PRESS RELEASE

For Immediate Release
Date: May 25, 2004
Contact: Deborah Love
804-643-6631
ramdirector@ramdocs.org

Virginians Improving Patient Care and Safety

RICHMOND, Va. -- Every year in America, as many people die from medical missteps as would perish if a jumbo jet crashed every day. The public wouldn’t stand for that kind of error rate from the aviation industry, yet the quiet deaths that result from preventable medical mistakes are somehow tolerated.

Most of the deaths are caused not by tough judgment calls during complicated surgeries, but by simple mistakes by otherwise competent workers: wrong medicine, wrong dosage, wrong patient. To catch those errors before they kill, medicine must embrace the kind of built-in redundancies like checkbacks and readbacks that aviation instituted decades ago, argues Dr. Robert M. Wachter, a professor of medicine at the University of California, San Francisco, in his best-selling book Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. Aviation safety didn’t improve by suddenly minting better pilots, Wachter notes. The industry set up failsafe checklist redundancies that took a lot of simple human error out of the equation.

Wachter is one of several prominent national experts on patient safety who will speak during the fourth  annual conference of Virginians Improving Patient Care and Safety, a non-profit coalition of medical professionals, hospitals, insurers, regulators and educators formed in the months following the Institute of Medicine’s groundbreaking 1999 report that estimated as many as 98,000 Americans die annually from medical errors.

More than 500 health professionals, associations and concerned consumers are expected to attend the event, titled “Embracing the Future: Implementing Break-Through Systems and Tools.” The conference, at the Greater Richmond Convention Center, begins at 9 a.m. and concludes at 4:30 p.m. May 26. Wachter’s keynote speech is scheduled for 10:30 – 11:20 a.m.

The New York Times called Internal Bleeding “erudite, readable, and well-argued.” Library Journal described it as “brilliant, well-balanced, and easy-to-comprehend.” The Baltimore Sun noted that Wachter and co-author Kaveh G. Shojania refrain from attacking medical workers as “untrained, lazy or evil staff.” Instead, the authors “use their insiders' passes to tell a truth more horrifying: many of these patients died because of the inevitable slips that happen in any workplace or home."

Each year since the conference began, VIPC&S has expanded the audience it is reaching out to in its safety improvement efforts. “At the beginning we were focused primarily on sharing knowledge among health care professionals,” said VIPC&S president Dr. Sallie S. Cook, chief medical officer for the Virginia Health Quality Center in Richmond. “Now we’re continuing our message to health care professionals and including business leaders and consumers, with the goal of sharing information that will help patients navigate the health care system.” The conference has evolved from consciousness raising to specific outlines of successful programs and remedies that have been implemented throughout the country to reduce errors.

“We’re trying to segue from talking about patient safety ... to engaging people’s minds on using tools or programs they get from the conference to implement within their own institution,” said Dr. Richardson Grinnan, head of quality support systems for Anthem Blue Cross and Blue Shield.

Dr. David K. Warren, an infectious diseases professor at Washington University School of Medicine, will talk about hospital-acquired infections -- a huge national problem -- and evidence-based methods to prevent them.

Many deaths result from “handoff errors” that occur when vital records and medical instructions fail to follow a patient as they transition to different parts of the hospital or to another facility. Dr. Blackford Middleton, director of clinical informatics research & development at Partners Healthcare System and a medical professor at Brigham and Women’s Hospital, Harvard Medical School, will describe the value of electronic health records and computerized data entry for improving healthcare quality.

VIPC&S is increasingly attracting interest from the business community, which provides health insurance coverage nationwide for two out of three Americans under age 65, according to a 2002 study by the Kaiser Family Foundation. Dr. Arnold Milstein, medical director of the Pacific Business Group on Health in San Francisco and one of the co-founders of The Leapfrog Group (a consortium of more than 150 Fortune 500 companies dedicated to safer health care) will discuss how robust companies ensure higher quality patient care for their employees by directing their health benefits spending toward hospitals and physicians with better performance records.

Other keynote speakers include Clarence J. Biddle, Ph.D., a professor in the Department of Nurse Anesthesia at Virginia Commonwealth University and a clinical staff anesthetist at VCU Medical Center, who will teach error-avoidance skills and low-cost strategies to improve results in complex clinical situations; and Jeff Goldsmith, Ph.D., president of Health Futures, Inc. and an associate professor of medical education at the University of Virginia’s School of Medicine. Goldsmith will analyze trends that indicate what future health care delivery systems will likely include.

Virginians Improving Patient Care and Safety (VIPC&S) is a statewide, not-for-profit organization dedicated to the measurable improvement of patient safety and making safety a fundamental priority in all hospitals, nursing homes and other healthcare settings. The Richmond Academy of Medicine manages the association.