution
Hospital or health system
Federal, State, or local government, community board, etc.
Other
Total
3
75
220
23
10
465
Missing
1%
16%
47%
5%
2%
100%
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Table 7 presents the implementation status of five common electronic tools in the medical
offices. The vast majority of medical offices (82%) had fully implemented electronic
appointment scheduling, while only 37% of medical offices had fully implemented electronic
ordering of tests, imaging, or procedures.
Table 7. Implementation Status of Electronic Tools
Implementation Status
Electronic Tools
Electronic appointment scheduling
Electronic ordering of medications
Electronic ordering of tests, imaging, or procedures
Electronic access to your patients’ test or imaging
results
Electronic medical/health records (EMR/EHR)
5
Fully
Implemented
82%
41%
37%
In Progress
13%
30%
26%
Not
Implemented
5%
29%
37%
59%
51%
29%
21%
12%
28%
Table 8 presents the average number of patient visits per week per provider across all medical
offices. i On average, the total number of patient visits per total number of providers was 69
(ranging from 1 to 450).
Table 8. Number of Patient Visits and Providers at the Medical Office
Medical Office Statistics
Number of Patient Visits and Providers at the Medical Office
Total number of patient visits/total number of providers
Average
69
Minimum
1
Maximum
450
Description of Medical Office Respondents
Tables 9 through 11 display distributions of the 10,567 medical office respondents by:
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•
•
Staff category,
Tenure in the medical office, and
Hours worked per week in the medical office.
According to the data on respondent characteristics shown in these tables:
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•
•
Twenty-eight percent of respondents were administrative or clerical staff, 21% were other
clinical staff or clinical support staff, and 19% were physicians.
About 60% of respondents had worked in their medical office for at least 3 years.
About 78% of respondents worked in their medical office at least 33 hours per week.
Table 9. Distribution of Respondents by Staff Category
All Medical Offices
Staff Category
Administrative or clerical staff
Other clinical staff or clinical support staff
Physician (M.D. or D.O.)
Nurse (RN), licensed vocational nurse (LVN), licensed practical nurse (LPN)
Management
Physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife,
advanced practice nurse, etc.
Other position
TOTAL
Missing
Overall total
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Number
2,860
2,155
1,941
1,564
749
Percent
28%
21%
19%
15%
7%
486
5%
435
10,190
377
10,567
4%
100%
The PBRN medical offices were asked to report two pieces of information: total number of patient visits in a
typical week and total number of providers working in the medical office in a typical week. The pilot test medical
offices were simply asked to report the average number of patient visits per week across all providers.
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Table 10. Distribution of Respondents by Tenure
All Medical Offices
Number
Percent
282
Tenure in Medical Office
Less than 2 months
2 months to less than 1 year
1 year to less than 3 years
3 years to less than 6 years
6 years to less than 11 years
11 years or more
Total
Missing
1,268
2,461
2,085
2,082
2,108
10,286
281
Overall total
10,567
3%
12%
24%
20%
20%
20%
100%
Table 11. Distribution of Respondents by Hours Worked per Week
Hours Worked per Week in the Medical Office
1 to 4 hours
5 to 16 hours
17 to 24 hours
25 to 32 hours
33 to 40 hours
41 hours or more
Total
Missing
Overall total
All Medical Offices
Number
Percent
118
492
706
996
5,245
2,735
10,292
275
10,567
1%
5%
7%
10%
51%
27%
100%
Composite-Level and Item-Level Comparative Results
You can obtain a summary view of how your medical office compares to other medical offices
by examining the composite-level and item-level percent positive scores displayed in Charts 1
through 4.
Calculating Item Percent Positive Scores
To compare your medical office results to the comparative results from the Medical Office
Survey on Patient Safety Culture, it is helpful to understand how the medical office percent
positive scores are calculated.
For positively worded items, percent positive is the total percentage of respondents who
answered positively. This total is the combined percentage of “Strongly agree” and “Agree”
responses or “Always” and “Most of the time” responses, depending on the response categories
used for the item.
For Section B (Information Exchange With Other Settings), percent positive is based on the
combined percentage of “Problems once or twice in the past 12 months” and “No problems in
the past 12 months.”
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For negatively worded items, percent positive is the total percentage of respondents who
answered negatively. This total is the combined percentage of “Strongly disagree” and
”Disagree” responses or “Never” and “Rarely” responses, since a negative answer on these items
indicates a positive response.
For Section A (List of Patient Safety and Quality Issues), all items are negatively worded, so the
combined percentage of “Once or twice in the past 12 months” and “Not in the past 12 months”
represents positive responses.
Calculating Composite Percent Positive Scores
A composite score summarizes how respondents answered groups of items that all measure the
same thing. Composite scores on the 12 patient safety culture survey dimensions tell you the
average percentage of respondents who answered positively when looking at the survey items
that measure each safety culture dimension. Composite scores allow a summary comparison
because you compare against only 12 safety culture dimensions rather than 52 separate survey
items.
To calculate each medical office’s composite score on a particular safety culture dimension,
calculate the average percent positive response of the items included in the composite. Table 12
shows an example of computing a composite score for Office Processes and Standardization. The
composite has four items. Two are positively worded (items C9 and C15) and two are negatively
worded (items C8 and C12). Keep in mind that DISAGREEING with a negatively worded item
indicates a POSITIVE response.
Table 12. Example of How To Calculate Item and Composite Percent Positive Scores
Office Processes and
Standardization
Item C9-positively worded:
“We have good procedures
for checking that work in this
office was done correctly”
Item C15-positively worded:
“Staff in this office follow
standardized processes to
get tasks done”
Item C8-negatively worded:
“This office is more
disorganized than it should
be”
Item C12-negatively worded:
“We have problems with
workflow in this office”
For positively
worded items, the
# of “Strongly
agree” or “Agree”
responses
For negatively
worded items, the #
of “Strongly disagree”
or “Disagree”
responses
Total # of
responses
to the item*
Percent
positive
response on
item
24
NA*
52
24/52=46%
26
NA*
50
26/50=52%
NA*
22
48
22/48=46%
NA*
28
50
28/50= 56%
Average percent positive response across the 4 items = 50%
* Excluding not applicable/don’t know and missing responses
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In this example, there were four items, with percent positive response scores of 46, 52, 46, and
56. Averaging these item-level percent positive scores ([46 + 52 + 46 + 56]/4 = 50) results in a
composite score of .50 or 50% on Office Processes and Standardization. That is, an average of
50% of the respondents responded positively to the survey items in this composite.
The charts on the following pages display the composite-level and item-level comparative results
from the 470 medical offices. Chart 1 shows the average percent positive response for each of
the survey’s patient safety culture composites, in order from most positive to least positive. Chart
2 provides the average percent positive response for the survey items. Chart 3 shows the average
distribution of responses for the Overall Ratings on Quality, and Chart 4 shows the average
distribution of responses for the Overall Rating on Patient Safety.
Use a difference of 5 percentage points as a rule when comparing medical office results to the
results shown. Medical office percentages should be at least 5 points higher than the comparative
results to be considered “better” (e.g., 75% vs. 70%) and should be at least 5 points lower to be
considered “lower” than the comparative results (e.g., 60% vs. 65%). A 5 percentage point
difference is likely to be statistically significant for most medical offices given the number of
responses per medical office and is also a meaningful difference to consider.
This information provides only relative comparisons. Although your medical office’s results may
be better than the comparative results, you may still believe there is room for improvement in an
absolute sense.
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Chart 1. Composite-Level Comparative Results From 470 Medical Offices
Patient Safety Culture Composites
% Positive Response
1. Teamwork
82%
2. Patient Care Tracking/Followup
77%
3. Organizational Learning
74%
4. Overall Perceptions of Patient Safety and
Quality
74%
5. Staff Training
72%
6. Owner/Managing Partner/Leadership
Support for Patient Safety
67%
7. Communication About Error
67%
65%
8. Communication Openness
9. Patient Safety and Quality Issues
60%
10. Office Processes and Standardization
59%
54%
11. Information Exchange With Other Settings
46%
12. Work Pressure and Pace
1
0
10
20
40
60
80
100
Chart 2. Item-Level Comparative Results from 470 Medical Offices
Item Survey Items By Patient Safety Culture
Average % Positive Response
1. Teamwork
C1
1. When someone in this office gets really
busy, others help out.
C2
2. In this office, there is a good working
relationship between staff and providers.
C5
3. In this office, we treat each other with
respect.
80%
C13
4. This office emphasizes teamwork in taking
care of patients.
80%
D3
83%
87%
2. Patient Care Tracking/Follow-up
1. This office reminds patients when they
need to schedule an appointment for
preventive or routine care.
78%
D5
2. This office documents how well our chroniccare patients follow their treatment plans.
D6
3. Our office follows up when we do not
receive a report we are expecting from an
outside provider.
D9
4. This office follows up with patients who
need monitoring.
