Evidence-Based Evaluation of American Medical Risk Monitoring and Precaution System_Chinese Journal of Evidence-Based Medicine

Authors：

 YANG Kehu ¹ , MA Bin ¹ , TIAN Jinhui ¹ , LIU Yali ¹ , Zhang Zhongnan ¹ , LI Youping ² , Wang li ² , DUAN Mingyou ³ , WANG Yu ⁴ , ZHANG Zongjiu ⁴ , ZHAO Minggang ⁴ , LU Jun ⁵ , LIU Qilin ⁵

1. Evidence-Based Medicine Center of Lanzhou University, Lanzhou 730000, China 2. Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu 610041, China 3. Tuha Petroleum Hospital, Hami 839009, China 4. Department of Medical Administration, Ministry of Health, Beijing 1000441,China 5. Chinese Medical Doctor Association, Beijing 100711, China;

Corresponding author：

YANG Kehu, Email: yangkh2006@163.com

Keywords：

Medical risk; Risk management; Medical error; Patient safety; Evidence-based evaluation; America

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Objective 　To evaluate evidence from American medical risk monitoring and precaution system (AMRMPS) which may affect the construction of Chinese medical risk monitoring and precaution system (CMRMPS).
Methods 　We searched relevant databases and Internet resources to identify literature on AMRMPS, medical errors, and patient safety. We used the quality evaluation system for medical risk management literature to extract and evaluate data.
Results 　In 1999, a report from the Institute of Medicine (IOM) not only showed the severity and cause of medical errors in America but also gave the solution of it. In 2000, the Quality Interagency Coordination Task Force (QuIC) was appointed to assess the IOM report and take specific steps to improve AMRMPS. After 5 years, a well-developed medical risk management system was established with the improvement in the public awareness of medical errors, patient safety, performance criteria of medical safety, information technology and error reporting system. There was still some weakness of this system in risk precaution and prevention.
Conclusion 　The experience from AMRMPS can be used to establish the CMRMPS. Firstly, we should disseminate and strengthen the awareness of medical risk and patient safety in public. Secondly, we should establish hospital audit system which includes auditing of medical staff and course of medical risk in continuing and academic education. Thirdly, we should develop regulations and guidelines on health care, medical purchase and drug supply which will benefit in management of regular work. Fourthly, we should develop computer information system for hospital which will regulate the management without the disturbance from human. Lastly, we should emphasize outcome evaluations and strive for perfection during the process.

Citation： YANG Kehu,MA Bin,TIAN Jinhui,LIU Yali,Zhang Zhongnan,LI Youping,Wang li,DUAN Mingyou,WANG Yu,ZHANG Zongjiu,ZHAO Minggang,LU Jun,LIU Qilin. Evidence-Based Evaluation of American Medical Risk Monitoring and Precaution System. Chinese Journal of Evidence-Based Medicine, 2006, 06(6): 439-450. doi: Copy

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2.	殷大奎. 医疗风险之我见. “2005国际医疗风险管理与病人安全研讨会”资料汇编; p22.
3.	李大川. 加强我国医疗风险建监管,确保病人安全.“2005国际医疗风险管理与病人安全研讨会”资料汇编 p28.
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8.	Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry, 1999; (36):255-264.
9.	Brennan TA, Leape LL, Laird NM. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New Engl J Med, 1991; 324(6): 370-376.
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16.	QuIC Fect Sheet. Available from URL: http://www.quic.gov/about/quicfact.htm.
17.	QuIC Workgroups. Available from URL: http://www.quic.gov/workgroups/index.htm .
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22.	Berman A. Reducing medication errors through naming, labeling, and packaging. Journal of Medical Systems, 2004; 28(1): 9~29.
23.	Dean B. Learning from prescribing errors. Quality & Safety in Health Care, 2002; 11(3): 258~260.
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39.	Liu TK, Tang HY, Zhu YJ. Overview of American Health Insurance and Health System Reform. Foreign Medicine: Hospital Administration, 1998; (4): 145-147.
40.	Available from URL: http://new.cms.hhs.gov/History/.
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45.	Yin DK. Dr Yin assess the medical risk. 2005 International Symposium on Healthcare Risk Management and Patient safety. BeiJing. China, 2005. p22.
46.	Li DC. Ensuring the patient safety by strengthening medical risk management in China. 2005 International Symposium on Healthcare Risk Management and Patient safety. BeiJing. China, 2005 p28.
47.	Bagian JP, Gosbee JW. Developing a culture of patient safety at the VA. Ambul Outreach 2000 Spring; 25-29.
48.	Lester H, Tritter JQ. Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error. Med Educ, 2001; 35(9): 855-861.
49.	Department of Health. The notice that drug administration published ,《Report System of the great medical error and incident》.Available from URL: http://www.moh.gov.cn/public/open.aspx?n_id=1570&seq=0.
50.	China will perform report system of great medical error and incident from 1 September, 2002.Available from URL:http://www.law999.net/news/doc/LAWN/2002/08/23/00003833.html.
51.	Xu HP, Hu fh, Cui JH. The compensation medical dispute under the protection of the doctor-patient interests. Law and Medicine, 2000, 1: 14-15.

