Improving Patient Safety: Will, Ideas, &Execution for the Prevention of Medical Errors Paula Griswold, Executive Director

Improvement Principles (IHI)  Every system is designed to produce exactly the results it achieves  Improvement: - Will - Ideas - Execution

Will: See the problem  Beliefs about frequency of medical error: Annual deaths in hospitals due to preventable medical error MDsPublic 50017%24% %36% 50,00025%20% 100,0009%7%

Ideas: Understand the causes  Bad people cause errors vs. competent, caring More important reasons for errors MDsPublic Mistakes made by individual health professionals 55%55% Mistakes made by institutions 43%43%

Ideas: Understand the causes  Systems failures result from complex interactions of latent failures, not simple single cause  Complexity can reduce reliability, rather than improve it  Errors need not cause harm; can intercept and mitigate them

Execution: Clinicians/workforce  Recognize causes of error and role of systems of care  Open and committed to continual change and improvement

Execution: Organizational Leadership  Recognize causes of error and role of systems of care: primacy of operations  Committed to continual change and improvement  Maintain priority and focus: measurement  Moral and strategic case for change

Execution: Payers  Create a business case for change

Execution: Regulators  Promote system-based safety improvements using sophisticated model of error  Communicates about types of errors and prevention methods  Educate the public about system-based causes of errors

Execution: Educators  Develop educational approaches based on systems-approach to care, human factors, and improvement methods

Execution: Public  Accurate model of how errors occur  Insist on improvement