F1
F5
F7
65%
77%
86%
3. Organizational Learning
1. When there is a problem in our office, we
see if we need to change the way we do
things.
2. This office is good at changing office
processes to make sure the same problems
don’t happen again.
82%
75%
3. After this office makes changes to improve
the patient care process, we check to see if
the changes worked.
67%
0%
Note: The item’s survey location is shown to the left.
11
20% 40%
60% 80% 100%
Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued
Item Survey Items By Patient Safety Culture
Average % Positive Response
4. Overall Perceptions of Patient Safety
and Quality
F2
1. Our office processes are good at preventing
mistakes that could affect patients.
F3R
2. Mistakes happen more than they should in
this office.
F4R
3. It is just by chance that we don’t make
more mistakes that affect our patients.
74%
F6R
4. In this office, getting more work done is
more important than quality of care.
73%
79%
70%
5. Staff Training
C4
1. This office trains staff when new processes
are put into place.
C7
2. This office makes sure staff get the on-thejob training they need.
71%
C10R
3. Staff in this office are asked to do tasks
they haven’t been trained to do.
69%
75%
6. Owner/Managing Partner/Leadership
Support for Patient Safety
E1R
1. They aren’t investing enough resources to
improve the quality of care in this office.
E2R
2. They overlook patient care mistakes that
happen over and over.
79%
E3
3. They place a high priority on improving
patient care processes.
78%
E4R
4. They make decisions too often based on
what is best for the office rather than what is
best for patients.
51%
61%
0%
20%
40% 60% 80% 100%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent
positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely”
(depending on the response category used for the item).
12
Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued
Item Survey Items By Patient Safety Culture
Average % Positive Response
7. Communication About Error
D7R
1. Staff feel like their mistakes are held
against them.
57%
D8
2. Providers and staff talk openly about office
problems.
59%
D11
3. In this office, we discuss ways to prevent
errors from happening again.
D12
4. Staff are willing to report mistakes they
observe in this office.
78%
72%
8. Communication Openness
D1
1. Providers in this office are open to staff
ideas about how to improve office processes.
69%
D2
2. Staff are encouraged to express alternative
viewpoints in this office.
68%
D4R
3. Staff are afraid to ask questions when
something does not seem right.
70%
D10R
4. It is difficult to voice disagreement in this
office.
53%
0%
20% 40%
60% 80% 100%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent
positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely”
(depending on the response category used for the item).
13
Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued
Item Survey Items By Patient Safety Culture
Average % Positive Response
9. Patient Safety and Quality Issues
In your best estimate, how often did the
following things happen in your medical office
over the past 12 months?
Access to Care
A1
1. A patient was unable to get an appointment
within 48 hours for an acute/serious problem.
69%
Patient Identification
A2
2. The wrong chart/medical record was used for
a patient.
86%
Charts/Medical Records
A3
3. A patient's chart/medical record was not
available when needed.
A4
4. Medical information was filed, scanned, or
entered into the wrong patient's chart/medical
record.
63%
70%
Medical Equipment
A5
5. Medical equipment was not working properly
or was in need of repair or replacement.
73%
Medication
A6
6. A pharmacy contacted our office to clarify or
correct a prescription.
A7
7. A patient's medication list was not updated
during his or her visit.
22%
44%
Diagnostics & Tests
A8
8. The results from a lab or imaging test were
not available when needed.
A9
9. A critical abnormal result from a lab or
imaging test was not followed up within 1
business day.
39%
79%
0%
20%
40%
60%
80% 100%
Note: The percent positive response is based on those who answered “Not in the past 12 months” or “Once or twice
in the past 12 months.”
14
Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued
Item Survey Items By Patient Safety Culture Area
Average % Positive Response
10. Office Processes and Standardization
C8R
1. This office is more disorganized than it should
be.
58%
C9
2. We have good procedures for checking that
work in this office was done correctly.
60%
C12R 3. We have problems with workflow in this office.
C15
47%
4. Staff in this office follow standardized
processes to get tasks done.
74%
11. Information Exchange With Other Settings
Over the past 12 months, how often has your
medical office had problems exchanging accurate,
complete, and timely information with:
B1
1. Outside labs/imaging centers?
B2
2. Other medical offices/Outside physicians?
50%
B3
3. Pharmacies?
52%
B4
4. Hospitals?
B5
5. Other? (Specify)
55%
58%
70%
0%
20% 40%
60% 80% 100%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent
positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely”
(depending on the response category used for the item). The percent positive response for items B1 through B5 is
based on those who answered “Not in the past 12 months” or “Once or twice in the past 12 months.”
15
Chart 2. Item-Level Comparative Results from 470 Medical Offices, continued
Item Survey Items By Patient Safety Culture
Average % Positive Response
12. Work Pressure and Pace
C3R
1. In this office, we often feel rushed when
taking care of patients.
C6R
2. We have too many patients for the number
of providers in this office.
C11
3. We have enough staff to handle our patient
load.
C14R
4. This office has too many patients to be
able to handle everything effectively.
28%
46%
49%
59%
0%
20% 40%
60% 80% 100%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent
positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely”
(depending on the response category used for the item).
16
Chart 3. Comparative Results for Overall Ratings on Quality From 470 Medical Offices
Item Survey Items By Patient Safety Culture Area
Overall, how would you rate your medical office on
each of the following areas of health care quality?
G1a.
Patient Centered
100%
Is responsive to individual patient preferences,
needs, and values.
80%
60%
42%
40%
27%
25%
20%
5%
1%
Fair
Poor
4%
0%
Fair
Poor
0%
Excellent
G1b.
Effective
Very
Good
Good
100%
80%
Is based on scientific knowledge.
60%
46%
40%
25%
25%
20%
0%
Excellent
G1c.
Timely
Minimizes waits and potentially harmful
delays.
Very
Good
Good
35%
32%
100%
80%
60%
40%
15%
20%
15%
4%
0%
Excellent Very Good
G1d.
Efficient
Ensures cost-effective care (avoids waste,
overuse, and misuse of services).
Good
Fair
Poor
100%
80%
60%
39%
40%
33%
16%
20%
10%
2%
0%
Excellent Very Good
G1e.
Equitable
Provides the same quality of care to all
individuals regardless of gender, race,
ethnicity, socioeconomic status, language,
etc.
Good
Fair
Poor
3%
1%
Fair
Poor
100%
80%
52%
60%
31%
40%
14%
20%
0%
Excellent Very Good Good
Note: Some percentages add to more than 100 due to rounding.
17
Chart 4. Comparative Results for Overall Rating on Patient Safety From 470 Medical Offices
100
Percent
80
60
44
40
27
20
20
8
1
0
Excellent Very Good
Good
Fair
Poor
Comparative Results Using Percentiles
In addition to comparing percent positive scores from your medical office with the average
percent positive scores from other medical offices, you may find it useful to examine additional
comparative statistics: minimum and maximum scores and percentiles.
The minimum and maximum percent positive scores are presented for each composite. These
scores provide information about the range of percent positive scores from the pilot test medical
offices and are actual scores from the lowest and highest scoring offices. When comparing
against the minimum and maximum scores, keep in mind that these scores may represent offices
that are extreme outliers.
The 25th, 50th, and 75th percentile scores are displayed for the survey composites. Percentiles
provide information about the distribution of the medical office scores. To calculate percentile
scores, percent positive scores from the 470 medical offices were rank ordered from low to high.
A specific percentile score shows the percentage of medical offices that scored at or below a
particular score. For example, the 75th percentile is the percent positive score where 75 percent
of the medical offices scored the same or lower, and 25 percent of the medical offices scored
higher. Interpret the percentile scores as shown in Table 13.
Table 13. Interpretation of Percentile Scores
Percentile Score
25th percentile
Lower scoring medical offices
50th percentile
Middle-scoring medical offices
75th percentile
Higher scoring medical offices
Interpretation
25% of the medical offices scored the same or lower
75% of the medical offices scored higher
50% of the medical offices scored the same or lower
50% of the medical offices scored higher
75% of the medical offices scored the same or lower
25% of the medical offices scored higher
18
For example, for a survey composite in Table 14, the 25th percentile score is 49 percent positive,
and the 50th percentile score is 62 percent positive. If your medical office’s score on the
composite is 55 percent positive, it falls above the 25th percentile but below the 50th percentile,
meaning that your medical office scored higher than at least 25 percent of the other medical
offices. If your medical office’s score on the composite is 65 percent positive, it falls above the
50th percentile, meaning your medical office scored higher than at least 50 percent of the other
medical offices.
Table 14. Sample Percentile Statistics
Survey
Composite
Composite 1
Minimum
8%
Composite Percent Positive Response
25th
75th
Percentile 50th Percentile Percentile
49%
62%
85%
Maximum
96%
If your medical office’s score is 55%, your score falls here.
If your medical office’s score is 65%, your score falls here.
For each patient safety culture composite, Table 15 shows the average percent positive scores,
minimum score, 25th percentile, 50th percentile, 75th percentile, and maximum score for the 470
medical offices.
