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Quality Of Care

Improving Quality, Minimizing Error: Making It Happen

Abstract

 
Medical errors and the quality problems to which they lead harm millions of Americans each year. If we are to reduce errors and improve quality substantially, we must create systems and care processes that anticipate inevitable human errors and either prevent them or compensate for them before they cause harm. Formidable barriers now stand in the way of progress. Success will require a multifaceted strategy, including public education, government investment and regulation, payment system restructuring, and leadership from within the delivery system.

A Theoretical Framework

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Error. The definition of error adopted from cognitive psychology and used in the IOM report is "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."³ Researchers have observed recurring patterns in the kinds of errors people make in ordinary life. They have categorized types of errors on the basis of how those errors relate to particular aspects of normal thought processes. James Reason has summarized the history of this work, added his own insights, and integrated this body of knowledge into a powerful set of analytic principles.⁴

This theoretical framework identifies three types of error: slips, lapses, and mistakes. Slips are observable actions that deviate from what was planned (for example, pouring coffee into the sugar bowl). Lapses are usually failures of memory that also result in planned actions not being carried out (such as going to a bookshelf to retrieve a dictionary but removing a novel instead). While slips and lapses are errors of execution, mistakes involve failures of reasoning that result in the choice of a plan that is inadequate to achieve the intended objective (for example, selecting a half-inch wrench to turn a three-quarter-inch bolt). Each of these kinds of errors can be further subtyped based on the cognitive processes associated with it, and each has different implications for remediation.

Reason has used this formulation of error to explain the relationship between errors made by individuals and calamities such as the Challenger disaster and the Chernobyl nuclear reactor accident.⁵ These catastrophes, which Reason terms "organizational accidents," are not the result of single, identifiable errors made by single individuals. Rather, a series of individual errors occurs. To prevent a calamity, the organization’s defenses must be able to intercept or "absorb" the errors. Yet every organization experiences weaknesses in its defensive systems. It is the interaction between the errors of individuals ("active errors") and these system flaws ("latent conditions") that leads to harm. These insights have just begun to influence thinking about errors in health care.⁶

Quality and error. In the words of the IOM’s 1990 definition, "Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."⁷ Three kinds of quality problems expose patients to harm by decreasing the likelihood of desired outcomes.⁸ Overuse occurs when we provide health services even though their risk exceeds their benefit. Underuse occurs when we fail to provide effective care that would improve outcomes. Misuse occurs when we provide appropriate care without the requisite skill, thereby increasing the risk of complications.

So how can we integrate these two bodies of thought on quality and errors? We suggest that Reason’s analytic formulations of errors and organizational accidents provide important new insights into the nature of our quality problems. Although the IOM report focused on errors leading to misuse, errors trigger all three types of quality problems. But not all errors lead to quality problems—only those errors that decrease the likelihood of desired health outcomes do so. A patient need not suffer an injury as the result of an error to characterize its effect as a quality problem; all that is required is that the error decrease the likelihood of a desired outcome. Thus, quality problems include both near misses and actual injuries. At the same time, not all injuries that occur during the course of medical care are associated with errors. Injuries not associated with errors do not represent quality problems.

For example, giving an antibiotic to a patient with a cold is an error (the use of a wrong plan, since antibiotics do not kill the viruses that cause colds). This error can be further categorized as a mistake. It causes a quality problem because such patients are needlessly exposed to the risk of adverse drug reactions and infections with antibiotic-resistant organisms. On the other hand, if a patient without a known allergy to penicillin has a severe allergic reaction after it is appropriately prescribed, he suffers an injury due to medical care (often called an adverse event). But it is not a quality problem, because no errors were made.

Errors that lead to overuse are typically mistakes. Errors that lead to underuse, such as failing to administer influenza vaccine to an elderly patient during an office visit for hypertension, can be either lapses or mistakes. Misuse problems can be associated with all three kinds of errors. Medication errors, for example, may occur when a physician who intends to write a prescription for 0.5 milligrams of a drug instead writes 5 milligrams (a slip). A nurse may deliver a dose of a medication hours late because of a lapse. Mistakes occur when physicians fail to decrease medication dosages appropriately in patients with poor kidney function.

