The 131st Annual Meeting (November 15-19, 2003) of APHA

Abstract #65695

Stanley Edinger, Ph D, Center for Quality Improvement and Patient Safety, Agency for Healthcare Policy and Research, 5901 Montrose Road, 1400 South, Rockville, MD 20852, 301-594-1598, sedinger@ahrq.gov

According to a recent Institute of Medicine Report, errors in health care have been estimated to be responsible for injury in as many as 1 out of every 25 hospital patients; an estimated 48,000-98,000 patients die from medical errors each year. Errors in health care have been estimated to cost more than $5 million dollars per year in a large teaching hospital, and preventable health care-related injuries cost the economy from $17 to $29 billion each year. Even the lower estimate is higher than the annual mortality from motor vehicle accidents, breast cancer or AIDS making medical errors the eight leading cause of death in the United States. Agency for Health Care Policy and Research sponsored research has shown that medical errors may result most frequently from system errors – organization of health care delivery and how resources are provided in the delivery system. Medical errors may result in a patient inadvertently given the wrong medicine (Adverse Drug Events or ADEs), a clinician misreading the results of a test, an elderly woman with ambiguous symptoms whose heart attach is not diagnosed by emergency room staff. In one study ADE’s caused one out of five injuries or deaths per year to patients in the hospitals. In another study, surgical adverse events in two hospital systems accounted for two-thirds of all adverse events and 1 of 8 hospital deaths. The policy, public health, and patient implications of the research and various alternatives for monitoring patient safety will be discussed.

Learning Objectives:

At the conclusion of this session, the participant will be able to 1. Recognize several of the causes of Medical errors or patient satety problems-at least five 2. Articulate the mechanisms for addressing the major patient safety problems and recognize the policy, cost, and patient centered issues related to the alternative action plans.
• Develop possible action plans to address the areas of patient safety.

Keywords: Health Care Quality, Information Technology

Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: Agency for Healthcare Policy and Research
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: Employee