In 1999, the Institute of Medicine issued a first-of-its-kind report on the rate of medical errors. The findings were shocking. If the report was correct, medical errors were the eighth leading cause of death in the United States.

Researchers began investigating why medical error rates were so high and what could be done to reduce them. States are now finally in a position to employ some of the best methods to reduce medical errors, and PAMF is one of the more than 50 health care industry stakeholders in California who are leading the way.

PAMF is a charter member of the newly formed California Patient Safety Action Coalition (CAPSAC), a group of leading public and private health care organizations that seek to improve patient safety by changing how the health care system responds to errors and "near misses" (in other words, a "close call" in which an error almost happened but was caught in time).

In 2008, CAPSAC began holding regional meetings to educate health care providers on how to respond to medical errors in a way that will make them less likely to occur in the future.

"Simply implementing policies that forbid medical errors is ineffective," said Theresa Manley, R.N., chair of CAPSAC and patient safety officer at PAMF. "Together with the other CAPSAC members, PAMF is supporting changes that will allow health care providers to learn from mistakes and create systems that make errors less likely to happen in the future."

PAMF's commitment to keeping its patients safe is not limited to its involvement in CAPSAC. From the moment a patient is prescribed a drug, PAMF's electronic health record (EHR) system automatically alerts doctors if they have prescribed two drugs that could be harmful if taken together. The EHR also generates printed prescriptions, preventing errors that can occur when pharmacists or nurses cannot read a doctor’s handwriting.

Because it believes in a culture of safety rather than one of blame, PAMF recognizes its clinical staff members, such as nurses and medical assistants, for reporting either real or potentially unsafe situations. In addition, PAMF's Safety Notification and Follow-Up Committee alerts patients, physicians and other providers of drug and medical device warnings and recalls issued by the U.S. Food and Drug Administration (FDA) and other sources.

"By examining the cause of medical errors and implementing real solutions, we’re doing everything we can to keep our patients safe," said Manley.

Visit www.capsac.org to find out how PAMF and other organizations are working to improve patient safety in California.