Within complex health care delivery settings, we often observe the same patterns of individual errors and system flaws that Reason describes in his analysis of organizational accidents. Studies of medication errors that lead to injuries, for example, have found that multiple individual errors frequently occur in the setting of several dysfunctional systems (for example, those that attempt to verify patient identity or assure that information on allergies is always available) that fail to prevent the errors from resulting in harm.⁹ Similar patterns emerge from root-cause analyses of errors in which surgeons have operated on the wrong side of a patient’s body.¹⁰

The Magnitude Of The Problem

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Current evidence is overwhelming that errors and the three types of quality problems to which they lead harm millions of Americans every year. The evidence underlying this conclusion has been assembled and evaluated by a presidential commission, academic experts, and an interdisciplinary roundtable sponsored by the IOM.¹¹ Studies of overuse have found that twenty-four million Americans received antibiotics for colds and other upper respiratory viral infections in 1992; 16 percent of hysterectomies performed on women enrolled in a group of seven managed care plans were inappropriate; and 23 percent of recommended tympanostomy tube insertions (the most common surgical procedure of childhood) had inadequate clinical justification.¹² Recent Medicare data, primarily about underuse, from every state, show that in the median state only 55 percent of hospitalized patients with atrial fibrillation in 1998–99 received anticoagulation, a treatment proven to reduce the risk of stroke.¹³ Medication errors, perhaps the most common misuse problem, caused preventable injuries to hospitalized patients at a rate of about ten per week at each of two large (700-bed) urban teaching hospitals; one-fifth were life-threatening.¹⁴ The data are clear. Although the United States may have the capacity to produce the finest health care in the world, it fails to do so with a regularity that is shocking.

Two patterns of error. Two fundamentally different patterns of medical error deserve emphasis. Some health care providers are incompetent, impaired, or corrupt and make errors repeatedly despite multiple attempts at remediation. On the other hand, even the most highly trained and proficient professionals occasionally make mistakes. Although the types of errors made in these two sets of circumstances may at times be similar, they require very different improvement strategies. Addressing the latter requires major changes in the processes and systems through which health care is delivered, aiming to surround fallible individuals with mechanisms that prevent their unavoidable human limitations from leading to errors that do harm. Although most of our analysis focuses on this pattern of error, we must pay attention to both. System improvement can prevent some of the errors made by egregiously poor physicians from doing harm. Often, however, these physicians have distanced themselves from organizations such as hospitals or medical groups whose systems could affect them. Today’s disciplinary systems neither adequately identify these doctors nor mete out timely, appropriate punishment.¹⁵ We also emphasize that focusing on system improvement does not absolve individual practitioners from the responsibility to pursue excellence in the care they provide.

Recent Trends In Errors

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Very few studies have addressed how the magnitude of these problems has changed over time. There is good reason to believe, however, that the frequency and adverse impact of serious errors in medicine may be rising. Overall, evidence of improvement is weak. Sustained efforts, especially those involving multiple institutions or geographic regions, are very rare, and failure is common.¹⁶ Studies have demonstrated improvements in a few specific areas—such as anesthesia, coronary bypass graft surgery, percutaneous transluminal coronary angioplasty, and antibiotic overuse.¹⁷ Two hospitals have been particularly energetic and successful in reducing injuries resulting from medication errors.¹⁸

Growing body of knowledge. Unfortunately, several other powerful forces are operating in the other direction, widening the gulf between the benefit our health care system produces today and what it could deliver if errors were drastically reduced. One of these represents another side of the remarkable success we have had in developing new ways to fight disease. The amount of new research about what works to improve health and what does not has reached previously unimagined levels. As a rough index of this phenomenon, consider the form of research that generates the most valid data on the efficacy of health services, the randomized controlled trial (RCT). In the mid-1960s about 100 articles from RCTs were published annually in the medical research literature. By the mid-1990s the number was 10,000 per year and growing exponentially.¹⁹ Nonetheless, we have made little progress in creating mechanisms to synthesize this growing body of knowledge, package it in useful ways, and make it available to clinicians at the time they need it to improve decision making.

