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Making the world a safer place
Concurrent Review
MAKING THE WORLD A SAFER PLACE
A
s I put my thoughts together for this issue’s editorial, I await the birth of my third grandchild. My son has called, and we’ll meet at the hospital to be together for the safe delivery of this newest addition to our family. Thoughts of patient safety take on new meaning, because yes, it’s now personal. More and more we hear about medical errors and patient safety concerns when patients enter hospitals today. We learn about amputations of the wrong extremity, medication overdoses, instruments left in abdominal cavities, orders written on the wrong patient chart, etc., featured on the nightly news and illustrated as cases on TV programs such as Law and Order. Has the number of incidents risen so dramatically that it has commanded the attention of professionals, consumers, payers, the other stakeholders in our health care delivery system, and the media, or are we now more willing to acknowledge that mistakes occur? Certainly, case managers are aware of the increased number of errors and incidents and are well positioned as advocates to protect patients from the harm that occurs. However, as with other challenges in case management, the matter is not as easy or as simple as that. Each of us has a responsibility to promote patient safety. Our professional license, standards of practice, and codes of professional conduct provide direction and guidance. While we accept that individuals make mistakes, there are consequences when they are uncovered or disclosed, and these can be highly significant on a personal, professional, and financial basis. From the “routine” completion of an incident report all the way through the loss of license, professionals in every practice setting are concerned when they are involved in an error-causing event. For institutions or businesses, the financial consequences can be devastating when errors become publicized. It should be no surprise, then, that patient safety is no longer just a blip on a radar screen but rather a highly important matter that has taken on a life of its own, attracting widespread attention in TCM 14
May/June 2005
the private and public sectors. With all this attention, we would assume that we have buy-in from all involved, especially health care professionals and the institutions or organizations that employ them because patients are at the very center of their mission as providers. Unfortunately, in many cases a cone of silence exists regarding the disclosure of errors, with occasionally more time and effort expended to keep things quiet than examining causes and learning from the mistakes. The protection of the professionals involved and the business and financial concerns seems to supersede the best interests of the patient. It is our hope that this special focus issue will result in many conversations among our readers within their diverse practice settings and that these discussions will lead to initiatives and programs to prevent errors and promote a culture of honesty and a real desire to do the right thing. We also hope that our patients will receive safe, appropriate care in an environment that they and their families can trust. Our resident ethicist, John Banja, has two contributions to this important edition—a discussion of the basic issues and then a more specific examination and analysis of the conflicts facing case managers and their response. In an effort to reduce the risk of medical errors, the chair of the Commission on Case Management Certification, Hussein A. Tahan, provides an in-depth discussion of the core components of the process of case management, which certainly should reduce the potential risks. Because we live in a world where the common response to some situations, especially harm-causing ones, is legal action, we are very excited to introduce the newest member of The Case Manager family of contributors and columnists, Gayle Sullivan, RN, JD. Her column, Courtside, will be a regular feature, and she will discuss issues of concern and interest to case managers. Her inaugural column offers a fascinating discussion of a case that may be familiar to you, explores what went wrong, and then demonstrates how adherence to Case Management Society of America standards of practice might have resulted in an entirely differ-
ent outcome. It’s another encouraging reminder that these standards need to be an active part of our practice, rather than a document tucked away in a file drawer. Because nothing speaks louder than real life examples, we have also provided several excellent illustrations of situations that a few of our colleagues have faced and their responses to them. While we all need to know the issues and risks of medical errors, it’s also equally important to present the upside examples of effective patient safety programs and positive actions that you as case managers can incorporate within your own practice setting. Deborah Smith provides an analysis of the financial impact of medical errors, an overview of the patient safety movement in this country, and an encouraging discussion of how this problem offers incredible opportunities for case managers to demonstrate their value. In another thought-provoking article, Sherrie Dulworth encourages not only individuals to practice safely but entire organizations as well, urging us to develop a culture of patient safety. As I conclude my thoughts, I’m wondering if you recall how I began this column. Yes, my third grandson entered the world safely—Brendan Michael Mullahy has joined his brother, Matthew Ryan, and cousin, Declan Michael. Their Nana has completed another editorial, spring is finally here, and all is right with the world! Because this issue will be distributed at CMSA’s annual conference, I wish you a successful and enjoyable event. Take this special time to renew your spirit, network with friends and colleagues, and know that you make a difference— one case at a time. ❑
