An estimated 98,000 deaths per year are caused by medical errors.1 The Joint Commission has reported that errors in communication are the most frequent cause of medical mistakes resulting in patient harm and death.2 The cost to our economy is estimated to be a staggering $29 billion per year as a result of medical errors.1

CME plays a vital role in educating physicians by bridging the gap between what is actually taught in training and the realities of clinical practice. Clearly, one of the primary causes of today’s epidemic of medical errors results from the fact that physicians were never taught the intricacies on how to communicate well-both with patients and among themselves. CME provides a unique forum to teach physicians specific, well-proven communication techniques that can significantly improve medical care across all disciplines.

Historically, traditional medical school education and residency training did not place enough emphasis on effective communication techniques. More to the point, most physicians practicing today never received any formal training in medical error prevention during medical school or residency programs. As we move further into the 21st Century, health care organizations should strive to incorporate specific patient safety topics into their yearly CME schedules to address this educational need, not just as stand-alone topics, but in an integrated manner for all topics presented.

The Joint Commission is an excellent resource on patient safety topics, learning objectives and curricula content. Each year the Joint Commission publishes National Patient Safety Goals. This list alerts health care organizations and professionals to serious patient safety dangers and offers guidance for solutions. The 2009 National Patient Safety Goals cover key topics that include: improving the safety of using medications, reducing the risk for hospital infections, improving accuracy of patient identification, and improving the effectiveness of communication among caregivers.3 CME programs should address practical solutions for each of these important safety issues and help physicians implement practical solutions for themselves and the health care teams with which they work. For example, more than 29,000 abbreviation errors were reported to The US Pharmacopeia during the years 2004-2006, despite the fact that the Joint Commission published the Do Not Use List-a list of error prone abbreviations which should no longer be used.4,5 This list can be printed out and incorporated into almost any CME activity that addresses medication use. Furthermore, the list can be utilized by peer reviewers as part of their content validation process, and effective use of the list can be demonstrated to practitioners within a given CME activity on avoidance of medical errors.

CME professionals should contribute to the patient safety culture. For example, programs can be coordinated with the organization’s Risk Management and Quality Assurance Department as, at any given time, individual health care organizations have specific safety and risk issues. For example, one large teaching hospital noted that physicians and resident staff were not complying with new guidelines concerning the safety of ordering and administering mild sedation for patient procedures. Efforts were then coordinated between the CME speaker and hospital Risk Management Department to include this specific issue as part of a medical error prevention presentation. As a result of this CME activity, the hospital now has the ability to measure improvements in physician compliance outcomes.

In recent years, scientific journals and medical publications have alerted the health care industry about the significant role that poor communication plays as a root cause of medical errors. There are specific communication strategies that can be incorporated into CME programs and made available to all participants to improve patient safety. CME is a powerful delivery system for expanding knowledge and awareness, and for introducing these strategies to effect positive change.

References

1. Institute of Medicine. To Err is Human: Building a Safer Health System. Kohn, Corrigan and Donaldson, Eds. Washington, DC: National Academy Press; 2000.

2. The Joint Commission website. Available at: www.jointcommission.org/NR/rdonlyres/74540565-4D0F-4992-863E-8F9E949E6B56/0/SE_Stats_12_06.pdf. Accessed May 3, 2007.

3. The Joint Commission website. National Patient Safety Goals. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_hap_npsgs.htm. Accessed January 10, 2009.

4. Brunetti L, Santell JP, Hicks RW. The impact of abbreviations on patient safety. Joint Commission Journal on Quality and Patient Safety. 2007;33:576-583.

5. The Joint Commission website. Official “Do Not Use” List. Available at: www.jointcommission.org/NR/rdonlyres/2329F8F5-6EC5-4E21-B932-54B2B7D53F00/0/dnu_list.pdf. Accessed February 2, 2009.