UC Davis Leads National Patient Safety Movement
With Launch of Electronic Medical Records, Other Initiatives.
When a respected surgeon at Duke University Hospital transplanted a heart and lungs with
the wrong blood type into young Jessica Santillan in February, the outcome was tragic. But the resulting
headlines also spotlighted how even the most prestigious of health-care institutions are prone to medical
errors that cause them to fall short of the fundamental standard of "do no harm."
According to a 1999 report by the Institute of Medicine, medical errors result in between 44,000 and
98,000 deaths each year in the United States. Even using the lower number, that means medical errors would
rank as the eighth- leading cause of death in the country ahead of motor-vehicle accidents, breast cancer
Through a wide range of initiatives, UC Davis Medical Center is at the forefront of the movement to ensure
patient safety through technology, education and policy. In late 2001, UC Davis adopted a state-of-the-art
plan to reduce and ultimately eliminate drug- related errors, which, nationally, represent a major
portion of all medical errors. While the plan was developed in response to California legislation mandating
the use of electronic order-entry systems, UC Davis' plan far exceeds the requirements of the law. The
plan lays out an ambitious approach to identifying systems-related causes of actual and potential errors.
While systems are an important part of the solution, a cultural shift is also essential to ensure that
medical errors are reported so they can be fixed. Critical to these efforts is the promotion of a blame-free
environment where providers are encouraged to report errors and also to assist in the correction of processes
that cause errors. For instance, the UC Davis School of Medicine's state-of-the-art ethics curriculum
helps students focus on how to respond when medical errors do occur.
While many initiatives are playing an important role, none surpasses the scale of implement- ing a major
Electronic Medical Records (EMR) system that will ultimately displace the traditional paper-based medical
Like stethoscopes, tongue depressors and thermometers, the traditional paper patient chart is an icon
of the medical world. But it's an icon that will soon go the way other outdated medical practices and
with equally good reason. Many of the medical errors in the United States can be attributed to problems
with information on a paper chart that is inaccurate, inaccessible, illegible or incomplete.
As the EMR project rolls out in phases through early 2007, it will allow practitioners to access a single
source of comprehensive patient data any time, from any- where that patients are served. "The EMR system
will enhance patient safety across all venues of care, including clinics, hospitals, home health services
and hospice," said Tom Tinstman, associate director of UC Davis Medical Center and project executive for
its clinical information systems.
Moving to digital medicine is a massive undertaking when you consider that UC Davis Medical Center operates
one of the busiest trauma centers in the nation, with more than 50,000 visits annually to its emergency
department, and serves more than 300,000 patients, who visit its hospitals and clinics more than 750,000
times annually. Those visits generate a stack of paper patient files about 8 1/2 feet tall every day.
That's about the height of a six-story office building every week.
Converting all that paper to digital zeroes and ones involves combining 15 information systems into
one, installing thousands of new computers, developing new workflows that ensure people and technology
mesh effectively and training approximately 6,000 users of the system. Computer monitors are being placed
throughout all patient-care areas to ensure easy, immediate access to electronic records.
The initial deployment of the EMR system in the hospital and clinics this summer offers easier access
to results such as lab reports, radiology reports, transcriptions and inpatient pharmacy records. Use
of paper charts will continue, but the EMR system will provide a streamlined way to look up records.
Ultimately, the EMR system will transform health-care delivery, with improved quality of care, enhanced
patient experience and reduced costs, Tinstman noted.
"By giving practitioners easy access to the broadest information available, EMR will enable them to shift
from using 'all the knowledge that's in my head' to using 'all the knowledge that's in the world' to make
good decisions for our patients," he said.
And that is the ultimate safeguard to helping providers live up the standards Hippocrates set forth at
the dawn of civilized medicine.