Complex systems. Alongside the burgeoning amount of information care givers must manage, we have created more and more complex systems in which they must deliver care. Complexity breeds errors. If each step in a ten-step process can be performed with 99 percent reliability, that system functions error-free 90 percent of the time. A similar process with fifty steps functions error-free only 61 percent of the time. Consider, for example, the challenges we face in treating early-stage breast cancer, a condition that is curable more than 90 percent of the time with high-quality care. Typically, a primary care physician refers a woman to a different location for mammography to screen for the disease. If a suspicious lesion is found, another referral occurs—to a surgeon, whose office is usually at another location and who may perform a biopsy at yet another facility. When the surgeon receives the results of the biopsy, a definitive surgical procedure (lumpectomy or mastectomy) is performed (at possibly a fifth location). The woman who was treated with lumpectomy is then referred for radiation therapy (location 6) and then for chemotherapy or tamoxifen by a medical oncologist (location 7).

Often, the physicians involved in this woman’s care do not practice within any common organizational structure. Most often, none of them has direct access to the records kept by any of the others, to the results of previous tests or examinations, or to the recommendations or plans made by the other treating physicians. Too often, the patient serves as the communication link among her physicians. Can it be surprising, therefore, that errors are common? A study of the care provided to women with early-stage breast cancer at four teaching hospitals in the New York metropolitan area showed that the probability a woman would miss either radiation following lumpectomy or adjuvant treatment with chemotherapy or tamoxifen ranged from one in six to one in three.²⁰

Cross-sectional studies. No longitudinal studies have directly addressed the question of whether rates of errors and the quality problems to which they lead are increasing over time. However, one pair of cross-sectional studies does provide some insight. Timothy Lesar and colleagues used the same methods to measure the frequency of errors made by physicians in prescribing medications to inpatients at a large, tertiary care hospital in upstate New York during two twelve-month periods seven and a half years apart.²¹ Using the same procedures in both time periods, pharmacists caught and corrected errors in physicians’ medication orders. The researchers counted only those errors in which the physicians concurred that they had made errors and tabulated those that had the potential to do severe, serious, or significant harm. The rate of such errors increased 122 percent between 1987 and 1994, from 1.80 to 3.99 per 1,000 orders. Medication use also increased between these two time periods, so the total number of these errors increased more than fourfold, from 522 per year to 2,103 per year. All of these reported errors were intercepted and prevented from doing harm; the researchers did not look for injuries attributable to nonintercepted errors. Their findings do, however, provide evidence that errors of this kind may be increasing.

How physicians are trained. At the same time that error-free health care of high quality is becoming increasingly difficult to provide, we persist in using age-old, even medieval, strategies and methods for training physicians.²² The most prevalent model for educating medical students assumes that medical school faculty can identify a finite body of knowledge that all students must master to become physicians. Ordinarily, after learning the basic sciences, students begin apprenticeships that continue during their residency training programs in specific clinical fields. Teaching rounds are conducted with senior physician faculty members instructing rigidly hierarchical teams of trainees and students. Little or no attention is paid to the importance of collaborating with other health care professionals. Thus, physicians emerge convinced that they are the sole sources of all important health care decisions, with little experience in functioning as parts of interdependent teams of caregivers. In addition to cutting young physicians off from the perspectives of others who are vital to the provision of excellent care, this mode of training also leads physicians to expect perfection in themselves and to view errors as personal failures.

This approach to educating and training physicians has far outlived its utility. If ever there was a finite body of knowledge that students could assimilate, that time has long since passed. Given the increasing pace of accumulation of medical knowledge, the only surety is that today’s knowledge is obsolete tomorrow. Instead of being masters only of memorization, physicians must become masters of acquiring necessary information from many different sources in a timely enough fashion to make correct clinical decisions. The amount of knowledge necessary to practice high-quality health care is just too large and changing too rapidly to be carried around in any person’s brain.

Also, physicians must recognize the critical roles played by other members of the health care delivery team (nurses, pharmacists, respiratory therapists, and social workers, to name a few). High-quality health care today can be delivered only by well-functioning, truly interdisciplinary teams. In addition, the training of all health professionals should instill a balance between the importance of striving for personal excellence and the understanding that improving the performance of systems is very often the most effective route to quality improvement. Finally, we must train physicians to be committed to a lifelong process of assessing and improving the quality of care they provide. By reacting far too slowly to these realities, both the settings in which physicians practice and the schools and hospitals that teach them have become part of the problem.

