Background: The Institute of Medicine Report

In 1999 the Institute of Medicine released a report estimating that up to 98,000 people die each year in U.S. hospitals because of inadequate patient safety. Inpatient areas, especially critical care units, are particularly vulnerable to error. A complex interaction of attending physicians, residents, fellows, nurse practitioners, physician assistants, nurses, and pharmacists are responsible for the continuous and high-risk care dedicated to these patients; often there are multiple subspecialty services participating in patient care as well. Communication between team members may be fragmented and incomplete, leading to mistakes. In addition, the severity of disease leaves patients particularly vulnerable to morbidity and mortality resulting from medical error.

The Pediatric Experience

In the pediatric intensive care population, up to 8% of patients experience complications of care, and 4.6% of patients may experience iatrogenic illness, including infection, adverse drug reactions, and improper procedures.^1,2 Iatrogenic illness results in the need for further treatment, increasing risk to the patient from exposure to medications or procedures and causing increased expenditures. Studies show that preventable medical errors are more frequent in younger patients, in those with prolonged intensive care unit (ICU) stays, and in those with more severe illnesses. Although most mistakes are minor (78%), up to 3% may be serious events.³ In light of this increasing burden of evidence, much focus has been placed on system-wide improvements in patient safety. A large contribution to the change in culture has been driven by The Joint Commission, which provides national accreditation to hospitals meeting certain standards. Approximately half of The Joint Commission’s standards are safety related, covering topics including medication use, infection control, surgical safety, sedation and restraint use, staffing, fire safety, medical equipment safety, and emergency management. These national standards are designed in an attempt to ensure consistent application of care and thus reduce the risk for adverse events. One component of this system is The Joint Commission’s Sentinel Event Policy. Under this program, events that result in unexpected death or serious injury are evaluated by the hospital using a root cause analysis. This analysis is expected to result in changes to organizational systems and processes limiting the risk for similar events occurring in the future. These events and the interventions undertaken as a result may be reported to The Joint Commission and shared with health organizations throughout the country.

Pay-for-Performance as Incentive to Safer Care

In addition to The Joint Commission, private groups have emerged as a driving force in patient safety. One example is The Leapfrog Group. This group consists of several large corporations that are significant purchasers of health care. They produce a voluntary quality and safety survey that hospitals may choose to participate in. The results, emphasizing quality of care and safety, are published and publicly available. Meeting these types of standards may allow hospitals to negotiate preferred rates of reimbursements with insurers, adding a monetary incentive to the delivery of safe care. Some of the measures that The Leapfrog Groups tracks and reports include the use of computerized order entry, adherence to national quality practices, and the staffing of intensive care units with physicians specifically trained in intensive care medicine, all initiatives that have been shown to play a role in improving the quality of care and reducing medical errors.

This pay-for-performance model has gained popularity with both private and public insurers, and recent legislation requires the Centers for Medicare and Medicaid Services (CMS) to initiate this type of approach for Medicare.⁴ In order to ensure adherence to the quality and safety measures outlined in pay-for-performance programs, many hospitals and physicians have implemented care bundles. Based on disease or type of procedure, these bundles outline a consistent approach to care, incorporating the most recent safety and quality data.