Center Strives to Reduce Risk of Medical Errors

A five-year, $7.2 million grant by the U.S. Agency for Healthcare Research and Quality will fund research led by The University of Texas Medical School at Houston to better understand medical errors and develop interventions to benefit patient safety and health care providers.

The University of Texas Center of Excellence for Patient Safety Research and Practice is one of only three centers of excellence funded nationwide by the federal agency to address the problem of medical errors, which are estimated to cause 44,000 to 98,000 deaths in the United States each year. Overall the AHRQ, an agency of the U.S. Department of Health and Human Services, recently announced 94 projects totaling $50 million.

Principal investigator Dr. Eric Thomas, assistant professor in the UT-Houston Medical School Department of Internal Medicine, said the center taps the expertise of The University of Texas System to propose, test, and disseminate procedures to reduce error. Project investigators come from other UT-Houston schools, as well as The University of Texas M.D. Anderson Cancer Center and The University of Texas at Austin. Memorial Hermann Healthcare System is a partner in the project and much of the center’s research will take place at its hospitals.

Researchers will use a variety of observational methods, including videotaping of health care teams in action, to focus on communication and teamwork in the clinical setting, Dr. Thomas said, as well as how health care providers interact with medical devices. They also will scrutinize how errors and "close-calls" are noted and how organizations use that information.

"With this grant, The University of Texas Health Science Center at Houston will help us identify the causes of medical errors and develop effective solutions to strengthen quality of care nationwide," Health and Human Services Secretary Tommy G. Thompson said. "Nothing could be more important than making sure patients receive quality care that doesn’t cause unintended harm, and our investment in this kind of research will pay off in terms of improved patient safety for all Americans."

The other two centers of excellence funded by the agency are at Brigham and Women’s Hospital in Boston and the University of Pennsylvania.

"The exciting feature of this grant is that it brings together so many researchers representing multiple institutions in such a way that we can build a collaboration and synergy that might not otherwise exist," said Dr. Thomas.

Five project leaders will coordinate studies with funding from the center:

• Dr. Thomas will lead a two-year project that involves videotaping health care teamwork in trauma resuscitation and thoracic surgery. Objectives for the project include understanding how effective teamwork and communication reduce the risk of medical error. Health care providers will know they are being taped and only project researchers will see the tapes, Dr. Thomas said.
• Dr. Robert Helmreich, professor of psychology at UT-Austin, will lead a project to design and implement a training program to improve teamwork among health care providers. Dr. Helmreich will draw from his extensive work as an internationally recognized expert in aviation safety. It is believed that many safety principles developed by airlines can be translated to the health care environment.
• Sherry Martin, associate vice president for process improvement at M.D. Anderson, will lead a project addressing close-call reporting and error reduction. Developing a close-call reporting system and understanding where patterns of close calls occur is a crucial step in minimizing medical errors. Martin also will coordinate many of the center’s data collection and analysis efforts, and disseminate the center’s findings to other UT System components.
• Dr. Todd Johnson, associate professor in the UT-Houston School of Health Information Sciences, will study interactions among health care providers and medical devices such as monitors. Many devices have design or display problems that can lead to misinterpretation. The project also will develop guidelines to help hospitals purchase equipment.
• Dr. Michal Tamuz, at the UT-Houston School of Public Health, will address how organizations learn from medical errors.

The center also includes researchers from The University of Texas Medical Branch in Galveston and Columbia University.

Dr. Thomas said that understanding medical errors is not about placing blame. Medical errors are most often unintentional adverse events that occur for a variety of reasons, including miscommunication, faulty organizational systems, stress, or something as simple as poor handwriting. Nationwide, hospital accreditation is increasingly dependent on attention to medical errors and interventions to minimize them.

Work by Dr. Thomas and collaborators was cited in To Err Is Human: Building a Safer Health System. The report, published in 1999 by the Institute of Medicine of the National Academy of Sciences, estimated that between 44,000 and 98,000 deaths are caused each year by medical errors.

"Even the smaller of those two numbers would make medical error the eighth-leading cause of death in the United States," Dr. Thomas said.

Dr. Thomas directed the Utah-Colorado Medical Practice Study funded by the Robert Wood Johnson Foundation. The study, an examination of 15,000 randomly selected 1992 cases from 28 Utah and Colorado hospitals, and a landmark 1984 examination of errors among hospitals in New York, form the basis for national estimates of the rate of medical error and negligent care.

Dr. Thomas is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar.

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