Catherine M. Mullahy, RN, CCM Editor [email protected] doi:10.1016/j.casemgr.2005.05.001
MAKING THE WORLD A SAFER PLACE
A
s I put my thoughts together for this issue’s editorial, I await the birth of my third grandchild. My son has called, and we’ll meet at the hospital to be together for the safe delivery of this newest addition to our family. Thoughts of patient safety take on new meaning, because yes, it’s now personal. More and more we hear about medical errors and patient safety concerns when patients enter hospitals today. We learn about amputations of the wrong extremity, medication overdoses, instruments left in abdominal cavities, orders written on the wrong patient chart, etc., featured on the nightly news and illustrated as cases on TV programs such as Law and Order. Has the number of incidents risen so dramatically that it has commanded the attention of professionals, consumers, payers, the other stakeholders in our health care delivery system, and the media, or are we now more willing to acknowledge that mistakes occur? Certainly, case managers are aware of the increased number of errors and incidents and are well positioned as advocates to protect patients from the harm that occurs. However, as with other challenges in case management, the matter is not as easy or as simple as that. Each of us has a responsibility to promote patient safety. Our professional license, standards of practice, and codes of professional conduct provide direction and guidance. While we accept that individuals make mistakes, there are consequences when they are uncovered or disclosed, and these can be highly significant on a personal, professional, and financial basis. From the “routine” completion of an incident report all the way through the loss of license, professionals in every practice setting are concerned when they are involved in an error-causing event. For institutions or businesses, the financial consequences can be devastating when errors become publicized. It should be no surprise, then, that patient safety is no longer just a blip on a radar screen but rather a highly important matter that has taken on a life of its own, attracting widespread attention in TCM 14
May/June 2005
the private and public sectors. With all this attention, we would assume that we have buy-in from all involved, especially health care professionals and the institutions or organizations that employ them because patients are at the very center of their mission as providers. Unfortunately, in many cases a cone of silence exists regarding the disclosure of errors, with occasionally more time and effort expended to keep things quiet than examining causes and learning from the mistakes. The protection of the professionals involved and the business and financial concerns seems to supersede the best interests of the patient. It is our hope that this special focus issue will result in many conversations among our readers within their diverse practice settings and that these discussions will lead to initiatives and programs to prevent errors and promote a culture of honesty and a real desire to do the right thing. We also hope that our patients will receive safe, appropriate care in an environment that they and their families can trust. Our resident ethicist, John Banja, has two contributions to this important edition—a discussion of the basic issues and then a more specific examination and analysis of the conflicts facing case managers and their response. In an effort to reduce the risk of medical errors, the chair of the Commission on Case Management Certification, Hussein A. Tahan, provides an in-depth discussion of the core components of the process of case management, which certainly should reduce the potential risks. Because we live in a world where the common response to some situations, especially harm-causing ones, is legal action, we are very excited to introduce the newest member of The Case Manager family of contributors and columnists, Gayle Sullivan, RN, JD. Her column, Courtside, will be a regular feature, and she will discuss issues of concern and interest to case managers. Her inaugural column offers a fascinating discussion of a case that may be familiar to you, explores what went wrong, and then demonstrates how adherence to Case Management Society of America standards of practice might have resulted in an entirely differ-
ent outcome. It’s another encouraging reminder that these standards need to be an active part of our practice, rather than a document tucked away in a file drawer. Because nothing speaks louder than real life examples, we have also provided several excellent illustrations of situations that a few of our colleagues have faced and their responses to them. While we all need to know the issues and risks of medical errors, it’s also equally important to present the upside examples of effective patient safety programs and positive actions that you as case managers can incorporate within your own practice setting. Deborah Smith provides an analysis of the financial impact of medical errors, an overview of the patient safety movement in this country, and an encouraging discussion of how this problem offers incredible opportunities for case managers to demonstrate their value. In another thought-provoking article, Sherrie Dulworth encourages not only individuals to practice safely but entire organizations as well, urging us to develop a culture of patient safety. As I conclude my thoughts, I’m wondering if you recall how I began this column. Yes, my third grandson entered the world safely—Brendan Michael Mullahy has joined his brother, Matthew Ryan, and cousin, Declan Michael. Their Nana has completed another editorial, spring is finally here, and all is right with the world! Because this issue will be distributed at CMSA’s annual conference, I wish you a successful and enjoyable event. Take this special time to renew your spirit, network with friends and colleagues, and know that you make a difference— one case at a time. ❑
Catherine M. Mullahy, RN, CCM Editor [email protected] doi:10.1016/j.casemgr.2005.05.001