Table 15. Composite-Level Minimum, Maximum, and Percentile Results
% Positive Response
Patient Safety Culture Composites
1
Teamwork
2
3
4
5
6
7
8
9
10
11
12
Patient Care Tracking/Followup
Organizational Learning
Overall Perceptions of Patient
Safety and Quality
Staff Training
Owner/Managing
Partner/Leadership Support for
Patient Safety
Communication About Error
Communication Openness
Patient Safety and Quality Issues
Office Processes and
Standardization
Information Exchange With Other
Settings
Work Pressure and Pace
Average
%
Positive
82%
Min
25%
25th
%ile
75%
Median/
50th
%ile
84%
75th
%ile
92%
Max
100%
77%
74%
74%
31%
23%
18%
69%
67%
65%
78%
75%
75%
86%
84%
85%
100%
100%
100%
72%
67%
15%
15%
61%
56%
73%
68%
83%
79%
100%
100%
67%
65%
60%
59%
17%
21%
22%
13%
57%
54%
52%
47%
67%
64%
61%
60%
75%
77%
69%
71%
100%
100%
95%
100%
54%
8%
42%
54%
66%
100%
46%
0%
31%
46%
60%
95%
19
Table 16 shows the average percent positive scores, minimum score, 25th percentile, 50th
percentile, 75th percentile, and maximum score for the 470 medical offices on each survey item
sorted by patient safety culture composite.
Tables 17 and 18 show the average percent positive scores, minimum score, 25th percentile, 50th
percentile, 75th percentile, and maximum score for the overall ratings on quality and overall
ratings on patient safety, respectively.
Table 16. Item-Level Minimum, Maximum, and Percentile Results
Survey Items by Composite
Average
%
Positive
Min
% Positive Response
Median/
25th
50th
75th
%ile
%ile
%ile
Max
1. Teamwork
C1
1. When someone in this office gets
really busy, others help out.
C2
2. In this office, there is a good
working relationship between staff
and providers.
C5
3. In this office, we treat each other
with respect.
C13 4. This office emphasizes teamwork
in taking care of patients.
2. Patient Care Tracking/Followup
D3
1. This office reminds patients when
they need to schedule an
appointment for preventive or routine
care.
D5
2. This office documents how well
our chronic-care patients follow their
treatment plans.
D6
3. Our office follows up when we do
not receive a report we are
expecting from an outside provider.
D9
4. This office follows up with patients
who need monitoring.
3. Organizational Learning
F1
F5
F7
1. When there is a problem in our
office, we see if we need to change
the way we do things.
2. This office is good at changing
office processes to make sure the
same problems don’t happen again.
3. After this office makes changes to
improve the patient care process, we
check to see if the changes worked.
83%
25%
75%
85%
92%
100%
87%
20%
80%
90%
100%
100%
80%
0%
70%
82%
93%
100%
80%
17%
71%
82%
90%
100%
78%
18%
67%
80%
91%
100%
65%
17%
50%
67%
80%
100%
77%
18%
67%
80%
89%
100%
86%
40%
79%
88%
100%
100%
82%
20%
73%
82%
93%
100%
75%
8%
64%
75%
86%
100%
67%
11%
57%
68%
80%
100%
20
Table 16. Item-Level Minimum, Maximum, and Percentile Results, continued
Average
Survey Items by Composite
% Positive
4. Overall Perceptions of Patient Safety and Quality
F2
1. Our office processes are good at
79%
preventing mistakes that could affect
patients.
F3R 2. Mistakes happen more than they
70%
should in this office.
F4R 3. It is just by chance that we don’t
74%
make more mistakes that affect our
patients.
F6R 4. In this office, getting more work
73%
done is more important than quality
of care.
Min
% Positive Response
Median/
25th
50th
75th
%ile
%ile
%ile
Max
11%
69%
81%
90%
100%
11%
60%
71%
83%
100%
11%
64%
76%
88%
100%
17%
60%
75%
87%
100%
75%
13%
64%
78%
88%
100%
71%
17%
60%
72%
85%
100%
69%
14%
57%
70%
80%
100%
6. Owner/Managing Partner/Leadership Support for Patient Safety
E1R 1. They aren’t investing enough
51%
0%
resources to improve the quality of
care in this office.
33%
50%
67%
100%
E2R
2. They overlook patient care
mistakes that happen over and over.
79%
0%
71%
80%
92%
100%
E3
3. They place a high priority on
improving patient care processes.
78%
0%
70%
80%
90%
100%
4. They make decisions too often
based on what is best for the office
rather than what is best for patients.
7. Communication About Error
61%
0%
47%
60%
75%
100%
D7
R
1. Staff feel like their mistakes are
held against them.
57%
0%
41%
57%
71%
100%
D8
2. Providers and staff talk openly
about office problems.
59%
0%
46%
57%
71%
100%
D11
3. In this office, we discuss ways to
prevent errors from happening
again.
4. Staff are willing to report mistakes
they observe in this office.
78%
17%
69%
80%
89%
100%
5. Staff Training
C4
1. This office trains staff when new
processes are put into place.
C7
2. This office makes sure staff get
the on-the-job training they need.
C10 3. Staff in this office are asked to do
R
tasks they haven’t been trained to
do.
E4R
D12
72%
21
17%
63%
72%
82%
100%
Table 16. Item-Level Minimum, Maximum, and Percentile Results, continued
Survey Items by Composite
8. Communication Openness
D1
1. Providers in this office are open to
staff ideas about how to improve
office processes.
D2
2. Staff are encouraged to express
alternative viewpoints in this office.
D4
3. Staff are afraid to ask questions
R
when something does not seem
right.
D10 4. It is difficult to voice disagreement
R
in this office.
9. Patient Safety and Quality Issues
Access to Care
A1
1. A patient was unable to get an
appointment within 48 hours for an
acute/serious problem.
Patient Identification
A2
2. The wrong chart/medical record
was used for a patient.
Charts/Medical Records
A3
3. A patient's chart/medical record
was not available when needed.
A4
4. Medical information was filed,
scanned, or entered into the wrong
patient's chart/medical record.
Medical Equipment
A5
5. Medical equipment was not
working properly or was in need of
repair or replacement.
Medication
A6
6. A pharmacy contacted our office
to clarify or correct a prescription.
A7
7. A patient's medication list was not
updated during his or her visit.
Diagnostics and Tests
A8
8. The results from a lab or imaging
test were not available when
needed.
A9
9. A critical abnormal result from a
lab or imaging test was not followed
up within 1 business day.
Average
%
Positive
Min
% Positive Response
Median/
25th
50th
75th
%ile
%ile
%ile
Max
69%
13%
57%
70%
82%
100%
68%
0%
55%
68%
80%
100%
70%
20%
59%
71%
83%
100%
53%
0%
40%
50%
67%
100%
69%
0%
53%
75%
88%
100%
86%
14%
78%
89%
100%
100%
63%
0%
43%
70%
87%
100%
70%
10%
55%
71%
86%
100%
73%
14%
60%
73%
88%
100%
22%
0%
9%
18%
30%
100%
44%
0%
27%
43%
60%
100%
39%
0%
25%
38%
51%
100%
79%
17%
67%
82%
96%
100%
Note: For the A items (Patient Safety and Quality Issues), the percent positive response is based on those who
answered “Not in the past 12 months” or “Once or twice in the past 12 months.”
22
Table 16. Item-level Minimum, Maximum and Percentile Results, continued
% Positive Response
Median/
25th
50th
75th
%ile
%ile
%ile
Average
Survey Items by Composite
% Positive
Min
Max
10. Office Processes and Standardization
C8
1. This office is more
58%
0%
43%
59%
72%
100%
R
disorganized than it should be.
C9
2. We have good procedures for
60%
0%
45%
60%
72%
100%
checking that work in this office
was done correctly.
C12 3. We have problems with
47%
0%
31%
44%
62%
100%
R
workflow in this office.
C15 4. Staff in this office follow
74%
20%
63%
75%
86%
100%
standardized processes to get
tasks done.
11. Information Exchange With Other Settings
Over the past 12 months, how often has your medical office had problems exchanging accurate,
complete, and timely information with:
B1
1. Outside labs/imaging centers?
55%
0%
40%
56%
67%
100%
B2
2. Other medical offices/outside
50%
0%
38%
50%
63%
100%
physicians?
B3
3. Pharmacies?
52%
0%
39%
50%
69%
100%
B4
4. Hospitals?
58%
0%
45%
59%
72%
100%
B5
5. Other? (Specify)
70%
0%
50%
67%
100%
100%
12. Work Pressure and Pace
C3
1. In this office, we often feel
R
rushed when taking care of
patients.
C6
R
C11
C14
R
2. We have too many patients for
the number of providers in this
office.
3. We have enough staff to
handle our patient load.
4. This office has too many
patients to be able to handle
everything effectively.
