ABCD Exchange : September - October 2000 : Upfront - Patient Safety and Medical Errors

Research on Patient Safety and Medical Errors Needs to Include Problems at the End-of-Life
By Janice Lynch

Lynn described her experience with medical errors when her 88-year old mother-in-law was hospitalized last summer. “The experience of twelve hours in an emergency room, an utterly disrupted schedule, a welter of new people, and all manner of emotional and cognitive challenges completely disoriented this frail, previously functional, 88-year old lady….What happened to her was a series of errors, and the upshot has now blighted the end of her life,” Lynn said. Lynn recommended that the committee consider a research agenda that would track—and correct—errors that affect seriously ill patients. “Medical errors and other lapses in patient safety are particularly likely to harm patients in this phase of their lives, people who are suffering from serious, progressive, eventually fatal chronic illness,” she said.

These patients are more vulnerable to medical errors for three reasons: They have more frequent interactions with the healthcare system, creating a higher risk for error. They experience more serious effects from errors because of their poor health status. And the care system itself is so poorly constructed that these patients encounter recurring mistakes—that are not always viewed as mistakes. Lynn recommended that QuIC focus on gathering data that describe the needs of vulnerable patients and on implementing good practices. Among her recommendations are that QuIC:

• Target people with progressive, eventually fatal chronic illness as a special, named population in its research initiatives;
• Focus on these patients in research to prevent medical errors and enhance patient safety;
• Ensure that the merits of all proposed patient safety initiatives be specifically assessed in terms of these patients;
• Encourage NIH to sponsor clinical research on the effects of medical errors on these patients; and
• Develop a set of measures and practices surrounding medical errors that affect this population.

For a complete copy of Dr. Lynn’s testimony, visit www.abcd-caring.org. To learn more about the QuIC initiative, visit its website at www.quic.gov, where full testimony from each witness is posted.

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