Lessons from Europe on quality improvement: report on the Velen Castle WHO meeting.

BACKGROUND: In conjunction with the German Ministry of Health, the European Regional Office of the World Health Organization (WHO/EURO) held a workshop, "Experiences with Quality Management in an International Context," at Velen Castle, Velen (Nordrhein-Westfalen), Germany, January 15-17, 1998. The approximately 50 participants were selected in part on the basis of recommendations of their respective countries' health ministries. IMPLEMENTATION AND EVALUATION OF QUALITY MANAGEMENT: Possible ways to introduce quality management ranged from introduction of specific process control projects to total quality management (TQM) and reengineering. STRATEGIES FOR IMPLEMENTING QUALITY MANAGEMENT: Working group sessions identified specific strategies for high-level managers, health care providers, and various kinds of consumers to facilitate quality management. For example, managers need to transmit a vision, create a quality management infrastructure, develop reporting structures, establish a system of incentives, and manage the hospital according to the principles of continuous improvement. QUALITY MANAGEMENT MODELS AND TOOLS: Hospitals and other health care providers in Sweden are testing various methods and systems to assess and improve their organizations' ability to meet patients' demands. Benchmarking is being used as a tool for quality management of diabetes care (DiabCare-France). The benchmarking data are processed centrally and made available to the health care providers in a user-friendly format for application to their own quality improvement processes. Clinical databases-registries containing process and outcome data for a well-defined patient population-can be used for quality and technology assessment, to answer questions of treatment effectiveness, and as an information tool. PRINCIPLES AND STRATEGIES FOR QUALITY MANAGEMENT AND DEVELOPMENT: Successful implementation of quality improvement benefits from local, professional, and national policies and objectives. A balance of incentives can reward efficiency or specific activities. Laws, rules, and regulations can be useful, especially if used sparingly. More education is needed at all levels of the health care system about how to understand and use information and information systems. Research is needed on what processes result in favorable outcomes. Despite optimism about the cost-saving potential of quality improvement efforts, many interventions are likely to be cost-effective without actually saving costs. Public release of performance data requires careful consideration, with participation of the professions.     

Health information technologies for patients with diabetes

Patients with chronic illnesses, such as diabetes, need daily care and follow-up beyond occasional visits to healthcare providers. Research has shown that overcoming a multifaceted illness, such as diabetes, requires patients to be engaged in the monitoring and management of their own health. Health information technology (HIT) has been shown to empower chronically-ill patients to take charge of their healthcare, and alleviate their daily frustrations while they strive to lead a normal life. In this paper, we surveyed 31 patients with diabetes to identify the major frustrations they experience daily, examine the role of HIT in their current treatment, and identify gaps in their current care and education that, if addressed, could improve their quality of life. Themes identified in our survey results include a lack of interaction with healthcare providers, difficulties in scheduling appointments, a lack of timely communication with healthcare providers, and challenges in managing the complex care of diabetes. The contributions of this paper include a detailed set of recommendations on how HIT can be utilized to help chronically-ill patients live a better life despite their illnesses, with a particular emphasis on diabetes care and management.     

Identifying and addressing medical errors in pain mismanagement

BACKGROUND: There is strong evidence in the pain management literature that undertreatment of pain is pervasive despite several approaches, including use of national guidelines, to completely correct the problem. Although the concept of medical errors has primarily been concerned with adverse events, it is not unreasonable that mismanagement of pain could also be classified as a medical error. ERRORS OF PAIN MANAGEMENT: Error types can be classified as errors in assessment and documentation, errors in treatment and management, and errors in patient education. Within each of these categories, errors may be skill-, rule-, and/or knowledge-based, as suggested by evidence of mismanagement in various aspects of the pain management process as found in the literature. An examination of the root causes of medical errors may be used to detect system failures. At least ten steps can be identified in the process of pain management in the acute care setting, starting with admission, and errors can potentially occur at any step. A redesigned system could help improve error rates by incorporating use of skills, rules, and knowledge for effective management. CONCLUSION: A new approach to the unsolved problem of pain management in acute care settings is proposed; this approach uses the concept of mismanagement as a medical error.     

Federal efforts to improve quality of care: the Quality Interagency Coordination Task Force (QuIC)

FORMATION OF THE QUIC: The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems. STUDY, MEASURE, AND IMPROVE CARE: The QuIC's initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction. DEVELOP A RESEARCH BASE AND INFRASTRUCTURE: The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection. PROVIDE INFORMATION TO AMERICANS ABOUT HEALTH CARE QUALITY: The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care. MOVING THE QUALITY IMPROVEMENT AGENDA FORWARD: Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.     

Applying quality improvement principles to achieve healthy work organizations

BACKGROUND: Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work. INTEGRATING TQM/QI INTO THE HWO PARADIGM: If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables. SUMMARY: Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.     

John M. Eisenberg Patient Safety Awards. Individual lifetime achievement: Julianne M. Morath,RN, MS

BACKGROUND: This article provides a brief biography of Julianne M. Morath, describes the scope and impact of her patient safety initiatives at Children's Hospitals and Clinics in Minneapolis and St Paul, and includes an interview in which Morath responds to questions about challenges to patient safety and medical accident reduction. BIOGRAPHY IN BRIEF: With a 25-year career spanning the spectrum of health care, Morath has served in leadership positions in health care organizations in Minnesota, Rhode Island, Ohio, and Georgia. LEADERSHIP AT THE FRONT LINE: Morath joined Children's Hospitals and Clinics in 1999 and launched a major patient safety initiative that put Children's on the map. Elements of the initiative included a culture of learning, patient safety action teams, open discussion of medical accidents and error, blameless reporting, and a full accident disclosure policy. AN INTERVIEW WITH JULIE MORATH: As the greatest challenge to leadership ownership of the patient safety initiative, Morath cites the need to confront the myths of the medical system and to develop the awareness of the issues of patient safety. She believes that clinicians on the front lines will be convinced that patient safety isn't "just another fad of the month" when leadership action is disciplined and aligns with what is being espoused. She advises other leaders of health care organizations interested in establishing a culture of safety to start with a personal and passionate belief that harm-free care is possible, to commit to informed action, and to identify and develop champions throughout the organization and medical staff.     

