Conference Update – December 1996 [Archive]

AMA, JCAHO Announce New Initiatives at Opening of
Nation’s Most Comprehensive Health Care Error Prevention Conference
RANCHO MIRAGE, CA, October 13 — The nation’s most comprehensive conference on preventing health care errors opened here today with the announcement of a new patient safety foundation and a national “accreditation watch” policy, and a call from keynoter Dr. Lucian L. Leape of Harvard University for hospitals and health care organizations to shift their focus in error prevention from punishing people to correcting systems.

“Even with the best training, resources and facilities, error can occur,” said Nancy W. Dickey, MD, chair of the Board of Trustees of the American Medical Association. “Every patient should know that medical professionals are working to make our great system even safer. One error will always be one too many.”

“In today’s health care environment, we are all accountable and we all must work together to prevent errors,” explained Dickey, “which is why the National Patient Safety Foundation will be a collaborative initiative involving all members of the health care community. Hopefully, by working together, as we are doing at this conference, we can make health care safer for our patients.”

The accreditation watch policy is being instituted by the Joint Commission on Accreditation of Healthcare Organizations. The new accreditation watch designation will be assigned to a health care organization if a Joint Commission-conducted on-site evaluation determines that the organization could have had control over circumstances leading to a sentinel event involving death or serious injury. Within 30 days of receiving an accreditation watch designation, an organization will be required to provide the Joint Commission with a written, root-cause analysis summary. The analysis is to focus primarily on systems and processes, not individual performance, and is to identify changes that will be made to reduce the risk of sentinel events in the future.

“No one, be it an individual or an organization, is immune to errors, but we believe strongly that accreditation must become an increasingly effective risk-reduction activity,” said Joint Commission president Dennis S. O’Leary, MD. “This new policy and approach should help us amass an expanding library of ‘lessons learned’ that can be shared with the 16,000 organizations across the country which are accredited by the Joint Commission.”

Leape noted that while much is known about how to decrease errors, “hospitals have been locked into a ‘crime and punishment’ approach to error reduction that is directed at individuals instead of the real root causes of error — faulty systems. Many systems changes that have been effective have not been sufficiently disseminated and implemented. Leape is the author of pathbreaking research articles on health care error, the most recent of which explored medication errors and was published by the Journal of the American Medical Association.

“There have been many advances in recent years in our ability to reduce errors in health care, particularly in anesthesia and medication usage, but we have a lot to learn from industries such as aviation and nuclear power,” observed Leape. “The purpose of this conference is to get people to talk to one another and then go home and implement proven remedies.”

Joining Leape, Dickey and O’Leary as speakers are Pulitzer Prize nominee Diane Vaughan, PhD, author of The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA, James H. Reason, PhD, professor of psychology at the University of Manchester, U.K., Pamela Liapakis, immediate past president of the Association of Trial Lawyers of America, William Hendee, PhD, of the Medical College of Wisconsin, and John J. Nance, an aviation safety expert. Moderating the opening session will be ABC News medical correspondent George Strait.

Additional conference speakers include Jim Conway, chief operating officer of the Dana Farber Cancer Institute, Linda Golodner, president of the National Consumers League, Marjorie Beyers, PhD, RN, executive director of the American Association of Nurse Executives, Donald M. Berwick, MD, president and chief executive officer of the Institute for Healthcare Improvement, Alexander Fleming, chief executive officer of the Massachusetts State Licensing Board, and Ellison Pierce, MD, founder and president of the Anesthesia Patient Safety Foundation.

Other speakers include A. Bruce Campbell, PhD, MD, associate chief medical officer, Aetna Health Plans, John Fletcher, PhD, a University of Virginia bioethicist, Victor Cohn, former science editor of the Washington Post and author of the column, The Patient’s Advocate, Linda L. Emanuel, MD, PhD, vice president, Ethics Standards Division, American Medical Association, Jack Christy of the California Physician Review Organization, and Brent James, MD, vice president for quality, Intermountain Health Care.

More than 50 presentations will be offered during 13 break-out sessions covering topics such as education and training, communication, legal issues, organizational processes, human factors, fatigue, drug use, anesthesia, surgery, drug treatment for deparession and other medication errors. In addition, a panel examining an actual instance of error will highlight the emotional, legal, ethical and professional issues that arise when an error is made that causes or contributes to injury.

With more than 300 participants, the conference has been organized by the American Association for the Advancement of Science, the American Medical Association, the Annenberg Center for Health Sciences at Eisenhower and the Joint Commission on Accreditation of Healthcare Organizations. Conference cosponsors include Aetna, the Agency for Health Care Policy and Research, the American Hospital Association, the American Society of Health-System Pharmacists Research and Education Foundation, CNA HealthPro, Glaxo Wellcome, Inc., the Institute for Healthcare Improvement, MMI Companies, Inc., Pfizer, Inc., the Physician Insurers Association of America, The Robert Wood Johnson Foundation, and 3M Company.

Media Contact: Steve Littlejohn 314-982-8649 or

1-800-SKY-PAGE (PIN#: 255-5380)

Conference Press Room: 619-773-1600

The media briefing conference call on Monday morning, October 14, 1996, beginning at 7am (Pacific)/10am (Eastern), can be reached by dialing 1-800-289-0437 and providing the access code 281571. The briefing will feature conference speakers and presenters, including Mark S. Frankel, Ph.D., director of the Scientific Freedom, Responsibility and Law Program of the American Association for the Advancement of Science, Dennis S. O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations; Ellison S. Pierce, MD, and David Gaba, MD, who will discuss advances in anesthesia error reduction; Nancy Dickey, MD, chairman of the Board of Trustees, American Medical Association; and Pam Lockowitz, senior vice president, MMI Risk Management Resources, Inc.