The University of Texas Medical School
Memorial Hermann Center
for Health Care Quality and Safety

Improving medical error rates
through research, education

By Darla Brown

Heart disease. Cancer. Common causes of death, right?
Medical errors?

The eighth-most common cause of death.

On average, Americans are treated correctly only 54 percent of the time, according to a 2003 New England Journal of Medicine study.

In order to improve these numbers for current and future patients, a collaborative partnership has been formed – The University of Texas Medical School Memorial Hermann Center for Health Care Quality and Safety.

The center will focus on discoveries and practical applications to promote quality improvement in medical settings and is aimed at both students and practicing professionals.

The center is part of a nationwide call to action to address medical errors. Last month, the New York City Health and Hospitals Corporation began to make infection and death rates public in response to concerns over hospital mistakes. And Medicare officials have announced they will no longer cover extra costs of preventable hospital errors and conditions. Across the country, hospitals have begun to volunteer error rates to patients, while in other states information is mandated as the public’s right to know – promoting accountability.

Back at the Medical School, the new center is the culmination of 13 years of patient safety research by Eric Thomas, M.D., associate professor of internal medicine, who directed the UT Center of Excellence for Patient Safety Research and Practice, a collaborative effort established by the Agency for Healthcare Research and Quality that translated aviation safety methodology to the health care arena.

The type of research the new center’s faculty will tackle includes improving teamwork among providers, measuring and improving safety culture, and diagnostic errors.

“We’re continuing to work on how to measure and improve teamwork among doctors and nurses using aviation training programs,” explains Dr. Thomas, holder of the Griff T. Ross Professor in Humanities and Technology in Health Care.

Nowhere is this training more critical than for new interns who are learning neonatal resuscitation. In the Medical School’s Surgical and Clinical Skills Center (SCSC), residents practice their technique using high fidelity simulators that respond to mistakes and proper procedures.

“We are going to be generating new knowledge that providers find useful, for instance the safety attitude questionnaire that several hundred thousands of health care providers have already filled out and is used annually by dozens of hospitals,” Dr. Thomas says.

Uncovering attitudes regarding teamwork and the climate for reporting errors are important when looking at the root cause of mistakes and organizational impediments, Dr. Thomas says.

“We are looking at the safety culture and studying organizational learning, analyzing how hospitals learn from reporting of errors. We also will investigate the implementation of error reporting systems, which hospitals can use to track and learn from errors, adverse events, and close calls,” he adds.

Projects with Memorial Hermann System include studying the effectiveness of their electronic intensive care unit, which uses telemedicine to broadcast specialists to outlying hospitals. “We’ll be evaluating its impact on patient care,” Dr. Thomas says.

Positive outcomes for patient care are the results Memorial Hermann System officials are seeking through this unique partnership.

“The Memorial Hermann Healthcare System is committed to providing the ‘Best of the Best’ care to our patients, with compassion and exceptional service,” says Michael Shabot, M.D., chief medical officer for the Memorial Hermann Healthcare System. “By ‘Best of the Best,’ we mean the safest possible care and the most effective evidence-based treatment protocols, measured on a national scale. We have partnered with The University of Texas to create The University of Texas Medical School Memorial Hermann Center for Health Care Quality and Safety to expedite the achievement of these goals for our patients.”

The center also will create an innovative safety curriculum for the Medical School, aimed at fourth-year students.

The SCSC also will be used in partnership as a site to study missed and delayed diagnoses of breast, colon, and lung cancers, facilitated by standardized patients. “We’re going to try to understand some of the mistake physicians make and learn from that,” Dr. Thomas says.

In addition to the core faculty, which will include two new faculty members in addition to Dr. Thomas, the center is highly multidisciplinary and will seek collaboration from faculty throughout the Health Science Center, the Texas Medical Center, and beyond.

“The area of patient safety involves statistics, sociology, social psychologists, human factors engineers – collaboration is key,” Dr. Thomas says.

The center will join forces with UT’s new National Institutes of Health-funded Center for Clinical and Translational Science (CCTS), sharing resources and space.

“The CCTS focuses on the translation of basic science to the bedside, and we focus on a subsequent step of translation, to safe, effective care,” Dr. Thomas explains.