28%
0%
15%
25%
40%
100%
46%
0%
25%
44%
67%
100%
49%
0%
29%
47%
67%
100%
59%
0%
43%
59%
78%
100%
23
Table 17. Overall Rating on Quality Minimum, Maximum, and Percentile Results
% Positive Response
Median/
25th
50th
75th
%ile
%ile
%ile
Survey Items by Composite
Average %
Min
Max
G1a. Patient Centered
Is responsive to individual patient preferences, needs, and values.
Excellent
25%
0%
13%
22% 33% 100%
Very Good
42%
0%
33%
42% 50%
89%
Good
27%
0%
17%
27% 38%
71%
Fair
5%
0%
0%
2%
8%
38%
Poor
1%
0%
0%
0%
0%
13%
G1b. Effective
Is based on scientific knowledge.
Excellent
25%
0%
13%
22% 33% 100%
Very Good
46%
0%
36%
45% 55% 100%
Good
25%
0%
14%
25% 35%
86%
Fair
4%
0%
0%
0%
6%
29%
Poor
0%
0%
0%
0%
0%
29%
G1c. Timely
Minimizes waits and potentially harmful delays.
Excellent
15%
0%
5%
11% 20%
86%
Very Good
35%
0%
22%
33% 44%
83%
Good
32%
0%
22%
33% 41%
75%
Fair
15%
0%
5%
13% 22%
75%
Poor
4%
0%
0%
0%
6%
80%
G1d. Efficient
Ensures cost-effective care (avoids waste, overuse, and misuse of services).
Excellent
16%
0%
6%
14% 22% 100%
Very Good
39%
0%
27%
38% 50% 100%
Good
33%
0%
23%
33% 43%
83%
Fair
10%
0%
0%
9% 15%
38%
Poor
2%
0%
0%
0%
3%
32%
G1e. Equitable
Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socioeconomic
status, language, etc.
Excellent
52%
0%
39%
50% 63% 100%
Very Good
31%
0%
21%
31% 40%
80%
Good
14%
0%
5%
13% 20%
50%
Fair
3%
0%
0%
0%
6%
33%
Poor
1%
0%
0%
0%
0%
20%
24
Table 18. Overall Rating on Patient Safety Minimum, Maximum, and Percentile Results
G2a. Overall Rating on Patient Safety
Excellent
Very Good
Good
Fair
Poor
Average %
20%
44%
27%
8%
1%
Min
0%
0%
0%
0%
0%
% Positive Response
Median/
25th
50th
75th
%ile
%ile
%ile
10%
17%
27%
33%
43%
54%
18%
27%
37%
0%
6%
13%
0%
0%
0%
Max
80%
88%
88%
47%
40%
Composite-Level and Item-Level Results by Staff Position
Tables 19 through 22 show the average percent positive scores for the survey composites and
items across medical offices, broken down by staff position. These tables allow comparison of
the survey results of various staff positions in the medical office. In the following four tables, the
precise number of medical offices and respondents corresponding to each data cell varies, due to
omission of survey items by some medical offices, individual nonresponse, and missing data.
Table 19. Composite-Level Results by Staff Position
Staff Position
Patient Safety Culture Composites
# Medical Offices
# Respondents
1.
Teamwork
2.
Patient Care Tracking/Followup
3.
Organizational Learning
4.
Overall Perceptions of Patient
Safety and Quality
5.
Staff Training
6.
7.
8.
9.
10.
11.
12.
Owner/Managing Partner/
Leadership Support for Patient
Safety
Communication About Error
Communication Openness
Patient Safety and Quality Issues
Office Processes and
Standardization
Information Exchange With Other
Settings
Work Pressure and Pace
PA, NP,
Admin
Physician CNS, N,
or
(M.D. or
Midwife,
Clerical
D.O.)
APN
Mgmt
Staff
127
12
24
222
1,251
61
159
2,265
87%
82%
87%
75%
62%
78%
72%
80%
75%
54%
85%
70%
70%
57%
77%
67%
RN/
LVN/
LPN
125
1,132
79%
74%
69%
70%
Other
Clinical
Staff or
Clinical
Support
Staff
157
1,557
78%
80%
72%
70%
77%
66%
77%
63%
67%
65%
66%
61%
68%
65%
61%
64%
71%
76%
54%
54%
60%
68%
55%
49%
67%
64%
55%
58%
57%
53%
58%
55%
62%
54%
58%
53%
61%
55%
60%
57%
43%
36%
36%
53%
56%
58%
45%
38%
40%
40%
33%
41%
Note: Respondents who selected “Other” and missing are not shown; results are not calculated when a staff position
has fewer than five respondents or an item in the composite has fewer than three respondents.
25
Table 20. Item-Level Results by Staff Position
Staff Position
Survey Items by Composite
# Medical Offices
# Respondents
1. Teamwork
C1
1. When someone in this office
gets really busy, others help out.
C2
2. In this office, there is a good
working relationship between
staff and providers.
C5
3. In this office, we treat each
other with respect.
C13 4. This office emphasizes
teamwork in taking care of
patients.
2. Patient Care Tracking/Followup
D3
1. This office reminds patients
when they need to schedule an
appointment for preventive or
routine care.
D5
2. This office documents how well
our chronic-care patients follow
their treatment plans.
D6
3. Our office follows up when we
do not receive a report we are
expecting from an outside
provider.
D9
4. This office follows up with
patients who need monitoring.
3. Organizational Learning
F1
1. When there is a problem in our
office, we see if we need to
change the way we do things.
F5
2. This office is good at changing
office processes to make sure the
same problems don’t happen
again.
F7
3. After this office makes
changes to improve the patient
care process, we check to see if
the changes worked.
PA, NP,
Physician CNS, N,
Admin or
(M.D. or
Midwife,
Clerical
D.O.)
APN
Mgmt
Staff
127
12
24
222
1,251
61
159
2,265
Other
Clinical
Staff or
RN/
Clinical
LVN/
Support
LPN
Staff
125
157
1,132
1,557
86%
81%
90%
77%
79%
77%
91%
87%
89%
80%
87%
85%
92%
85%
82%
70%
76%
73%
80%
76%
86%
75%
75%
76%
64%
71%
66%
81%
78%
83%
50%
68%
65%
75%
59%
73%
56%
76%
79%
81%
76%
81%
78%
94%
82%
85%
82%
85%
88%
65%
90%
73%
78%
76%
70%
52%
85%
69%
66%
73%
66%
47%
79%
66%
64%
67%
Note: Respondents who selected “Other” and missing are not shown; R indicates a negatively worded item; and
results are not calculated when a staff position has fewer than five respondents or an item has fewer than three
respondents.
26
Table 20. Item-Level Results by Staff Position, continued
Staff Position
PA, NP,
Physician CNS, N,
Admin or
(M.D. or
Midwife,
Clerical
Survey Items by Composite
D.O.)
APN
Mgmt
Staff
4. Overall Perceptions of Patient Safety and Quality
F2
1. Our office processes are good
73%
58%
78%
73%
at preventing mistakes that could
affect patients.
F3R 2. Mistakes happen more than
63%
60%
74%
60%
they should in this office.
F4R 3. It is just by chance that we
73%
57%
74%
65%
don’t make more mistakes that
affect our patients.
F6R 4. In this office, getting more work
68%
53%
82%
69%
done is more important than
quality of care.
5. Staff Training
C4
1. This office trains staff when
83%
66%
80%
66%
new processes are put into place.
C7
2. This office makes sure staff get
75%
63%
77%
66%
the on-the-job training they need.
C10R 3. Staff in this office are asked to
73%
68%
74%
57%
do tasks they haven’t been
trained to do.
6. Owner/Managing Partner/Leadership Support for Patient Safety
E1R 1. They aren’t investing enough
48%
47%
45%
49%
resources to improve the quality
of care in this office.
E2R 2. They overlook patient care
82%
83%
76%
75%
mistakes that happen over and
over.
E3
3. They place a high priority on
78%
73%
85%
79%
improving patient care processes.
E4R 4. They make decisions too often
59%
40%
63%
59%
based on what is best for the
office rather than what is best for
patients.
7. Communication About Error
D7R 1. Staff feel like their mistakes are
65%
42%
51%
45%
held against them.
D8
2. Providers and staff talk openly
69%
58%
61%
45%
about office problems.
D11 3. In this office, we discuss ways
77%
73%
87%
72%
to prevent errors from happening
again.
D12 4. Staff are willing to report
71%
68%
68%
65%
mistakes they observe in this
office.
27
RN/
LVN/
LPN
Other
Clinical
Staff or
Clinical
Support
Staff
77%
77%
72%
68%
72%
70%
58%
64%
69%
70%
66%
65%
66%
62%
41%
47%
77%
73%
75%
79%
51%
56%
51%
47%
50%
50%
77%
78%
69%
68%
Table 20. Item-Level Results by Staff Position, continued
Staff Position
Survey Items by Composite
8. Communication Openness
D1
1. Providers in this office are
open to staff ideas about how to
improve office processes.