What Must Change?

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Changes in three areas are necessary to propel major improvements in health care. As just discussed, we must entirely revamp the education and training of health professionals. We must also improve the effectiveness of our disciplinary procedures in appropriately sanctioning health care practitioners who repeatedly make serious errors. Third, we must learn how to develop and deploy systems for delivering health services that will either prevent or anticipate and compensate for the errors that human beings inevitably make.²³ We focus on this third area here.

The aviation example. Although our processes and systems for delivering health care have become progressively more complex, we have not yet learned from other sectors of our society that have equally complex systems and for which failure is also a life-and-death matter. Some of these have become highly reliable, with rates of serious errors far lower than those to which we are accustomed in health care.²⁴ Air travel is a case in point. From 1995 through 1999, 483 people died in aircraft accidents while flying on U.S. commercial airlines. This translates to a death rate of eleven per million departures.²⁵ By comparison, underuse of proven-effective treatments for heart attacks leads to as many as 18,000 preventable deaths each year.²⁶ Some 750,000 Americans suffer heart attacks annually and get to hospitals in time for treatment to be initiated; therefore, our failure rate in this one disease is 24,000 preventable deaths per million patients hospitalized, more than 2,000 times the U.S. airlines’ death rate.

High-reliability industries share a simple set of ideas and practices. First, they understand that complex systems make it difficult for even the best-trained and -motivated workers to do a good job. They understand and prepare for the most common kinds of errors people make, and they design systems that anticipate and either prevent errors or compensate for them before they do harm. We are only beginning to understand that in health care a large number of preventable bad outcomes bear many of the characteristics of organizational accidents. They are commonly preceded by multiple failures, most of which are ultimately the result of poorly designed systems. Health care systems rely heavily on near-perfect performance by people. Our quality assurance processes emphasize finding the one person to blame for an error and punishing that individual in the expectation that better individual performance will result in fewer errors.

When the National Aeronautics and Space Administration (NASA) investigated a series of airplane crashes in the 1970s, it concluded that the most frequent immediate cause of crashes was failure of the cockpit crew to act as a team.²⁷ Aviation’s response was to create an entirely new training program—Crew Resource Management—that was designed to foster more effective communications among crew members. It focused on improving performance by improving the rate of error detection and reporting and appropriate and timely action within the structure of the cockpit team.²⁸ All airlines now use this method of improving teamwork. In health care, with equally or even more complex teams of professionals charged with caring for critically ill patients, real teamwork is rare.

Barriers To Change

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The effort to create, disseminate, and put in place these numerous new systems and approaches to reducing errors and improving quality is daunting. It demands that all parts of the delivery system —hospitals, physician practices, integrated delivery systems, nursing homes, and hospices—devote their scarce resources to the task. It will require a substantial investment of time, talent, energy, and money. The task is made much more difficult by the fact that there are no exemplars of excellence, institutions, or practices that have succeeded in achieving extremely low rates of errors across all dimensions of quality and across all of the services they provide.²⁹

If the evidence of errors and quality problems is so clear and compelling, what is standing in the way of improvement?

Little demand for higher quality. Neither consumers nor their representatives demand higher quality or fewer errors. Survey data indicate that consumers want wide choice among doctors and hospitals, low cost, and unimpeded access to their caregivers; they do not ask for information about quality, health outcomes, or rates of errors.³⁰ Neither public nor private purchasers of care have used their purchasing power to demand high quality, preferring to focus their efforts on obtaining low prices. Some voices from the purchaser community (such as the Leapfrog Group) are calling for greater attention to quality.³¹ Their initial efforts, however, are not focused on obtaining data on performance or improvement. Rather, they will provide information to employees on surrogate measures, such as the volume of services hospitals provide. Even in those rare circumstances when data on quality are available, research shows that neither consumers nor managed care companies use them to select higher-quality providers.³²