1. 刘同奎, 汤洪延. 美国医疗保障制度与卫生体制改革概述. 国外医学: 医院管理分册, 1998; (4): 145-147.
2. 殷大奎. 医疗风险之我见. “2005国际医疗风险管理与病人安全研讨会”资料汇编; p22.
3. 李大川. 加强我国医疗风险建监管,确保病人安全.“2005国际医疗风险管理与病人安全研讨会”资料汇编 p28.
4. 卫生部国家中医药管理局关于印发《重大医疗过失行为和医疗事故报告制度的规定》的通知. Available from URL: http://www.moh.gov.cn/public/open.aspx?n_id=1570&seq=0.
5. 中国9月1日起将实行重大医疗过失事故报告制度. Available from URL:http://www.law999.net/news/doc/LAWN/2002/08/23/00003833.html.
6. 徐红平, 胡丰涵, 崔建华. 医患利益保护下的医疗纠纷赔偿. 法律与医学杂志, 2000; 1: 14~15.
7. The Quality Interagency Coordination Task Force (QuIC). Doing what counts for partient saferty: federal actions to reduce medical errors and their impact (report to the president). February 2000.
8. Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry, 1999; (36):255-264.
9. Brennan TA, Leape LL, Laird NM. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New Engl J Med, 1991; 324(6): 370-376.
10. Leape LL, Brennan TA, Laird N. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med, 1991; 324(6): 377-384.
11. Kohn LT, Corrigan JM, Donaldson MS, eds. The Institute of Medicine. To Error is Human: Building a Safety Health System. (Washington: National Academy Press, 1999) .
12. Allen S, Staff G. Five years later, medical errors is still a leading killer. November 9, 2004.
13. The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. March 2001. Available from URL: http://www.iom.edu/Object.File/Master/27/184/Chasm-8pager.pdf.
14. About the Commission. Available from URL:http://www.hcqualitycommission.gov/about.html.
15. The White House Office of the Press Secretary. Establishment of QuIC Task Force . March 13, 1998. Available from: URL: http://www.quic.gov/press/press1.htm.
16. QuIC Fect Sheet. Available from URL: http://www.quic.gov/about/quicfact.htm.
17. QuIC Workgroups. Available from URL: http://www.quic.gov/workgroups/index.htm .
18. Schrappe M. Patient safety and risk management. Medizinische Klinik, 2005; 100(8): 478-485.
19. Battles JB, Lilford RJ. Organizing patient safety research to identify risks and hazards. Quality and Safety in Health Care, 2003; 12 Suppl 2: ii2-7.
20. Berte LM. Patient safety: Getting there from here - Quality management is the best patient safety program. Clinical Leadership and Management Review, 2004; 18(6): 311-315.
21. Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Affairs, 2004; 23(4): 22-32.
22. Berman A. Reducing medication errors through naming, labeling, and packaging. Journal of Medical Systems, 2004; 28(1): 9~29.
23. Dean B. Learning from prescribing errors. Quality & Safety in Health Care, 2002; 11(3): 258~260.
24. Lambert BL., Lambert BL, Chang KY, et al. Effect of orthographic and phonological similarity on false recognition of drug names. Social Science and Medicine, 2001; 52(12): 1843-1857.
25. Resident education in quality and risk management. QRC advisor, 1989; 5(10): 1-2.
26. Risk management education for the office staff. An important ingredient to successful malpractice prevention. Michigan medicine, 1994; 93(3): 20-22.
27. Grenvik A, Schaefer JJ. New aspects on critical care medicine training. Current Opinion in Critical Care, 2004; 10(4): 233-237.
28. Patient Safety Research in Progress. No. 05-P003-3 Revised, No. 05-P003-1 & 05-P003-2. AHRQ Pub. June 2005.
