President's
Message:
Pressing for Patient Safety
 In
the wake of three tragic deaths at Children's Hospital Boston, the
issue
of patient safety has once again made national headlines. These
events
painfully highlight the shortcomings in our existing health care
system
-- skilled and caring physicians make mistakes primarily due to
errors
in protocols and in methods of communication, often involving complex
conditions.
This sentiment is supported by the
Institute of
Medicine in its landmark 1999 study of medical errors: "The
majority
of medical errors do not result from individual recklessness or the
actions of a particular group. More commonly, errors are caused by
faulty systems, processes and conditions that lead people to make
mistakes or fail to prevent them."
Unfortunately, the current regulatory and
legislative climate does not support positive incentives to promote
enhanced safety and error prevention. Despite these ongoing
challenges,
the MMS diligently continues to champion the cause of patient
safety.
It is the Medical Society's position to
promote a
new system design that makes it difficult to do the "wrong"
thing and
easy to do the "right" thing. This is encouraged by
allowing
professionals to re-engineer workflow in patient care settings, while
eliminating the current culture of "shame, blame and finger
pointing."
Reporting errors and analyzing the best way to change habits is our
goal, as long as the reporting is designed to be confidential, yet
accountable and productive of meaningful change. We can learn from
other
industries about using confidential error reporting to discover and
correct system-related problems.
For many years, the MMS has pursued specific
and
broad-based initiatives to promote safety within health care. In
2002,
the state Board of Registration in Medicine endorsed guidelines
developed by the MMS to govern office-based surgery, including the
recommended qualification of practitioners and staff, equipment,
facilities, and policies and procedures for patient assessment and
monitoring.
The Medical Society also has adopted and is
encouraging the use of the Institute for Safe Medication Practices'
list
of abbreviations not to use. These abbreviations are often
misinterpreted and can be a source of potential patient safety
problems.
Most recently, the MMS designed a unique and
comprehensive online curriculum to educate physicians on ways to
illustrate the scope and magnitude of medical errors and the
information
available on the nature, distribution, prevention, and control of
medical errors.
The MMS is committed to system change through
confidential reporting and system redesign. It is our hope that
lawmakers and industry stakeholders will join us in this vision.
-Thomas E. Sullivan, M.D.
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