Lack of information technology. Another barrier is the high investment cost of creating the necessary measurement and improvement systems. Information technology (IT) does not yet link the myriad sources of information required to understand quality of care. The price tag is immense for developing and deploying a system to integrate data from doctors’ offices, clinical laboratories, hospital diagnostic imaging facilities, freestanding ambulatory surgery centers, radiation therapy facilities, and hospital medical records. And this list is not exhaustive. Although some commercial products are available to accomplish this task on a small scale, such systems are not available for medium-size or large hospitals, health systems, or populations. Further, assembling computerized data is just the beginning of quality measurement. In most circumstances, data from harder-to-reach clinical sources must be added to the more readily available automated data to produce measures clinicians will believe and on which they are willing to act. Finally, understanding how to alter complex clinical care systems to improve performance, intervening to improve, and sustaining that improvement require yet additional investments.

Skewed financial incentives. Even for organizations that are financially secure enough to consider investing in quality improvement, today’s health care payment environment is perverse. Even when quality improvement and cost savings can be achieved simultaneously, the cost of the improvement is borne by the health care provider, and the savings are often realized by another party. If a hospital reduces the number of unnecessary hysterectomies performed by its physicians, unless it is in the unusual situation of receiving a large share of its payments in the form of capitation, the savings from this improvement will accrue to a managed care company, to a private employer, to Medicare, or to Medicaid. Likewise, a state-of-the-art management program for improving quality and functioning in patients with asthma or heart failure is likely to reduce the number of hospital admissions and, again, reduce hospital revenue.

Policy Directions

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To make substantial progress toward improving health care quality, we call for a multifaceted strategy that involves all parties.

Education. First, to increase public demand for higher quality and fewer errors in health care, more vigorous efforts to educate the public about quality might be effective. Public and private employers could initiate such efforts by helping their employees to understand that they are not getting the full potential benefit from available health care—that quality problems imperil their health. Organizations representing consumers also have a responsibility in this regard; we note that the problem of overuse has gone nearly unrecognized as a major quality problem by the general public.

Reduced expense. Second, the cost of creating tools and systems to measure and improve quality must be reduced. The federal government should invest far more than it does today in research and demonstrations to build, evaluate, and disseminate the tools that hospitals, physician practices, nursing homes, and integrated delivery systems need. Private foundations should also participate. This effort is exactly analogous to the enormous postwar investment in the National Institutes of Health (NIH), which led to today’s new drugs, medical devices, and treatment regimens. If we are ever to realize the full potential benefit of that investment, we will have to make a large, sustained commitment to investing in quality improvement tools and systems.

Financial rewards. Third, to accelerate the pace of adoption of these tools and systems, purchasers of health care need to develop payment methods that reward excellence in quality. At present, no such method exists. Instead, the traditional fee-for-service mode of payment encourages overuse. Capitation or per case payments encourage underuse. Most providers of care face a bewildering array of payment methods, each with its own set of perverse quality incentives. A large number of valid measures of quality exist today. Purchasers should pay more for high-quality care. They could begin by reserving a portion—say, 10 percent—of their payments for particular services as a premium for high quality. Based on objective measures of quality for these conditions (for example, the proportion of heart attack survivors who are treated with beta-blockers), providers who most often provide all components of effective care would receive higher payments than those with poorer performance. Similar incentives should be designed for controlling overuse and misuse problems.

State regulation. Fourth, although regulation is out of favor, state governments continue to administer programs to identify and punish physicians and other health professionals whose performance is egregiously poor. These programs require substantial improvement. They now devote most of their resources to punishing physicians who abuse patients sexually, traffic in illegal drugs, or violate other criminal laws. They should pay far more attention to identifying and sanctioning physicians who routinely endanger patients because the quality of their care is so inadequate.

