Patient Safety Concerns Prompt Special Sessions

APA’s Task Force on Patient Safety encourages all members to attend one or more educational programs at APA’s 2003 annual meeting relevant to patient safety. The scientific program includes a lecture by Lucien Leape, M.D., M.P.H., of the Harvard School of Public Health. A pioneer in this area, he will discuss “Making Health Care Safe.” In addition, the task force is sponsoring three workshops (Original article: see box).

Over the past three years, national attention has highlighted patient safety, and many organizations, such as the Institute of Medicine, the Joint Commission on Accreditation of Healthcare Organizations, and the Agency for Healthcare Research and Quality, have identified relevant issues and called for change.

Acknowledging the national concern, in late 2001 the APA Board of Trustees created the Task Force on Patient Safety. It was charged with making recommendations to improve patient safety and reduce preventable adverse events in three domains of psychiatric practice (seclusion and restraint, adverse medication events, and suicide assessment and intervention), addressed in the context of the systems in which care is delivered and achieved in collaboration with other major players in those systems of care.

In late 2002, the task force presented the Board with a report that includes recommendations for action by the APA leadership, practicing psychiatrists, district branches and state societies, and academia (Psychiatric News, December 20, 2002).

Success of a patient safety movement will require a change in clinical culture. Many physicians train and perform in an atmosphere that supports silence when an adverse event or “near miss” occurs. At the same time, many physicians recognize that errors in health care are more likely to result from failures in complex and interdependent medical, administrative, and communication processes rather than individual culpability. In light of this, susceptible environments that nearly or actually result in patient harm or death require systemwide redress, calling into question the basic notions of institutional culture regarding reporting and remediation. The report of the task force will be posted on APA’s Web site this month. ▪

Ms. Hart is director of APA’s Office of Quality Improvement and Psychiatric Services.