Medical errors have caused a crisis in the national health care system. According to the Bureau of Primary Health Care, using studies from Colorado, Utah and New York, estimates that 44,000 -- 98,000 hospitalized people die in the U.S. annually due to medical errors (BPHC Task Force on Patient Safety, 2001, p. 5). In addition, as of March 31, 2010, the ten most frequently reported sentinel events within U.S. healthcare organizations are: "wrong site surgery; suicide; operative/post-operative complication; delay in treatment; medical error; patient fall; unintended retention of a foreign body; assault, rape or homicide; perinatal death or loss of function; patient death or injury in restraints" (HealthLeaders Media, 2012). Clearly, many of these injuries/deaths are avoidable. Furthermore, according to JCAHO's L.D. 5.2, patient safety concerns demand that "an ongoing, proactive program for identifying risks to patient safety and reducing medical/health care errors" be "defined and implemented" (Joint Commission on Accreditation of Healthcare Organizations, 2001). Consequently, the Industry must design safer systems and demand accountability for daily choices, actions and omissions within those systems.
Causes of Medical Errors
When questioning consumers about medical errors, researchers from the Kaiser Family Foundation/Agency for Healthcare Research and Quality first defined "medical error" with this statement: "Sometimes when people are ill and receive medical care, mistakes are made that result in serious harm, such as death, disability, or additional prolonged treatment. These are called medical errors. Some of these errors are preventable, while others may not be" (Henry J. Kaiser Family Foundation, 2004). With that understanding, consumers have traced medical errors to specific causes: approximately 74% believe that workload, stress and/or fatigue among health care providers are important causes; 70% claim that the lack of time doctors spend with patients is another factor; 69% claim that some medical errors are caused by having too few nurses; 68% claim that lack of coordination/communication among health care providers is another important cause of medical errors (Henry J. Kaiser Family Foundation, 2004).
Systemic Barriers to Providing Safe Care
While there are a number of systemic barriers to providing safe care, Kaiser Permanente has specifically addressed 2 barriers to its efforts. Within Kaiser Permanente's system, the sheer size and scope of the organization can form a systemic barrier to providing safe care: coordinating efforts in a system serving over 9 million members in 8 regions with 180,600 employees (Kaiser Permanente, 2012) is a daunting task. Furthermore, Kaiser Permanente has pointed to a legal/social system that is too focused on punishing providers through medical malpractice suits, resulting in high malpractice insurance costs and a culture of fear, rather than promoting a culture that justly compensates victims of medical errors while promoting education and improvement. As a result, The Leapfrog Group has given relatively high ratings to Kaiser Permanente hospitals in the area of safety (Kaiser Permanente, 2012).
Specific ways Kaiser Permanente has Responded to the Crisis in Medical Errors
Kaiser Permanente has responded to the crises in medical errors by developing a culture dedicated to heightening the quality of patient care while reducing costs. While there are specific protocols to prevent/deal with specific medical errors, in order to attain its goals in a very large system serving over 9 million members in 8 regions with 180,600 employees (Kaiser Permanente, 2012), Kaiser has developed some fundamental principles that have been lauded by the Commonwealth Fund. By studying Kaiser Permanente's operations, The Commonwealth Fund discerned six attributes that it highly recommends to other health care providers: Information Continuity, ensuring that every patient's medically relevant data is made available to all providers "at the point of care" and to the patient himself/herself through electronic records; Care Coordination and Transitions, that manages coordinated patient care among multiple health care providers and across multiple care settings; System Accountability, which provides clear-cut accountability for a patient's total care; Peer Review and Teamwork for High-Value Care, in which health care provider teams, both within a health care institution and across Kaiser's multiple health care institutions, are accountable to each other, review each other's work and continually collaborate to improve the quality and value of care; Continuous Innovation, in which providers throughout the system are continually learning and innovating to tirelessly improve patient care; Easy Access to Appropriate Care, in which easy access to appropriate care is available throughout the system at all hours and providers within each care setting are "culturally competent" and responsive to the…