State governments can also facilitate the collection, analysis, and public dissemination of key data on health care quality. More state agencies should replicate the program established in New York State more than a decade ago to improve mortality following cardiac surgery.³³ The state health department receives data from hospitals on every patient who undergoes cardiac surgery, verifies their accuracy, and publishes risk-adjusted mortality data by surgeon and hospital annually. The improvement efforts undertaken by hospitals throughout the state have resulted in dramatic statewide declines in mortality following coronary artery bypass surgery. A study from researchers at Duke showed that New York had the lowest risk adjusted mortality of any state in the nation in 1992, the fourth year of the program, and experienced twice the national average rate of decline in this mortality rate from 1987 to 1992.³⁴

Provider leadership. Finally, health care providers should seize the leadership in error reduction and quality improvement by establishing evidence-based measures for all three kinds of quality problems. They should create model programs for improvement, document their impact, and disseminate their successes. Despite the high cost of such investments and the lack of payment schemes that reward high quality, it is nevertheless possible for providers to craft strategies that take advantage of those instances where quality improvement does result in a favorable impact on the hospital’s or system’s bottom line. If a few such institutions made quality improvement their highest priority in this way, their successes could motivate others by demonstrating what is possible.

An immense reservoir of professionalism still exists among physicians, nurses, and other caregivers. It is waiting to be effectively mobilized in the service of quality improvement. A great opportunity exists for those institutions that can ignite this enthusiasm and show all of us what truly high quality health care can be.

Editor's Notes

 
Elise Becher is assistant professor of pediatrics and health policy, Mount Sinai School of Medicine, in New York City. Mark Chassin is professor and chairman of the Department of Health Policy there.

An earlier version of this paper was presented at the Commonwealth Fund International Symposium on Health Care Policy, "Quality and Innovation: Issues, Strategies, and Implications for Policy," in Washington, D.C., 11–13 October 2000.

