The Institute of Medicine (IOM) published data indicating that 98,000 patients died in hospitals each year as a result of medical errors. The HealthGrades 2004 Quality Study indicates that the number is almost twice that large. The authors note, “Despite the shocking and widely publicized statistics on preventable deaths due to medical errors in America’s hospitals, there is little evidence that patient safety has improved in the last five years. ²” The financial costs attributable to medical errors are staggering … approximately $29 billion annually¹. The human cost is incalculable. The majority of medical errors do not result from individual recklessness or the actions of a particular individual … more commonly errors are caused by faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them¹.

As a result of the medical malpractice crisis realized in several states over the past several years (in varying degrees) many integrated delivery systems and community-based facilities have incorporated significant self-insured retentions and are now looking to service providers to help them manage the risks associated with these higher retentions. These clinical and financial drivers are causing most health care organizations to prominently position patient safety within their strategic plans and to reposition the organization’s financial priorities accordingly.

There is growing consensus about the need for healthcare institutions – particularly academic medical centers and large acute hospitals – to implement data driven risk management strategies and programs that provide accurate information and insights into how best to identify, measure, and mitigate the risk of harm to patients. Such a data-driven program will enable health care institutions to identify exposures and mitigate organizational risk at the same time³.

Broadly, these data-driven programs should have the following objectives: a) to detect potential failures in clinical processes before errors can occur; b) to satisfy the growing demands from constituents (patients, payers, insurers, credentialing bodies, and the public) for initiatives to manage clinical risk; to measure financial exposures created by medical error; and c) to manage scarce clinical quality resources to provide the best ROI while reducing exposure and creating the safest patient environment possible³.

The focus on Patient Safety will be the catalyst that drives health care facilities to become “high reliability organizations” that “functions consistently and reliably over long periods of time with minimal error” ⁴. The Health Care risk management community is making a critical shift in its RMIS orientation … moving from retrospective analysis driven by a measurement / matter management-centric RMIS systems (CS STARS, CSC RiskMaster, etc.) … to concurrent and prospective analysis driven by decision support-centric RMIS systems (Peminic, MedStat, Quantros, RL Solutions, CS STARS / AIMS etc.)

One of the results of Florida’s past medical malpractice crises was the formation of the Florida Patient Safety Corporation. In one of FPSC’s first efforts to promote Patient Safety efforts in Florida, they let a contract out to the Jackson Memorial/ University of Miami Center for Patient Safety. The charge was to set up a pilot “web based” Near Miss Reporting System to be accessed by Florida Hospitals to report blinded Near Miss data for analysis. The Center, headed by Dr. David Burnbach, contracted with Marsh USA and CS STARS to create the system to collect data and aid in the issuance of “Advisories” reporting blinded “lessons learned”. The system has the ability to relate this data to the Australian Incident Reporting System’s causation factor analysis data base to assist in further clinical drill down into causation factors for Near Misses. The first Advisory is on the FPSC’s website http://www.floridapatientsafetycorp.com/. In this first view of data and lessons learned Dr. Birnbach points to several real world examples of Near Misses that are common in a hospital setting. The sharing of this data and blinded information is one more step in making Patient Safety data relevant to patient care. The next Advisory will be published on the website by April 1, 2007.

It is clear that as we continue to advance in efforts to share blinded data that not only Near Misses can be recorded but, as in Pennsylvania, incidents and claims can be blinded and an analysis for “lessons learned” performed. As recently as this week the newly appointed Secretary of the Agency for Healthcare Administration Andrew Agwunobi M.D. stated in front of the South Florida Hospital and Healthcare Association that “incident and data management” was on his priority for his first year. This may give hope for the better use of Code 15 data currently collected by AHCA.

In conclusion, it is clear that the more a sophisticated use of data will drive the efforts of healthcare providers to find better clinical interventions and procedures thus promoting a safer environment for their patients.