D2
2. Staff are encouraged to
express alternative viewpoints in
this office.
D4R
3. Staff are afraid to ask
questions when something does
not seem right.
D10R 4. It is difficult to voice
disagreement in this office.
9. Patient Safety and Quality Issues
Access to Care
A1
1. A patient was unable to get
an appointment within 48 hours
for an acute/serious problem.
Patient Identification
A2
2. The wrong chart/medical
record was used for a patient.
Charts/Medical Records
A3
3. A patient's chart/medical
record was not available when
needed.
A4
4. Medical information was filed,
scanned, or entered into the
wrong patient's chart/medical
record.
Medical Equipment
A5
5. Medical equipment was not
working properly or was in need
of repair or replacement.
Medication
A6
6. A pharmacy contacted our
office to clarify or correct a
prescription.
A7
7. A patient's medication list was
not updated during his or her
visit.
Physician
(M.D. or
D.O.)
PA, NP,
CNS, N,
Midwife,
APN
Mgmt
Admin or
Clerical
Staff
RN/
LVN/
LPN
Other
Clinical
Staff or
Clinical
Support
Staff
83%
80%
60%
53%
55%
58%
77%
73%
77%
56%
55%
56%
71%
64%
66%
62%
64%
65%
72%
50%
53%
41%
42%
41%
65%
42%
55%
65%
63%
67%
84%
83%
84%
82%
85%
85%
59%
50%
55%
59%
62%
61%
64%
58%
63%
69%
72%
76%
64%
66%
69%
71%
62%
67%
22%
29%
15%
14%
22%
19%
30%
34%
35%
45%
41%
47%
Note: For the A items (Patient Safety and Quality Issues), the percent positive response is based on those who
answered “Not in the past 12 months” or “Once or twice in the past 12 months.”
28
Table 20. Item-Level Results by Staff Position, continued
Staff Position
Physician
(M.D. or
D.O.)
PA, NP,
CNS, N,
Midwife,
APN
Admin
or
Clerical
Staff
RN/
LVN/
LPN
Survey Items by Composite
Mgmt
Diagnostics and Tests
A8
8. The results from a lab or
32%
42%
42%
44%
37%
imaging test were not available
when needed.
A9
9. A critical abnormal result from
71%
69%
81%
68%
80%
a lab or imaging test was not
followed up within 1 business
day.
10. Office Processes and Standardization
C8R
1. This office is more
54%
51%
60%
53%
52%
disorganized than it should be.
C9
2. We have good procedures for
56%
51%
60%
56%
51%
checking that work in this office
was done correctly.
C12R
3. We have problems with
37%
35%
42%
44%
40%
workflow in this office.
C15
4. Staff in this office follow
71%
59%
71%
70%
70%
standardized processes to get
tasks done.
11. Information Exchange With Other Settings
Over the past 12 months, how often has your medical office had problems exchanging accurate,
complete, and timely information with:
B1
1. Outside labs/imaging
43%
37%
41%
55%
57%
centers?
B2
2. Other medical offices/outside
34%
38%
35%
53%
52%
physicians?
B3
3. Pharmacies?
50%
46%
42%
42%
55%
B4
4. Hospitals?
45%
36%
41%
59%
62%
B5
5. Other? (Specify)
77%
73%
81%
12. Work Pressure and Pace
C3R
1. In this office, we often feel
19%
11%
20%
26%
19%
rushed when taking care of
patients.
C6R
2. We have too many patients
48%
37%
40%
38%
31%
for the number of providers in
this office.
C11
3. We have enough staff to
52%
47%
44%
42%
36%
handle our patient load.
C14R
4. This office has too many
60%
56%
56%
52%
44%
patients to be able to handle
everything effectively.
29
Other
Clinical
Staff or
Clinical
Support
Staff
45%
80%
55%
58%
43%
72%
60%
56%
56%
63%
74%
28%
38%
45%
53%
Table 21. Overall Rating on Quality Results by Staff Position
Staff Position
Physician
(M.D. or
D.O.)
127
1,251
PA, NP,
CNS, N,
Midwife,
APN
12
61
Admin
or
Clerical
Mgmt
Staff
24
222
159
2,265
Other
Clinical
Staff or
RN/
Clinical
LVN/
Support
LPN
Staff
125
157
1,132
1,557
Survey Items by Composite
# Medical Offices
# Respondents
G1a. Patient Centered
Is responsive to individual patient preferences, needs, and values.
Excellent
23%
7%
18%
18%
18%
21%
Very Good
43%
51%
48%
38%
43%
37%
Good
25%
34%
28%
34%
32%
35%
Fair
8%
8%
6%
9%
6%
6%
Poor
1%
0%
0%
1%
1%
0%
G1b. Effective
Is based on scientific knowledge.
Excellent
30%
12%
19%
18%
20%
20%
Very Good
47%
52%
55%
41%
47%
43%
Good
20%
30%
24%
35%
27%
32%
Fair
2%
5%
2%
6%
5%
5%
Poor
0%
2%
0%
1%
0%
0%
G1c. Timely
Minimizes waits and potentially harmful delays.
Excellent
14%
5%
9%
10%
8%
10%
Very Good
34%
33%
37%
29%
35%
33%
Good
31%
35%
37%
35%
34%
34%
Fair
17%
24%
14%
19%
18%
18%
Poor
4%
2%
3%
7%
6%
5%
G1d. Efficient
Ensures cost-effective care (avoids waste, overuse, and misuse of services).
Excellent
13%
12%
9%
13%
9%
13%
Very Good
36%
29%
41%
33%
38%
34%
Good
35%
40%
38%
38%
37%
37%
Fair
13%
13%
10%
13%
13%
12%
Poor
3%
6%
2%
3%
3%
4%
G1e. Equitable
Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socioeconomic
status, language, etc.
Excellent
55%
48%
51%
41%
43%
46%
Very Good
32%
34%
33%
33%
37%
30%
Good
11%
15%
12%
20%
17%
19%
Fair
2%
2%
3%
5%
3%
4%
Poor
0%
2%
1%
2%
1%
2%
Note: Respondents who selected “Other” and missing are not shown; results are not calculated when a staff position
has fewer than five respondents or an item has fewer than three respondents. Percentages for each position may not
add to 100 due to rounding.
30
Table 22. Overall Rating on Patient Safety Results by Staff Position
Staff Position
G2a. Overall Rating on Patient Safety
# Medical Offices
# Respondents
Excellent
Very Good
Good
Fair
Poor
Physician
(M.D. or
D.O.)
127
1,251
16%
42%
31%
9%
1%
PA, NP,
CNS, N,
Midwife,
APN
12
61
14%
34%
34%
10%
8%
Mgmt
24
159
14%
52%
26%
7%
0%
Admin
or
Clerical
Staff
222
2,265
17%
41%
31%
10%
1%
RN/
LVN/
LPN
125
1,132
16%
44%
30%
9%
1%
Other
Clinical
Staff or
Clinical
Support
Staff
157
1,557
19%
41%
31%
8%
1%
Note: Respondents who selected “Other” and missing are not shown; results are not calculated when a staff position
has fewer than five respondents or an item has fewer than three respondents. Percentages for each position may not
add to 100 due to rounding.
31
To Err Is Human: Building a Safer Health System (Free Executive Summary)
http://www.nap.edu/catalog/9728.html
Free Executive Summary
To Err Is Human: Building a Safer Health System
Linda T. Kohn, Janet M. Corrigan, and Molla S.
Donaldson, Editors; Committee on Quality of Health
Care in America, Institute of Medicine
ISBN: 978-0-309-06837-6, 312 pages, 6 x 9, hardback (2000)
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As many as 98,000 people die each year from medical errors that occur in hospitals.
That's more than die from motor vehicle accidents, breast cancer and AIDS--making
medical errors the fifth leading cause of death in this country. The Institute of Medicine
now spearheads an initiative to improve the quality of care in America by focusing on the
facts and making wide-ranging recommendations. Central to the ideas proposed by the
IOM is the notion that skilled and caring professionals can--and do--make mistakes
because, after all, to err is human. This is why it is vital that we put this issue at the top of
our national agenda and seek ways to reduce these errors through the design of a safer
health system.
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Executive
Summary
T
he knowledgeable health reporter for the Boston Globe, Betsy
Lehman, died from an overdose during chemotherapy. Willie King
had the wrong leg amputated. Ben Kolb was eight years old when he
died during “minor” surgery due to a drug mix-up.1
These horrific cases that make the headlines are just the tip of the iceberg. Two large studies, one conducted in Colorado and Utah and the other
in New York, found that adverse events occurred in 2.9 and 3.7 percent of
hospitalizations, respectively.2 In Colorado and Utah hospitals, 6.6 percent
of adverse events led to death, as compared with 13.6 percent in New York
hospitals. In both of these studies, over half of these adverse events resulted
from medical errors and could have been prevented.
