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Medical errors take a major toll in the U.S., with the Institute ofMedicine estimating that 98,000 people die each year as a result ofpreventable medicalerrors.1
People with diabetes bear a disproportionately high risk because they arefar more likely to be treated with insulin, which has been labeled one of thetop "high-risk medications" in an inpatientsetting.2
"We found that 33% of the medical errors that caused death within 48hours of the error involved insulin therapy and administration in the care ofa hospitalized patient," Richard Hellman, MD, FACE, FACP, wrote in theMarch/April 2004 issue of EndocrinePractice.2
In January, the medical community came together at the 2-day Patient Safetyand Medical-System Errors in Diabetes and Endocrinology Consensus Conferencein Washington, D.C., to address head-on the issue of how to reduce medicalerrors.
Hellman chairs the task force for the conference, which was sponsored bythe American College of Endocrinology (ACE) and the American Association ofClinical Endocrinologists (AACE) and drew participation from a wide variety oforganizations, including the American Diabetes Association (ADA).
WHO'S TO BLAME?
While some medication errors can be attributed to individual practitioners,the problem isn't always that clear-cut. Hellman and others—includingthe Institute of Medicine—have found that many errors aren't due to aclinician's mistake. Instead, he attests, flaws in how the medical systemdeals with patients with diabetes invite errors due to failures incommunication and lack of coordination among hospital departments or withinoffice staffs:
In flawed systems, errors are made even when individuals do their jobscorrectly. No matter the setting—inpatient unit or primary carepractice—Hellman recommends moving away from the culture of blame:"The sad truth is, if you just fire the nurse or physician who makes theerror, there's a high probability that their replacement will make the sameerror," he says.
A punitive model fosters an environment that leads to underreporting ofmedical incidents because most accidents are blamed on individuals rather thanthe environment in which they work, Hellman notes. "As a result,accidents rarely are investigated in sufficient detail to identify thesystematic causes."
CREATING A CULTURE OF SAFETY
How do health care providers remedy systems that invite error? It's asimple yet challenging endeavor, Hellman says. The key is in creating aculture of safety. The consensus group has come up with the "TIE"model: Team, Informatics, and Education:
Team. The consensus group recommends a "blame-free"reporting system that would use a systematic approach to identify errors,followed by a "thorough and frank" discussion of errors that wouldgive insights into underlying system problems that lead to medicalaccidents.
The group calls for state and national initiatives to develop a"workable medical-error reporting system."
Informatics. The group endorses implementing electronic patientrecords and widespread information-sharing systems. Similarly, standardizedsoftware that would allow data to be exchanged between systems would be a stepin the right direction. A computerized physician-order entry (CPOE) systemalso would help reduce medication errors that arise from illegiblehandwriting, ambiguous abbreviations, inappropriate combinations ofmedications, and wrong medications or doses.
"Medication errors and drug events are common in the outpatientsetting," the group notes in its position statement released at theconsensus conference. "However, the causes are somewhat different thanin the inpatient setting, and problems with follow-up are especiallyprominent. Implementing the electronic health record, including computerizedprescribing, will probably represent the most important strategy for improvingoutpatient medication safety."
Education. Better health education and communication betweenpractitioners and patients is a must, the group finds. "Patients neededucation that is more evidence-based and more flexible as to who that personis," Hellman says, and racial and cultural hurdles must be overcome.
Input from endocrinologists must be built into medical systems, Hellmaninsists. "[Endocrinologists] should become part of the multidisciplinarycare team in their hospitals to develop or adapt their protocols, educate teammembers, and help evaluate the performance of the team in the role ofmaintenance of euglycemia in more criticalsettings."2
The group's next goal is to come up with a consensus statement. They planto work with state commissions—starting with Maryland and Ohio, whosepatient-safety organizations sent representatives to the conference.
Patient-safety issues are sure to continue to emerge, Hellman says."With more insulins, more choices, more medications, and moreinterventions, you have more hazards and a greater threat to safety."The question remains: How can patients get the fruits of modern sciencewithout the hazards? 
References
2. Hellman R: A systems approach to reducing errors in insulin therapyin the inpatient setting. Endocr Pract 10 (Suppl. 2): 100–108, 2004.
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