Report from the Field: National Conference on Patient Safety

By Mary R. Anderlik
Health Law & Policy Institute

In 1996, a cascade of reports of patient injury or death due to medical mistakes resulted in a first-of-its-kind multidisciplinary conference devoted to issues of patient safety. The conference was hosted by the Annenberg Center for Health Sciences in Rancho Mirage, California. A second Annenberg conference, "Enhancing Patient Safety and Reducing Errors in Health Care," was held on November 8-10, 1998. The American Association for the Advancement of Science, the Annenberg Center, the Joint Commission on Accreditation of Healthcare Organizations, the National Patient Safety Foundation at the American Medical Association (AMA), and the U.S. Department of Veterans Affairs convened this major event. Donald M. Berwick, one of the national leaders in the movement to improve the quality of health care, and a member of the President’s President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, served as keynote speaker. Nancy W. Dickey, current president of the AMA, moderated the panel that closed the conference.

As a prelude to "Annenberg II," Berwick and others authored an editorial in the October 28, 1998, issue of the Journal of the American Medical Association on the topic of patient safety. The editorial concluded: "Increasingly, patients and physicians in the United States live and interact in a culture characterized by anger, blame, guilt, fear, frustration, and distrust regarding health care errors. The public has responded by escalating the punishment for error. Clinicians and some health care organizations generally have responded by suppression, stonewalling, and cover-up…. We now hope to create a predominant culture of error recognition, accountability, honesty, and rapid and fair settlement for injuries, addressing the risk of harm as a systems problem and preventing the problems from occurring again in that or similar settings."

William R. Hendee, chair of the organizing committee, set the tone for the conference in stressing the importance of replacing a culture of "blame and punishment" with a culture of "vigilance and cooperation" that exposes system weaknesses that may combine to produce error and injury, e.g., confusing product names or labeling and poor staff training. In the course of the conference, attention was repeatedly drawn to the complexity of modern health care and the importance of getting beyond social and psychological barriers to systems thinking.

The presentations ranged from the concrete to the highly theoretical. In several presentations, representatives of hospitals described how they increased incident reporting by eliminating sanctions for reported errors. The reports were used to identify and address areas of weakness, resulting in substantial decreases in bad patient outcomes and significant cost-savings. One presentation described the role mediation can play in making injured patients or their family members collaborators in the search to find out what went wrong and ensure that it does not happen again. Massachusetts has several pioneering programs, which have been supported by the state medical society and bar association. (In Massachusetts and many other states, disclosures in the context of mediation cannot be used later in litigation, hence mediation creates a "safe harbor" for free communication.) There were also presentations concerning the use of information technology to support safe practice, barriers to culture change in institutions, the experience with national incident databases in industries such as aviation (and, in Australia, health care), the contributions of "human factors" research and cognitive science to safety, and the impact of fatigue and sleep deprivation on the performance of physicians.

The centerpiece of the 1996 conference was a panel discussion of a case in which a 7-year-old Florida boy died as the result of a drug mix-up. The hospital admitted responsibility and entered into a financial settlement with the family. Hospital representatives also promised to spread the word concerning the error and the factors that contributed to its occurrence. For the 1998 event, conference organizers selected a Colorado case in which three nurses were charged with criminal negligence in the death of a newborn infant. The panel included the district attorney who prosecuted the case, and the discussion focused on a theme that emerged again and again: in shifting the focus to systems and advancing a "non-punitive" culture, what becomes of personal accountability and the public right to know and judge? While many participants lamented a legal system that creates fear of liability, and hence discourages reporting and investigation of error, a few noted that those in health care were themselves guilty of ignoring complexity and pointing the finger (at the lawyers). There was widespread agreement that quality assurance and improvement activities should be shielded from discovery in litigation.

Growing out of this discussion, several of the panelists in the closing session called for greater involvement of state and federal regulators, legislators, and consumers and patients in the dialogue concerning patient safety. These groups should be better represented at the next Annenberg conference and in the regional forums sponsored by the National Patient Safety Foundation. Patient safety deserves increased attention as part of the larger movement to improve quality in health care, for as one panelist noted, it is difficult to imagine a form of health care that is "of high quality, but unsafe."

Note: Houston is one of the cities that will be hosting a forum on patient safety in the near future. Those interested in more information on the conference, and patient safety issues generally, can visit the conference website at