When extrapolated to the over 33.6 million admissions to U.S. hospitals
in 1997, the results of the study in Colorado and Utah imply that at least
44,000 Americans die each year as a result of medical errors.3 The results of
the New York Study suggest the number may be as high as 98,000.4 Even
when using the lower estimate, deaths due to medical errors exceed the
number attributable to the 8th-leading cause of death.5 More people die in
a given year as a result of medical errors than from motor vehicle accidents
(43,458), breast cancer (42,297), or AIDS (16,516).6
Total national costs (lost income, lost household production, disability
and health care costs) of preventable adverse events (medical errors result1
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TO ERR IS HUMAN
ing in injury) are estimated to be between $17 billion and $29 billion, of
which health care costs represent over one-half.7
In terms of lives lost, patient safety is as important an issue as worker
safety. Every year, over 6,000 Americans die from workplace injuries.8 Medication errors alone, occurring either in or out of the hospital, are estimated
to account for over 7,000 deaths annually.9
Medication-related errors occur frequently in hospitals and although
not all result in actual harm, those that do, are costly. One recent study
conducted at two prestigious teaching hospitals, found that about two out
of every 100 admissions experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,700 per admission or about
$2.8 million annually for a 700-bed teaching hospital.10 If these findings are
generalizable, the increased hospital costs alone of preventable adverse drug
events affecting inpatients are about $2 billion for the nation as a whole.
These figures offer only a very modest estimate of the magnitude of the
problem since hospital patients represent only a small proportion of the
total population at risk, and direct hospital costs are only a fraction of total
costs. More care and increasingly complex care is provided in ambulatory
settings. Outpatient surgical centers, physician offices and clinics serve thousands of patients daily. Home care requires patients and their families to use
complicated equipment and perform follow-up care. Retail pharmacies play
a major role in filling prescriptions for patients and educating them about
their use. Other institutional settings, such as nursing homes, provide a broad
array of services to vulnerable populations. Although many of the available
studies have focused on the hospital setting, medical errors present a problem in any setting, not just hospitals.
Errors are also costly in terms of opportunity costs. Dollars spent on
having to repeat diagnostic tests or counteract adverse drug events are dollars unavailable for other purposes. Purchasers and patients pay for errors
when insurance costs and copayments are inflated by services that would
not have been necessary had proper care been provided. It is impossible for
the nation to achieve the greatest value possible from the billions of dollars
spent on medical care if the care contains errors.
But not all the costs can be directly measured. Errors are also costly in
terms of loss of trust in the system by patients and diminished satisfaction by
both patients and health professionals. Patients who experience a longer
hospital stay or disability as a result of errors pay with physical and psychological discomfort. Health care professionals pay with loss of morale and
frustration at not being able to provide the best care possible. Employers
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EXECUTIVE SUMMARY
3
and society, in general, pay in terms of lost worker productivity, reduced
school attendance by children, and lower levels of population health status.
Yet silence surrounds this issue. For the most part, consumers believe
they are protected. Media coverage has been limited to reporting of anecdotal cases. Licensure and accreditation confer, in the eyes of the public, a
“Good Housekeeping Seal of Approval.” Yet, licensing and accreditation
processes have focused only limited attention on the issue, and even these
minimal efforts have confronted some resistance from health care organizations and providers. Providers also perceive the medical liability system as a
serious impediment to systematic efforts to uncover and learn from errors.11
The decentralized and fragmented nature of the health care delivery
system (some would say “nonsystem”) also contributes to unsafe conditions
for patients, and serves as an impediment to efforts to improve safety. Even
within hospitals and large medical groups, there are rigidly-defined areas of
specialization and influence. For example, when patients see multiple providers in different settings, none of whom have access to complete information, it is easier for something to go wrong than when care is better coordinated. At the same time, the provision of care to patients by a collection of
loosely affiliated organizations and providers makes it difficult to implement
improved clinical information systems capable of providing timely access to
complete patient information. Unsafe care is one of the prices we pay for not
having organized systems of care with clear lines of accountability.
Lastly, the context in which health care is purchased further exacerbates
these problems. Group purchasers have made few demands for improvements in safety.12 Most third party payment systems provide little incentive
for a health care organization to improve safety, nor do they recognize and
reward safety or quality.
The goal of this report is to break this cycle of inaction. The status quo is
not acceptable and cannot be tolerated any longer. Despite the cost pressures, liability constraints, resistance to change and other seemingly insurmountable barriers, it is simply not acceptable for patients to be harmed by
the same health care system that is supposed to offer healing and comfort.
“First do no harm” is an often quoted term from Hippocrates.13 Everyone
working in health care is familiar with the term. At a very minimum, the
health system needs to offer that assurance and security to the public.
A comprehensive approach to improving patient safety is needed. This
approach cannot focus on a single solution since there is no “magic bullet”
that will solve this problem, and indeed, no single recommendation in this
report should be considered as the answer. Rather, large, complex problems
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TO ERR IS HUMAN
require thoughtful, multifaceted responses. The combined goal of the recommendations is for the external environment to create sufficient pressure
to make errors costly to health care organizations and providers, so they are
compelled to take action to improve safety. At the same time, there is a need
to enhance knowledge and tools to improve safety and break down legal and
cultural barriers that impede safety improvement. Given current knowledge
about the magnitude of the problem, the committee believes it would be
irresponsible to expect anything less than a 50 percent reduction in errors
over five years.
In this report, safety is defined as freedom from accidental injury. This
definition recognizes that this is the primary safety goal from the patient’s
perspective. Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. According
to noted expert James Reason, errors depend on two kinds of failures: either
the correct action does not proceed as intended (an error of execution) or
the original intended action is not correct (an error of planning).14 Errors
can happen in all stages in the process of care, from diagnosis, to treatment,
to preventive care.
Not all errors result in harm. Errors that do result in injury are sometimes called preventable adverse events. An adverse event is an injury resulting from a medical intervention, or in other words, it is not due to the underlying condition of the patient. While all adverse events result from medical
management, not all are preventable (i.e., not all are attributable to errors).
For example, if a patient has surgery and dies from pneumonia he or she got
postoperatively, it is an adverse event. If analysis of the case reveals that the
patient got pneumonia because of poor hand washing or instrument cleaning techniques by staff, the adverse event was preventable (attributable to an
error of execution). But the analysis may conclude that no error occurred
and the patient would be presumed to have had a difficult surgery and recovery (not a preventable adverse event).
Much can be learned from the analysis of errors. All adverse events
resulting in serious injury or death should be evaluated to assess whether
improvements in the delivery system can be made to reduce the likelihood
of similar events occurring in the future. Errors that do not result in harm
also represent an important opportunity to identify system improvements
having the potential to prevent adverse events. Preventing errors means designing the health care system at all levels to make it safer. Building safety
into processes of care is a more effective way to reduce errors than blaming
individuals (some experts, such as Deming, believe improving processes is
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EXECUTIVE SUMMARY
5
the only way to improve quality15 ). The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing
safety into the system. This does not mean that individuals can be careless.
People must still be vigilant and held responsible for their actions. But when
an error occurs, blaming an individual does little to make the system safer
and prevent someone else from committing the same error.
Health care is a decade or more behind other high-risk industries in its
attention to ensuring basic safety. Aviation has focused extensively on building safe systems and has been doing so since World War II. Between 1990
and 1994, the U.S. airline fatality rate was less than one-third the rate experienced in mid century.16 In 1998, there were no deaths in the United States in
commercial aviation. In health care, preventable injuries from care have been
estimated to affect between three to four percent of hospital patients.17 Although health care may never achieve aviation’s impressive record, there is
clearly room for improvement.
To err is human, but errors can be prevented. Safety is a critical first step
in improving quality of care. The Harvard Medical Practice Study, a seminal
research study on this issue, was published almost ten years ago; other studies have corroborated its findings. Yet few tangible actions to improve patient safety can be found. Must we wait another decade to be safe in our
health system?
RECOMMENDATIONS
The IOM Quality of Health Care in America Committee was formed in
June 1998 to develop a strategy that will result in a threshold improvement
in quality over the next ten years. This report addresses issues related to
patient safety, a subset of overall quality-related concerns, and lays out a
national agenda for reducing errors in health care and improving patient
safety. Although it is a national agenda, many activities are aimed at prompting responses at the state and local levels and within health care organizations and professional groups.
The committee believes that although there is still much to learn about
the types of errors committed in health care and why they occur, enough is
known today to recognize that a serious concern exists for patients. Whether
a person is sick or just trying to stay healthy, they should not have to worry
about being harmed by the health system itself. This report is a call to action
to make health care safer for patients.
The committee believes that a major force for improving patient safety
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6
TO ERR IS HUMAN
is the intrinsic motivation of health care providers, shaped by professional
ethics, norms and expectations. But the interaction between factors in the
external environment and factors inside health care organizations can also
prompt the changes needed to improve patient safety. Factors in the external environment include availability of knowledge and tools to improve
safety, strong and visible professional leadership, legislative and regulatory
initiatives, and actions of purchasers and consumers to demand safety improvements. Factors inside health care organizations include strong leadership for safety, an organizational culture that encourages recognition and
learning from errors, and an effective patient safety program.