NOTES

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1. Institute of Medicine, To Err Is Human: Building a Safer Health System (Washington: National Academy Press, 1999); R. Weiss, "Medical Errors Blamed for Many Deaths," Washington Post, 30 November 1999, A1; Editorial, "Preventing Fatal Errors," Boston Globe, 23 February 2000, A18; R. Knox and G. Staff, "Patient Safety Center Advances: Groups Divided on Defining Errors," Boston Globe, 10 May 2000, A1; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000, A1; and M. Kaufman, "Clinton Seeks Medical Error Reports," Washington Post, 22 February 2000, A2.
2. L. Altman, "The Doctor’s World; Getting to the Core of Mistakes in Medicine," New York Times, 29 February 2000, F1.
3. IOM, To Err Is Human; and J. Reason, Human Error (Cambridge: Cambridge University Press, 1990).
4. Reason, Human Error.
5. J. Reason, Managing the Risk of Organizational Accidents (Aldershot, U.K.: Ashgate Publishing Ltd., 1997).
6. L. Leape, "Error in Medicine," Journal of the American Medical Association 272, no. 23 (1994): 1851–1857[Medline]; and J. Reason, "Human Error. Models and Management," British Medical Journal (18March 2000): 768–770.
7. K. Lohr, ed., Medicare: A Strategy for Quality Assurance (Washington: National Academy Press, 1990).
8. M. Chassin, "Quality of Care: Time to Act," Journal of the American Medical Association 266, no. 24 (1991): 3472–3473.[Medline]
9. L. Leape et al., "Systems Analysis of Adverse Drug Events," Journal of the American Medical Association 274, no. 1 (1995): 35–43.[Abstract]
10. Joint Commission on Accreditation of Healthcare Organizations, What Every Hospital Should Know about Sentinel Events (Oakbrook Terrace, Ill.: JCAHO, 2000).
11. Advisory Commission on Health Consumer Protection and Quality in the Health Care Industry, Quality First: Better Health Care for All Americans (Washington: U.S. Government Printing Office, 1998); M. Schuster, E.McGlynn, and R. Brook, "How Good Is the Quality of Health Care in the United States?" Milbank Quarterly 76, no. 4 (1998): 517–563[Medline]; and M. Chassin and R. Galvin, "The Urgent Need to Improve Health Care Quality," Journal of the American Medical Association 280, no. 11 (1998): 1000–1005.[Abstract/Free Full Text]
12. See, for example, R. Gonzales, J. Steiner, and M. Sande, "Antibiotic Prescribing for Adults with Colds, Upper Respiratory Tract Infections, and Bronchitis by Ambulatory Care Physicians," Journal of the American Medical Association 278, no. 11 (1997): 901–904[Abstract]; A.C. Nyquist et al., "Antibiotic Prescribing for Children with Colds, Upper Respiratory Tract Infections, and Bronchitis," Journal of the American Medical Association 279, no. 11 (1998): 875–877[Abstract/Free Full Text]; S.J. Bernstein et al., "The Appropriateness of Hysterectomy," Journal of the American Medical Association 269, no. 18 (1993): 2398–2402[Abstract]; and L.C. Kleinman, et al., "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger than 16 Years in the United States," Journal of the American Medical Association 271, no. 16 (1994): 1250–1255.[Abstract]
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15. J. Steinhauer, "Death in Surgery Reveals Troubled Practice and Lax Hospital," New York Times, 15 November 1998, A37; and J. Steinhauer, "Doctors’ Licenses Suspended over Faulty Mammograms," New York Times, 1 June 2000, B1.
16. Chassin et al., "The Urgent Need to Improve Health Care Quality";; S. Shortell, C. Bennett, and G. Byck, "Assessing the Impact of Continuous Quality Improvement on Clinical Practice," Milbank Quarterly 76, no. 4 (1998): 593–624[Medline]; and D. Blumenthal and C. Kilo, "A Report Card on Continuous Quality Improvement," Milbank Quarterly 76, no. 4 (1998): 625–648.[Medline]
17. See, for example, F. Orkin, "Patient Monitoring during Anesthesia as an Exercise in Technology Assessment," in Monitoring in Anesthesia, ed. L. Saidman and N. Smith (London: Butterworth-Heineman, 1993); E. Peterson et al., "The Effects of New York’s Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly," Journal of the American College of Cardiology 32, no. 4 (1998): 993–999[Abstract/Free Full Text]; E. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association 271, no. 10 (1994): 761–766[Abstract]; V. Ho, "Evolution of the Volume-Outcome Relation for Hospitals Performing Coronary Angioplasty," Circulation 101, no. 15 (2000): 1806–1811[Abstract/Free Full Text]; and R. Gonzales et al., "Decreasing Antibiotic Use in Ambulatory Practice," Journal of the American Medical Association 281, no. 16 (1999): 1512–1519.[Abstract/Free Full Text]
18. S. Pestotnik et al., "Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support," Annals of Internal Medicine 124, no. 10 (1996): 884–890[Abstract/Free Full Text]; and D. Bates et al., "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors," Journal of the American Medical Association 280, no. 15 (1998): 1311–1316.[Abstract/Free Full Text]
19. M. Chassin, "Is Health Care Ready for Six Sigma Quality?" Milbank Quarterly 76, no. 4 (1998): 565–591.[Medline]
20. N. Bickell, A. Aufses, and M. Chassin, "The Quality of Early-Stage Breast Cancer Care," Annals of Surgery 232, no. 2 (2000): 220–224.[Medline]
21. T. Lesar, L. Briceland, and D. Stein, "Factors Related to Errors in Medication Prescribing," Journal of the American Medical Association 277, no. 4 (1997): 312–317[Abstract]; and T. Lesar et al., "Medication Prescribing Errors in a Teaching Hospital," Journal of the American Medical Association 263, no. 17 (1990): 2329–2334.[Abstract]
22. Chassin, "Is Health Care Ready for Six Sigma Quality?"
23. Leape, "Error in Medicine."
24. J. Hicks, "A Revamping at Alcoa as Pressures Mount," New York Times, 10 August 1991, A33; C. Deutsch, "Six Sigma Enlightenment," New York Times, 7 December 1998, C1; and Chassin, "Is Health Care Ready for Six Sigma Quality?"
25. National Transportation Safety Board, "Passenger Injuries and Injury Rates, 1982 through 1999, for U.S. Air Carriers Operating under 14 CFR 121," Table 3, <www.ntsb.gov/aviation/table3.htm> (8 November 2000); and Aviation Federal Bureau of Transportation Statistics, "Activity Data for U.S. Air Carriers, 1994," <www.asy.faa.gov/safety_handbook> (8 November 2000).
26. M. Chassin, "Assessing Strategies for Quality Improvement," Health Affairs (May/June 1997): 151–161.
27. R. Helmreich, "Managing Human Error in Aviation," Scientific American (May 1997): 62–67.
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