29. Rosenthal J, Booth M. Maximizing the Use of State Adverse Event Data to Improve Patient Safety. October 2005.
30. Healthgrade Quality Study: Second Annual Patient Safety in American Hospital Report by Health Grades Inc. May 2005.
31. The Kaiser Family Foundation, Agency for Healthcare Research and Quality and the Harvard School of Public Health. November 2004.
32. Woodcock J, Overview of drug Safty in the US. Committee on the Assessment of the US Drug Safety System, June 8, 2005.
33. FDA . Medication errors: An FDA perspective. January 6, 2005 Available from URL: http://www.iom.edu/CMS/3809/22526/24262/24536.aspx .
34. Zhan, C., E. Kelley, et al. Assessing patient safety in the United States: Challenges and opportunities. Medical Care, 2005; 43(3 SUPPL).
35. MedPAC. Quality of care for Medicare beneficiaries. Report to the Congress: Medicare Payment Policy. March 2005.
36. Advances in Patient Safety：From Research to Implementation. Brent C. James. Prologue: Five years later—Are we any safety?.
37. Berwick DM. Invisible injuries. (Op-ed column) The Washington Post 2003 July 29; p.A17.
38. Morrissey J. Patient safety proves elusive. Mod Healthc, 2004; 6-7, 24-5, 30, 32.
39. Liu TK, Tang HY, Zhu YJ. Overview of American Health Insurance and Health System Reform. Foreign Medicine: Hospital Administration, 1998; (4): 145-147.
40. Available from URL: http://new.cms.hhs.gov/History/.
41. Fostering Rapid Advances in Health Care: Learning from System Demonstrations. Available from URL: http://www.iom.edu/CMS/3809/4639/4294.aspx .
42. Priority Areas for National Action: Transforming Health Care Quality. Jan 7, 2003. Available from URL: http://www4.nationalacademies.org/news.nsf/isbn/0309085438?OpenDocument.
43. Patient Safety: Achieving a New Standard for Care. Available from URL: http://www.iom.edu/CMS/3809/4629/16663/27174.aspx.
44. 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities. September14, 2004. Available from URL:http://www.iom.edu/CMS/3809/9868/22344.aspx.
45. Yin DK. Dr Yin assess the medical risk. 2005 International Symposium on Healthcare Risk Management and Patient safety. BeiJing. China, 2005. p22.
46. Li DC. Ensuring the patient safety by strengthening medical risk management in China. 2005 International Symposium on Healthcare Risk Management and Patient safety. BeiJing. China, 2005 p28.
47. Bagian JP, Gosbee JW. Developing a culture of patient safety at the VA. Ambul Outreach 2000 Spring; 25-29.
48. Lester H, Tritter JQ. Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error. Med Educ, 2001; 35(9): 855-861.
49. Department of Health. The notice that drug administration published ,《Report System of the great medical error and incident》.Available from URL: http://www.moh.gov.cn/public/open.aspx?n_id=1570&seq=0.
50. China will perform report system of great medical error and incident from 1 September, 2002.Available from URL:http://www.law999.net/news/doc/LAWN/2002/08/23/00003833.html.
51. Xu HP, Hu fh, Cui JH. The compensation medical dispute under the protection of the doctor-patient interests. Law and Medicine, 2000, 1: 14-15.

Chinese Journal of Evidence-Based Medicine

Evidence-Based Evaluation of American Medical Risk Monitoring and Precaution System

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