A recent poll conducted by the Heartland Health Research Institute found that nearly one in five Iowans say they have had personal experience with medical errors in the past five years. While unintended consequences of medical care are unfortunate, the focus should not be on how many occur. Frankly, one is too many.

Iowa health care providers believe the focus should be on prevention, and building systems that reduce the opportunity for errors to even occur. Since 2005, the Iowa Healthcare Collaborative has been working with hospitals, physicians and communities to improve processes that reduce the unintended consequences of medical care.

Many factors contribute to the ultimate diagnosis and associated care plan for the patient. Hospitals are a particularly complex working environment that require detailed information and coordination between multiple parties. Unfortunately, in complex systems there are sometimes unintended consequences to the process.

Recognizing this, IHC has been partnering with the healthcare provider community to reduce chances for these events to occur. These efforts have demonstrated meaningful success. For example, since 2012 we have seen an 85 percent reduction in medication errors, 78 percent reduction in early elective deliveries, a 32 percent reduction in catheter associated urinary tract infections, and a 50 percent reduction in postoperative infections such as sepsis. And there is a lot of improvement on the horizon.

Numerous patient safety efforts are underway, such as addressing antimicrobial stewardship, falls prevention, and reduction of health care acquired infections. IHC is working with partners across the country in a national project that addresses diagnostic error. Finally, IHC is working with Iowa hospitals to reduce all-cause 30-day readmissions by 12 percent, reduce adverse drug events through medication safety and effectiveness initiatives, and addressing the national opioid epidemic with improved prescribing practices through IHC’s Opioid Guardianship program.

Eliminating these unintended consequences of medical care is a team sport. It requires both the provider and the patient as active partners to be successful. Health care organizations are working collaboratively to engage patients and families in new ways to promote improved quality, patient safety and reduced cost.

One example is IHC’s CANDOR program, a program specifically designed to facilitate open and honest communication between health care providers and their patients.

Conditions where people, technology and process intermingle often introduce unpredictable or unforeseen situations. But one medical error is too many. This work will continue to be a part of IHC’s efforts to align and equip Iowa health care providers for continuous improvement and to raise the standard of care in Iowa.

Dr. Tom Evans is a family physician and president of the Iowa Healthcare Collaborative.

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