In developing its recommendations, the committee seeks to strike a balance between regulatory and market-based initiatives, and between the roles
of professionals and organizations. No single action represents a complete
answer, nor can any single group or sector offer a complete fix to the problem. However, different groups can, and should, make significant contributions to the solution. The committee recognizes that a number of groups are
already working on improving patient safety, such as the National Patient
Safety Foundation and the Anesthesia Patient Safety Foundation.
The recommendations contained in this report lay out a four-tiered approach:
• establishing a national focus to create leadership, research, tools and
protocols to enhance the knowledge base about safety;
• identifying and learning from errors through immediate and strong
mandatory reporting efforts, as well as the encouragement of voluntary efforts, both with the aim of making sure the system continues to be made
safer for patients;
• raising standards and expectations for improvements in safety
through the actions of oversight organizations, group purchasers, and professional groups; and
• creating safety systems inside health care organizations through the
implementation of safe practices at the delivery level. This level is the ultimate target of all the recommendations.
Leadership and Knowledge
Other industries that have been successful in improving safety, such as
aviation and occupational health, have had the support of a designated
agency that sets and communicates priorities, monitors progress in achiev-
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EXECUTIVE SUMMARY
7
ing goals, directs resources toward areas of need, and brings visibility to
important issues. Although various agencies and organizations in health care
may contribute to certain of these activities, there is no focal point for raising and sustaining attention to patient safety. Without it, health care is unlikely to match the safety improvements achieved in other industries.
The growing awareness of the frequency and significance of errors in
health care creates an imperative to improve our understanding of the problem and devise workable solutions. For some types of errors, the knowledge
of how to prevent them exists today. In these areas, the need is for widespread dissemination of this information. For other areas, however, additional work is needed to develop and apply the knowledge that will make
care safer for patients. Resources invested in building the knowledge base
and diffusing the expertise throughout the industry can pay large dividends
to both patients and the health professionals caring for them and produce
savings for the health system.
RECOMMENDATION 4.1 Congress should create a Center for Patient Safety within the Agency for Healthcare Research and Quality.
This center should
• set the national goals for patient safety, track progress in meeting these goals, and issue an annual report to the President and Congress on patient safety; and
• develop knowledge and understanding of errors in health care
by developing a research agenda, funding Centers of Excellence, evaluating methods for identifying and preventing errors, and funding dissemination and communication activities to improve patient safety.
To make significant improvements in patient safety, a highly visible center is needed, with secure and adequate funding. The Center should establish goals for safety; develop a research agenda; define prototype safety systems; develop and disseminate tools for identifying and analyzing errors and
evaluate approaches taken; develop tools and methods for educating consumers about patient safety; issue an annual report on the state of patient
safety, and recommend additional improvements as needed.
The committee recommends initial annual funding for the Center of
$30 to $35 million. This initial funding would permit a center to conduct
activities in goal setting, tracking, research and dissemination. Funding
should grow over time to at least $100 million, or approximately 1% of the
$8.8 billion in health care costs attributable to preventable adverse events.18
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This initial level of funding is modest relative to the resources devoted to
other public health issues. The Center for Patient Safety should be created
within the Agency for Healthcare Research and Quality because the agency
is already involved in a broad range of quality and safety issues, and has
established the infrastructure and experience to fund research, educational
and coordinating activities.
Identifying and Learning from Errors
Another critical component of a comprehensive strategy to improve patient safety is to create an environment that encourages organizations to identify errors, evaluate causes and take appropriate actions to improve performance in the future. External reporting systems represent one mechanism to
enhance our understanding of errors and the underlying factors that contribute to them.
Reporting systems can be designed to meet two purposes. They can be
designed as part of a public system for holding health care organizations
accountable for performance. In this instance, reporting is often mandatory,
usually focuses on specific cases that involve serious harm or death, may
result in fines or penalties relative to the specific case, and information about
the event may become known to the public. Such systems ensure a response
to specific reports of serious injury, hold organizations and providers accountable for maintaining safety, respond to the public’s right to know, and
provide incentives to health care organizations to implement internal safety
systems that reduce the likelihood of such events occurring. Currently, at
least twenty states have mandatory adverse event reporting systems.
Voluntary, confidential reporting systems can also be part of an overall
program for improving patient safety and can be designed to complement
the mandatory reporting systems previously described. Voluntary reporting
systems, which generally focus on a much broader set of errors and strive to
detect system weaknesses before the occurrence of serious harm, can provide rich information to health care organizations in support of their quality
improvement efforts.
For either purpose, the goal of reporting systems is to analyze the information they gather and identify ways to prevent future errors from occurring. The goal is not data collection. Collecting reports and not doing anything with the information serves no useful purpose. Adequate resources
and other support must be provided for analysis and response to critical
issues.
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EXECUTIVE SUMMARY
RECOMMENDATION 5.1 A nationwide mandatory reporting system should be established that provides for the collection of standardized information by state governments about adverse events that result in death or serious harm. Reporting should initially be required
of hospitals and eventually be required of other institutional and ambulatory care delivery settings. Congress should
• designate the National Forum for Health Care Quality Measurement and Reporting as the entity responsible for promulgating
and maintaining a core set of reporting standards to be used by states,
including a nomenclature and taxonomy for reporting;
• require all health care organizations to report standardized information on a defined list of adverse events;
• provide funds and technical expertise for state governments to
establish or adapt their current error reporting systems to collect the
standardized information, analyze it and conduct follow-up action as
needed with health care organizations. Should a state choose not to
implement the mandatory reporting system, the Department of Health
and Human Services should be designated as the responsible entity;
and
• designate the Center for Patient Safety to:
(1) convene states to share information and expertise, and to
evaluate alternative approaches taken for implementing reporting
programs, identify best practices for implementation, and assess
the impact of state programs; and
(2) receive and analyze aggregate reports from states to identify
persistent safety issues that require more intensive analysis and/or
a broader-based response (e.g., designing prototype systems or
requesting a response by agencies, manufacturers or others).
RECOMMENDATION 5.2 The development of voluntary reporting efforts should be encouraged. The Center for Patient Safety should
• describe and disseminate information on external voluntary reporting programs to encourage greater participation in them and track
the development of new reporting systems as they form;
• convene sponsors and users of external reporting systems to
evaluate what works and what does not work well in the programs,
and ways to make them more effective;
• periodically assess whether additional efforts are needed to address gaps in information to improve patient safety and to encourage
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TO ERR IS HUMAN
health care organizations to participate in voluntary reporting programs; and
• fund and evaluate pilot projects for reporting systems, both
within individual health care organizations and collaborative efforts
among health care organizations.
The committee believes there is a role both for mandatory, public reporting systems and voluntary, confidential reporting systems. However, because of their distinct purposes, such systems should be operated and maintained separately. A nationwide mandatory reporting system should be
established by building upon the current patchwork of state systems and by
standardizing the types of adverse events and information to be reported.
The newly established National Forum for Health Care Quality Measurement and Reporting, a public/private partnership, should be charged with
the establishment of such standards. Voluntary reporting systems should
also be promoted and the participation of health care organizations in them
should be encouraged by accrediting bodies.
RECOMMENDATION 6.1 Congress should pass legislation to extend peer review protections to data related to patient safety and
quality improvement that are collected and analyzed by health care
organizations for internal use or shared with others solely for purposes of improving safety and quality.
The committee believes that information about the most serious adverse
events which result in harm to patients and which are subsequently found to
result from errors should not be protected from public disclosure. However,
the committee also recognizes that for events not falling under this category,
fears about the legal discoverability of information may undercut motivations to detect and analyze errors to improve safety. Unless such data are
assured protection, information about errors will continue to be hidden and
errors will be repeated. A more conducive environment is needed to encourage health care professionals and organizations to identify, analyze, and report errors without threat of litigation and without compromising patients’
legal rights.
Setting Performance Standards and
Expectations for Safety
Setting and enforcing explicit standards for safety through regulatory
and related mechanisms, such as licensing, certification, and accreditation,
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EXECUTIVE SUMMARY
11
can define minimum performance levels for health care organizations and
professionals. Additionally, the process of developing and adopting standards helps to form expectations for safety among providers and consumers.
However, standards and expectations are not only set through regulations.
The actions of purchasers and consumers affect the behaviors of health care
organizations, and the values and norms set by health professions influence
standards of practice, training and education for providers. Standards for
patient safety can be applied to health care professionals, the organizations
in which they work, and the tools (drugs and devices) they use to care for
patients.
RECOMMENDATION 7.1 Performance standards and expectations for health care organizations should focus greater attention on
patient safety.
• Regulators and accreditors should require health care organizations to implement meaningful patient safety programs with defined
executive responsibility.
• Public and private purchasers should provide incentives to
health care organizations to demonstrate continuous improvement in
patient safety.
