NEW YORK, October 9, 1997 - More than 100 million Americans may have been touched by what they consider a medical mistake according to a nationwide poll conducted by Louis Harris & Associates, an independent survey research and consulting firm, and released today by the National Patient Safety Foundation (NPSF) at the AMA. Of those randomly surveyed, 42% said they have been involved in a situation where a medical mistake was made, either personally or through a friend or relative. The margin of error was less than 3% plus or minus. The report was released at a special briefing Finding Cures for Medical Error hosted by NPSF.

Topping the list of what respondents believed to be medical mistakes were misdiagnoses and wrong treatments, cited by 40% of those affected by a health care error. Other frequently cited mistakes were medication errors, mentioned by 28%, and mistakes during a medical procedure, cited by 22%. Causes cited by more than half the respondents affected were what they believed to be carelessness, improper training and poor communication.

"Patients and their families are among the first whose views on patient safety need to be incorporated in NPSF initiatives to reduce errors and that is why we commissioned this survey of the general public," said Nancy W. Dickey, M.D., president-elect of the American Medical Association (AMA) which launched the NPSF as an independent organization earlier this year. The NPSF sponsored the survey in partnership with the National Consumers League and Research!America.

Mary Woolley, M.A., president of Research!America presented the findings as part of a day of presentations by experts and leaders who are redefining how health care professionals understand and learn from medical errors. The briefing also focused on the complex systems in which providers and patients interact.

"Most errors result from faulty systems -- poorly designed processes that 'set people up' to make mistakes by putting them in situations where errors are more likely to be made", said Lucian Leape, M.D., of the Institute for Health Care Improvement at the Harvard School of Public Health and a founding board member of the NPSF.

Research cited by Dr. Leape at the briefing echoes the findings from the opinion poll. According to Dr. Leape, the number of injuries caused by medical errors in inpatient hospital settings nationwide could be as high as three million and could cost as much as $200 billion.

Richard Cook, M.D., assistant professor at the University of Chicago Department of Anesthesia and Critical Care, and David Woods, Ph.D., professor of industrial and system engineering at Ohio State University, both agree that understanding the system in which health care is delivered is a critical component of error prevention.

"An accident is a message from the underlying system. To be able to read that message, it is important to understand the systematic factors behind the behaviors commonly labeled human error," explained Dr. Cook, who, along with Dr. Woods presented at today's briefing.

Pointing toward potential solutions, the briefing reviewed improvements in reducing medical mistakes, including the dramatic advances that have been made in reducing anesthesia risk through the use of simulators.

"Just like anything else, it takes practice to know how to effectively deal with significant crises," said David Gaba, M.D. director of the laboratory on human performance in health care at V.A. Palo Alto Health Care System and Stanford University. "Other industries and the military know this and train their people with simulators. Medical professionals need to adopt this same approach and undertake more simulation training in order to eliminate errors or reduce the impact of errors."

Dr. Gaba, with his colleague Jeffrey Cooper, Ph.D., chair of the Anesthesia Patient Safety Foundation Scientific Evaluation Committee and associate professor of Anesthesia, Massachusetts General Hospital, spoke about the critical role simulators play in teaching physicians and other medical personnel crisis management skills and in reducing human error.

In the area of pharmacy, the issue of bar coding was discussed as a way to improve the tracking of medications delivered to patients in the hospital.

"I am amazed that we have not seen more bar-coding used in the hospital setting, particularly since it has been readily adopted by so many other industries. As consumers, for example, we see it every day in the supermarket," commented Charles Myers, M.S., assistant vice president of the American Society of Health-System Pharmacists.

The NPSF is an unprecedented initiative to improve health care safety by studying why errors in the health care system occur and implementing safeguards to prevent such failures from injuring patients. NPSF board members represent every major segment of the health care system, as well as employers, medical ethicists, public health advocates and distinguished scientific research institutions. Finding Cures for Medical Error was sponsored in part by an educational grant from Hoescht Marion Roussel.

With support from the Annenberg Center for Health Sciences the briefing will be made available by live audio simulcast via the World Wide Web.

For audio simulcast see: http://www.ama-assn.org/med-sci/npsf/live.htm
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