Dear Friend of the UT System,
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Dr. Kenneth Shine |
At all of The University of Texas System health institutions, our greatest priorities are the safety of our patients and continuous improvement of their care. Right now, the health institutions are making important improvements such as the implementation of electronic health records, computerized physician order entries and other strategies that encourage teamwork to improve patient care.
One of the most significant strategies addresses individual or team errors that can harm patients. By systematically investigating these events, we’re adapting practices used by the airline industry that have effectively improved airline safety for passengers. At UT M. D. Anderson Cancer Center, for example, a program called “Good Catch” encourages nursing teams to compete by recognizing and reporting near-misses in patient care. Afterwards, the staff analyzes these occurrences to ensure they don’t happen again. Other UT System health institutions are establishing similar programs.
As part of this effort, we have started a program of early explanation of any unanticipated outcomes to our patients and their families. Although the details vary from institution to institution, overall UT System policies require early acknowledgment to patients and families when an unanticipated outcome or error has occurred. Along with this acknowledgment, when information becomes available, we may offer an apology and explain why we believe the event has occurred and what our institutions will do to prevent similar occurrences in the future. Across the country, this kind of early recognition and acknowledgment has led to fewer lawsuits and smaller financial settlements. Instead of protracted litigation, financial settlements can be made as quickly as possible.
Immediate recognition and acknowledgment of such unanticipated outcomes are critical to the culture we want to create to educate our young medical and nursing students. In the past, these students watched faculty and staff try to avoid discussions of errors and unanticipated events with patients. Systematic attempts to analyze and learn from mistakes were discouraged. This created a bitter litigious environment and steered students away from the fundamental value of telling the truth.
"Our strategy is to improve patient safety by decreasing medical errors and by creating... interdisciplinary collaborations and teamwork that will continuously improve the quality of care for all our patients."
The UT System insures itself and its physicians against malpractice suits, collecting premiums from UT System institutions, and processing all legal claims. Since the Texas Legislature’s 2003 tort reform, there has been a significant decrease in overall liability claims. So far, as we implemented early disclosure of adverse and unanticipated outcomes, there has been no noticeable increase in the numbers of claims, but we will be closely monitoring this program for its long-term impact. Several states disallow the use of these disclosures in courtrooms or mediations, and similar legislation has been considered, but not yet enacted, in Texas. We do believe that careful testing of this approach is quite valuable, though.
Federal law allows us to collect information about medical errors at our institutions without fear of legal disclosure. Although this doesn’t prevent lawsuits based on other sources of information and experiences, it does permit confidential collection of information and analysis about where we need to improve the quality and safety of our care. Currently, we are initiating this kind of database, which is protected by federal law.
Our strategy is to improve patient safety by decreasing medical errors and by creating information systems, organizational strategies, interdisciplinary collaborations and teamwork that will continuously improve the quality of care for all our patients. Additional discussion of this subject can be seen in the winter 2006/ spring 2007 and the fall 2005 edition of the Foreseeable Future, the newsletter from the Office of General Counsel.
The next edition of Chancellor Mark G. Yudof's e-newsletter will specifically address highlights from the recently adjourned 80th Legislature. I am pleased to report that many of the recommendations from Code Red: The Critical Condition of Health Care in Texas were addressed. Look for additional details in the Chancellor's e-newsletter. If you do not currently receive the newsletter, you may subscribe online.
Finally, I want to call your attention to an exciting development we are certain will enhance the quality of care for all Texans and be a shot in the arm for medical research in our state. The T. Boone Pickens Foundation, the charitable organization created by energy leader and philanthropist T. Boone Pickens, recently announced its largest-ever gifts of $50 million each to UT Southwestern Medical Center at Dallas and UT M. D. Anderson Cancer Center in Houston. We are deeply grateful for Mr. Pickens’ generosity.
Best regards,
Dr. Kenneth I. Shine
Executive Vice Chancellor for Health Affairs
The University of Texas System
