New Web Site Highlights Medical Errors, Patient Safety Lessons: A Newsmaker Interview With Carolyn M. Clancy, MD

Cathy Tokarski

February 20, 2003

Feb. 20, 2003 — The Agency for Healthcare Research and Quality (AHRQ), an arm of the Department of Health and Human Services, launched a monthly Web-based medical journal last week that highlights patient safety lessons taken from real-life instances of medical errors.

The Web journal, called AHRQ WebM&M (, is part of an ongoing effort by the agency to educate healthcare professionals about how to prevent medical errors in a blame-free environment, according to AHRQ Director Carolyn M. Clancy, MD. Little discussed outside of hospital walls until recently, the magnitude of medical errors grabbed national headlines in 1999, with the publication of the Institute of Medicine's landmark report, "To Err is Human: Building a Safer Health System." That report concluded that as many as 98,000 people die in any given year from medical errors that occur in hospitals.

AHRQ WebM&M will feature five "near-miss" cases or those that do no permanent harm each month, including commentaries from experts and a forum for readers' comments. The February issue includes a case in which a man nearly received a medication intended for another patient with the same last name located in the same room and another case in which a woman is required to have emergency vascular surgery due to a complication during a routine tubal ligation.

Named AHRQ's director on Feb. 5, Dr. Clancy has served as AHRQ's acting director since March 2002. A general internist and health services researcher, Dr. Clancy was an assistant professor in the Department of Internal Medicine at the Medical College of Virginia in Richmond before joining AHRQ in 1990. Medscape's Cathy Tokarski interviewed Dr. Clancy to discuss how the new journal might help healthcare professionals.

Medscape: Why did AHRQ decide to develop a Web journal on patient safety problems and medical errors? Are you concerned that individual institutions and physicians aren't doing enough to reduce them?

Dr. Clancy: The Institute of Medicine report clearly focused our attention on the issue of patient safety and medical errors, and the really good news is that healthcare professionals and institutions have responded to this with vigor and enthusiasm.

Having said that, getting to systems that work and a culture that promotes patient safety and also removes some of the fear of reporting errors is going to take a lot of work. The number one reason that many health professionals are unwilling to report errors is that they are fearful of lawsuits, followed by fear of losing one's job. That doesn't create an environment that says, 'Let me tell you about my near miss.'

There is a long-standing tradition with morbidity and mortality rounds in our healthcare institutions. Discussions that take place within the institution are protected, and health professionals can discuss and learn from the errors that others have made.

The IOM report made it clear that there is a huge need to promote a culture of learning from errors. A Web-based morbidity and mortality format is familiar to physicians and would allow, very importantly, a corrective analysis and action without any fear of reprisal.

Medscape: Educating health professionals about medical errors in a blame-free environment continues to be an important concept. Does the issue of who is to blame when a mistake occurs prevent patient safety lessons from being used?

Dr. Clancy: Some of it is human psychology. It is much easier to point to someone and say they were to blame, and the idea is that all of us potentially contribute to patient safety. Health professionals are still trained quite separately from each other and yet are expected to function as a highly effective team. Sadly, that does not happen.

The New England Journal of Medicine recently ran an article about public perception of medical errors. What I found astounding was that this concept that it is the system that is so important has not yet taken hold. Both [consumer and physician] groups were given scenarios that involved an error to react to — one that involved a bad outcome, and one without a bad outcome. Interestingly, they did not make a distinction between whether the outcome was bad or not. There was more emphasis on punishing the doctor than on [recognizing the mistakes] in the system overall.

Medscape: Where will the cases for AHRQ's WebM&M come from?

Dr. Clancy: Hospitals and doctors can provide them anonymously, and they get an honorarium for doing so if they're selected by our contractor.

We're making a specific effort to select cases in different fields. The first issue has cases from medicine, anesthesiology, ob/gyn, pediatrics and psychiatry. We won't have any shortage of material.

Some people have concerns about how widespread the skills will be by the reporting institution to perform a root cause analysis [of what caused the medical error]. This site will be helpful to us in terms of understanding what kinds of skills reside in these institutions. They might only be getting to the first level of depth. With this information we can better determine how to help these institutions.

Medscape: Why are you selecting cases that are near-misses and those that do no permanent harm?

Dr. Clancy: Institutions will be more likely to report those. It gets back to the issue of culture of reporting. It's a little easier to report something along the lines of, 'I almost hit a kid with my car; you really ought to watch that hill...' versus 'I hit a kid.'

Medscape: What advantages, if any, does the Web offer in helping health professionals learn about and possibly prevent medical errors? Does the Web offer advantages that print journals or medical meetings on this complex subject don't provide?

Dr. Clancy: The Web provides people with a sense of urgency that can be very helpful. For busy health professionals, they can look at it any time. And more and more health professionals use the Web for many things — for information for their patients, to look up something on a condition — it's become more of a part of the fabric of their workday. Also, you can read as much as you like. The advantage you have in a Web-based format is you can keep clicking if you want more information.

Medscape: Your appointment as AHRQ's director was made on Feb. 5, although you had been serving in an acting capacity since last March. What other major goals for the agency do you hope to realize?

Dr. Clancy: The major initiatives are to produce evidence to improve healthcare and to make sure that the evidence will be used. We have a terrific track record on producing the evidence, but where we need to expand is to make sure that the evidence is used. The Web site is one place where we're starting that.

We have a number of other exciting initiatives that we didn't just start on two weeks ago. We have a national network of nine primary care groups where the doctors want their practice to be a part of a larger clinical enterprise. Our proposed budget has $50 million to explore the opportunities of information systems to reduce errors and improve patient safety [in small and rural institutions].

Our focus is going to be on use. We have found that research on this issue is great stuff, but our focus is shifting to getting all health professionals to actually do this. What we want to learn is how do you integrate information systems in a way that enhances the work I'm doing already instead of replicating how a computer guy thinks it should be working.

Two new reports are coming out in September. One is the first annual report on the quality of healthcare, and the other is on disparity in healthcare. We've never had a national report on quality and safety, so for the first time we'll have a comprehensive report of how we're doing. The data that will be used to develop the report is the same as what hospitals now use. All of this we hope will enhance the use of reporting as a pathway to improvement.

Reviewed by Gary D. Vogin, MD


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