Quality and Patient Safety
In the late 1980's, empirical data began to raise alarms about the quality of health care in US Medicine. In the mid 1990's, Mount Sinai's Dr. Larry Kleinman and his colleague Dr. Charlie Homer, then both at Harvard Medical School and Children's Hospital Boston, presented at two consecutive the Pediatric Academic Societies' meetings the first integrated model for understanding the quality of pediatric health care. In so doing they launched the academic study of children's health care as a defined field. In 2000, the seminal Institute of Medicine report, To Err is Human, elevated to prominence the branch of quality that focuses on reducing errors and ensuring patient safety.
One critical recommendation to enhance patient safety was to "Identify and learn from errors through reporting systems." The Quality and Patient Safety Group – Dr. Hal Kaplan and Ms. Barbara Rabin, and Ron Levitan – spearheaded the development of novel web-based medical event reporting systems for analysis of near miss and actual patient harm events. The first system was developed in the domain of transfusion medicine (core components of which have been recently integrated into the newly created U.S. Biovigilance Network), and the second, a system for use hospital-wide and in ambulatory care. The information derived from these systems is utilized to improve health care delivery processes, to assist in the examination of economic outcomes associated with medical events, as well as to potentially explore the pros and cons of alternative policy strategies in the patient safety arena.
In addition to the development of these event-reporting systems, Dr. Kaplan and Ms. Rabin, who are prominent in the national dialogue on patient safety, have served on various editorial, hospital quality, and Patient Safety Organization Boards and on committees of the AMA, AHRQ, CMS, NQF, CDC, WHO, and AABB. They serve as consultants to AHRQ in the development of the national Common Formats for event reporting and the Network of Patient Safety Databases. Additionally, they are developing an error/solution matrix intended to enhance the breadth of potential solutions for consideration after completion of an event problem analysis. Furthermore, to afford better utilization of data captured by event reporting and other methods, they developed a modular Patient Safety Analysis Training program for use in the DoD healthcare system, and to be made publicly available through AHRQ. Materials are web-based, train-the-trainer, and classroom-oriented, covering topics such as event theory and management, causal analysis, FMEA, PRA, Case-Based Reasoning, data mining, neural networks, change implementation, and safety culture.
The group also works with the hospital and conducts research in the area of hospital-acquired conditions such as infection, glycemic control, and falls, and meets regularly with members of the Mount Sinai Office for Excellence in Patient Care to assist in the development of medical event causal analyses and patient safety-related action plans. Dr Kaplan and Rabin are key collaborators with the CAPQuaM team, described in the Pediatric Quality section below.