By Carolyn M. Clancy, MD; Dwight McNeill, PhD, MPH;

Ernest Moy, MD

In many ways, it seems like only yesterday that the Institute of Medicine (IOM) published its watershed report, To Err Is Human: Building a Safer Health System (2000). One of its key messages, that an estimated 44,000 to 98,000 Americans die each year from preventable medical errors, is as sobering now as it was 6 years ago. While the issue of patient safety had certainly received attention before the IOM report from a number of sources, including the Agency for Healthcare Research and Quality (AHRQ), publication of the report heightened awareness of patient safety issues among the public, clinicians, policymakers, and researchers.

In the intervening 6 years, the attention devoted to patient safety has grown dramatically. Hardly a day passes without some media consideration of patient safety issues, and the scientific literature in this area has expanded significantly. As the need for more and better information about patient safety has grown, AHRQ has stepped up its efforts to support patient safety research, disseminate knowledge, and build public-private partnerships to reduce medical errors and help make patient care safer.

With the enactment of the Patient Safety and Quality Improvement Act on July 29, 2005, AHRQ was given important new responsibilities with respect to the creation, operation, and certification of Patient Safety Organizations (PSOs). Providers across the United States will have the opportunity to contract with PSOs, which will help them identify threats to patient safety and change the delivery of healthcare — without concerns about data disclosure or legal liability issues related to the reporting of safety problems.

Another AHRQ activity with important implications for patient safety is the publication earlier this year of the third editions of the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR). Both reports are published annually in accordance with a congressional mandate, and each publication contains a range of quality and patient safety measures that provide useful trend information and comparative data for policymakers, clinicians, and researchers across the country.

AHRQ's National Reports on Healthcare Quality and Disparities
The NHQR and the NHDR are the only reports that track the nation's progress each year in improving healthcare quality and reducing healthcare disparities across a broad range of conditions, services, and population groups. They identify nationwide strengths and opportunities for improvement in healthcare, highlight successes, and suggest where interventions are most needed and would yield the greatest results. While the reports make clear that excellence in healthcare is being achieved for many, they also reveal significant gaps in healthcare quality and access, especially for racial and ethnic minorities and the poor.

The patient safety data reported in the third annual editions of the NHQR and NHDR, published in January 2006, indicate noteworthy improvement since the reports were first issued a little over 2 years ago. This improvement reinforces one of the reports' major implicit "take home" messages—that focused national attention can make a difference. Even in the relatively brief span of 2 years, improvements in patient safety can and did take place.

For example, the NHQR indicates that five core measures of patient safety increased at an annual median rate of improvement of 10.2%, with a range of 2% to 39%. These five measures are:

1) hospital-acquired blood-stream infections in intensive care units (ICUs),

2) postoperative venous thromboembolic events, 3) mechanical adverse events associated with central vascular catheters, 4) ICU patients with ventilator-associated pneumonia, and 5) elderly patients who had at least one prescription that is potentially inappropriate for the elderly.

This subset of patient safety measures shows greater improvement than any other subset of measures in the NHQR. Thus, improvements in patient safety measures exceed the average rate of improvement for all measures combined as well as the rate for measures in the other quality domains: effectiveness, timeliness, and patient centeredness.

From these data, it is possible to infer that our nation's investments in patient safety are paying off with demonstrable improvements at a rate that is much higher than the relatively modest pace of improvements in other areas of healthcare. Obviously, however, the NHQR set of patient safety measures is only one lens through which to evaluate progress.

The second report, the NHDR, underscores the importance of leaving no stone unturned in our patient safety improvement efforts. The interrelationship between patient safety and race and ethnicity commands the attention of anyone working in this area. Clearly, we need to examine which populations experience what adverse events in which settings, so we can target improvement efforts to the groups where interventions are most needed and most likely to produce the greatest gains. To date, a relatively limited body of research has examined racial, ethnic, and socioeconomic variation in adverse events.

While the NHDR consistently reveals poorer quality of care for racial and ethnic minorities than for whites, the newest edition indicates that disparities in patient safety are less substantial than disparities in quality and more evenly distributed between differences that are to the advantage or disadvantage of minorities. Minorities experience poorer, similar, and better patient safety for 31%, 37%, and 32% of measures, respectively.

Although there are differences across minority groups, overall, minority hospital inpatients tend to have more nosocomial infections, potentially avoidable deaths, and complications of care compared with whites. On the other hand, minorities generally tend to have fewer hospital injuries, adverse events related to technical errors, and birth-related traumas.

Conclusion
With each passing year, the National Healthcare Quality and Disparities Reports will become increasingly useful as more and better data are collected, trend lines are extended, and more people use these measurement tools, especially at the state and regional level, to identify critical gaps in performance and target interventions to close these gaps.

However, the ultimate value of these reports does not lie in the statistics themselves but in the dialogue sparked by the findings and the continued discussion we have with policymakers, researchers, providers, and citizens who drive improvements in quality and safety. Your voice is an important part of this process, and we invite your attention and response to the newest editions of the NHQR and NHDR. They have important implications for all of us engaged in the vital area of improving patient safety.

We recognize that, as yet, the overall progress reflected in these reports is somewhat modest, and there is a pressing need for additional research, especially with respect to minority patient safety experience. But these reports can and should help inform and guide the patient safety movement. Your input can help us improve the research basis and data published in future editions of these reports. Both reports are available online at www.qualitytools.ahrq.gov.

Dwight McNeill is an expert in quality measurement and improvement at AHRQ.

Ernest Moy is a senior service fellow at AHRQ.

References

Institute of Medicine. (2000). To err is human: Building a safer health system. L. T. Kohn, J. M. Corrigan, & M. S. Donaldson (Eds.). Washington, DC: National Academy Press.