Health care organizations are currently subject to compliance with licensing and accreditation standards. Although both devote some attention
to issues related to patient safety, there is opportunity to strengthen such
efforts. Regulators and accreditors have a role in encouraging and supporting actions in health care organizations by holding them accountable for
ensuring a safe environment for patients. After a reasonable period of time
for health care organizations to develop patient safety programs, regulators
and accreditors should require them as a minimum standard.
Purchaser and consumer demands also exert influence on health care
organizations. Public and private purchasers should consider safety issues in
their contracting decisions and reinforce the importance of patient safety by
providing relevant information to their employees or beneficiaries. Purchasers should also communicate concerns about patient safety to accrediting
bodies to support stronger oversight for patient safety.
RECOMMENDATION 7.2 Performance standards and expectations for health professionals should focus greater attention on patient safety.
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• Health professional licensing bodies should
(1) implement periodic re-examinations and re-licensing of doctors, nurses, and other key providers, based on both competence
and knowledge of safety practices; and
(2) work with certifying and credentialing organizations to develop more effective methods to identify unsafe providers and take
action.
• Professional societies should make a visible commitment to
patient safety by establishing a permanent committee dedicated to
safety improvement. This committee should
(1) develop a curriculum on patient safety and encourage its adoption into training and certification requirements;
(2) disseminate information on patient safety to members through
special sessions at annual conferences, journal articles and editorials, newsletters, publications and websites on a regular basis;
(3) recognize patient safety considerations in practice guidelines
and in standards related to the introduction and diffusion of new
technologies, therapies and drugs;
(4) work with the Center for Patient Safety to develop community-based, collaborative initiatives for error reporting and analysis
and implementation of patient safety improvements; and
(5) collaborate with other professional societies and disciplines in
a national summit on the professional’s role in patient safety.
Although unsafe practitioners are believed to be few in number, the
rapid identification of such practitioners and corrective action are important to a comprehensive safety program. Responsibilities for documenting
continuing skills are dispersed among licensing boards, specialty boards and
professional groups, and health care organizations with little communication or coordination. In their ongoing assessments, existing licensing, certification and accreditation processes for health professionals should place
greater attention on safety and performance skills.
Additionally, professional societies and groups should become active
leaders in encouraging and demanding improvements in patient safety. Setting standards, convening and communicating with members about safety,
incorporating attention to patient safety into training programs and collabo-
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EXECUTIVE SUMMARY
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rating across disciplines are all mechanisms that will contribute to creating a
culture of safety.
RECOMMENDATION 7.3 The Food and Drug Administration
(FDA) should increase attention to the safe use of drugs in both preand post-marketing processes through the following actions:
• develop and enforce standards for the design of drug packaging
and labeling that will maximize safety in use;
• require pharmaceutical companies to test (using FDA-approved
methods) proposed drug names to identify and remedy potential
sound-alike and look-alike confusion with existing drug names; and
• work with physicians, pharmacists, consumers, and others to
establish appropriate responses to problems identified through postmarketing surveillance, especially for concerns that are perceived to
require immediate response to protect the safety of patients.
The FDA’s role is to regulate manufacturers for the safety and effectiveness of their drugs and devices. However, even approved products can
present safety problems in practice. For example, different drugs with similar sounding names can create confusion for both patients and providers.
Attention to the safety of products in actual use should be increased during
approval processes and in post-marketing monitoring systems. The FDA
should also work with drug manufacturers, distributors, pharmacy benefit
managers, health plans and other organizations to assist clinicians in identifying and preventing problems in the use of drugs.
Implementing Safety Systems in Health Care
Organizations
Experience in other high-risk industries has provided well-understood illustrations that can be used to improve health care safety. However,
health care management and professionals have rarely provided specific,
clear, high-level, organization-wide incentives to apply what has been learned
in other industries about ways to prevent error and reduce harm within their
own organizations. Chief Executive Officers and Boards of Trustees should
be held accountable for making a serious, visible and on-going commitment
to creating safe systems of care.
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RECOMMENDATION 8.1 Health care organizations and the professionals affiliated with them should make continually improved patient safety a declared and serious aim by establishing patient safety
programs with defined executive responsibility. Patient safety programs should
• provide strong, clear and visible attention to safety;
• implement non-punitive systems for reporting and analyzing errors within their organizations;
• incorporate well-understood safety principles, such as standardizing and simplifying equipment, supplies, and processes; and
• establish interdisciplinary team training programs for providers
that incorporate proven methods of team training, such as simulation.
Health care organizations must develop a culture of safety such that
an organization’s care processes and workforce are focused on improving
the reliability and safety of care for patients. Safety should be an explicit
organizational goal that is demonstrated by the strong direction and involvement of governance, management and clinical leadership. In addition, a
meaningful patient safety program should include defined program objectives, personnel, and budget and should be monitored by regular progress
reports to governance.
RECOMMENDATION 8.2 Health care organizations should implement proven medication safety practices.
A number of practices have been shown to reduce errors in the medication process. Several professional and collaborative organizations interested in patient safety have developed and published recommendations for
safe medication practices, especially for hospitals. Although some of these
recommendations have been implemented, none have been universally
adopted and some are not yet implemented in a majority of hospitals. Safe
medication practices should be implemented in all hospitals and health care
organizations in which they are appropriate.
SUMMARY
This report lays out a comprehensive strategy for addressing a serious
problem in health care to which we are all vulnerable. By laying out a concise list of recommendations, the committee does not underestimate the
many barriers that must be overcome to accomplish this agenda. Significant
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15
changes are required to improve awareness of the problem by the public
and health professionals, to align payment systems and the liability system so
they encourage safety improvements, to develop training and education programs that emphasize the importance of safety and for chief executive officers and trustees of health care organizations to create a culture of safety and
demonstrate it in their daily decisions.
Although no single activity can offer the solution, the combination of
activities proposed offers a roadmap toward a safer health system. The proposed program should be evaluated after five years to assess progress in
making the health system safer. With adequate leadership, attention and resources, improvements can be made. It may be part of human nature to err,
but it is also part of human nature to create solutions, find better alternatives
and meet the challenges ahead.
REFERENCES
1. Cook, Richard; Woods, David; Miller, Charlotte, A Tale of Two Stories: Contrasting Views of Patient Safety. Chicago: National Patient Safety Foundation, 1998.
2. Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M., et al. Incidence of adverse
events and negligence in hospitalized patients: Results of the Harvard Medical Practice
Study I. N Engl J Med. 324:370–376, 1991. See also: Leape, Lucian L.; Brennan, Troyen
A.; Laird, Nan M., et al. The Nature of Adverse Events in Hospitalized Patients: Results
of the Harvard Medical Practice Study II. N Engl J Med. 324(6):377–384, 1991. See also:
Thomas, Eric J.; Studdert, David M.; Burstin, Helen R., et al. Incidence and Types of
Adverse Events and Negligent Care in Utah and Colorado. Med Care forthcoming Spring
2000.
3. American Hospital Association. Hospital Statistics. Chicago. 1999. See also:
Thomas, Eric J.; Studdert, David M.; Burstin, Helen R., et al. Incidence and Types of
Adverse Events and Negligent Care in Utah and Colorado. Med Care forthcoming Spring
2000. See also: Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of
Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999.
4. American Hospital Association. Hospital Statistics. Chicago. 1999. See also:
Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M., et al. Incidence of adverse events
and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I.
N Engl J Med. 324:370–376, 1991. See also: Leape, Lucian L.; Brennan, Troyen A.; Laird,
Nan M., et al. The Nature of Adverse Events in Hospitalized Patients: Results of the
Harvard Medical Practice Study II. N Engl J Med. 324(6):377–384, 1991.
5. Centers for Disease Control and Prevention (National Center for Health Statistics). Deaths: Final Data for 1997. National Vital Statistics Reports. 47(19):27, 1999.
6. Centers for Disease Control and Prevention (National Center for Health Statistics). Births and Deaths: Preliminary Data for 1998. National Vital Statistics Reports.
47(25):6, 1999.
7. Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999. See also: Johnson, W.G.;
Copyright National Academy of Sciences. All rights reserved.
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To Err Is Human: Building a Safer Health System
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TO ERR IS HUMAN
Brennan, Troyen A.; Newhouse, Joseph P., et al. The Economic Consequences of Medical Injuries. JAMA. 267:2487–2492, 1992.
8. Occupational Safety and Health Administration. The New OSHA: Reinventing
Worker Safety and Health [Web Page]. Dec. 16, 1998. Available at: www.osha.gov/
oshinfo/reinvent.html.
9. Phillips, David P.; Christenfeld, Nicholas; and Glynn, Laura M. Increase in US
Medication-Error Deaths between 1983 and 1993. The Lancet. 351:643–644, 1998.
10. Bates, David W.; Spell, Nathan; Cullen, David J., et al. The Costs of Adverse
Drug Events in Hospitalized Patients. JAMA. 277:307–311, 1997.
11. Leape, Lucian; Brennan, Troyen; Laird, Nan; et al., T...
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