The once and future application of cost-effectiveness analysis.

BACKGROUND: Cost-effectiveness analysis (CEA) is used by payers to make coverage decisions, by providers to make formulary decisions, and by large purchasers/employers and policymakers to choose health care performance measures. However, it continues to be poorly utilized in the marketplace because of overriding financial imperatives to control costs and a low apparent willingness to pay for quality. There is no obvious relationship between the cost-effectiveness of life-saving interventions and their application. Health care decision makers consider financial impact, safety, and effectiveness before cost-effectiveness. WHY IS CEA NOT MORE WIDELY APPLIED? Most health care providers have a short-term parochial financial perspective, whereas CEA takes a long-term view that captures all costs, benefits, and hazards, regardless of to whom they accrue. In addition, a history of poor standardization of methods, unrealistic expectations that CEA could answer fundamental ethical and political issues, and society's failure to accept the need for allocating scarce resources more judiciously, have contributed to relatively little use of the method by decision makers. HOW WILL CEA FIND GREATER UTILITY IN THE FUTURE? As decision makers take a longer-term view and understand that CEA can provide a quantitative perspective on important resource allocation decisions, including the distributional consequences of alternative choices, CEA is likely to find greater use. However, it must be embedded within a framework that promotes confidence in the social justice of health care decision making through ongoing dialogue about how the value of health and health care are defined.     

The impact of quality report cards on choice of physicians, hospitals, and HMOs: a midcourse evaluation

BACKGROUND: Increasing competition in health care markets and ongoing pressures to contain costs raise concerns about possible deterioration in the quality of medical care. Publicly disseminated quality report cards are designed to inform consumers' choice of providers and health plans, thus counteracting incentives to provide low-quality care and improving the functioning of health care markets. METHODS: This article reviews and evaluates the published evidence on the impact of quality report cards on patients' choice of health care providers and health plans. RESULTS: Studies found only minimal effect of quality report cards on patient referral choices. These findings can be explained by several study design issues and by the economic forces governing health care markets. They cannot be construed to imply that quality report cards are not effective. DISCUSSION: Whether report cards are effective or not is still an unanswered question. Further efforts to improve the information contained in report cards and to make them more understandable could increase their effectiveness.     

Assessing performance reports to individual providers in the care of acute coronary syndromes

BACKGROUND: As part of a quality improvement initiative in the management of acute coronary syndromes, performance reports on care of patients with acute myocardial infarction (MI) or unstable angina (UA) who were admitted to two cardiology services at the University of Michigan Medical Center in 1999 were disseminated to a range of providers. METHODS: In 1999, data were routinely collected by chart review on presentation, comorbidities, treatments, outcomes, and key process of care indicators for nearly 300 patients with AMI and a similar number of patients with acute UA. Key process of care indicators and outcomes were the focus of the report cards for AMI and UA. RESULTS OF SURVEY ON REPORT CARDS: The return rate for the provider survey--a simple one-page, nine-item question/answer sheet--was highest among faculty who received physician-specific reports (14 out of 17; 82%). Overall, 18 (60%) of 30 providers indicated that the report was useful, 18 responded favorably to the format, and only 3 (10%) indicated that the information was repetitive. Importantly, 24 (80%) indicated a desire to see future performance reports. DISCUSSION: Although hospitalwide or even statewide reports have become familiar, their overall impact on care within hospitals or health systems is unknown. Because so many different caregivers affect the care of a single patient, it is difficult to identify all of these and to consider which part of the care oversight should be ascribed to each provider. The care process itself must be reengineered to build in the systems and time required to accomplish continuous evaluation and improvement.     

Developing performance indicators that reflect an expanded view of health: findings from the use of an innovative methodology

BACKGROUND: The increasing presence of managed health care in the United States has been accompanied by the widespread use of performance indicators to assess health plans along various dimensions of quality. Current performance indicator sets virtually ignore psychosocial and behavioral factors in the prevention and management of illness, especially chronic illness, in spite of documented evidence in the medical literature of the importance of these factors. Instead, current indicator sets focus primarily on biomedical interventions to prevent, treat, and manage illness. METHODOLOGY: In a novel method for developing performance indicators--the use of a storytelling methodology--eight interdisciplinary panels, composed of health care experts at the community, state, and national levels, each completed two stories about patients with chronic illnesses. The first story described experiences a patient might have in the health care system as it is today; the second story retold the events that might transpire if attention to psychosocial and behavioral factors were integrated into the health care system. FINDINGS: Differences between the two sets of stories developed by the panels revealed common themes and specific areas where indicator development might prove fruitful. Performance indicators were identified from these themes, and work is underway to operationalize them; to identify barriers and opportunities for their inclusion in indicator sets; and to further document their potential health and cost-effectiveness. DISCUSSION: Although not scientifically rigorous, the storytelling method was found to provide consistent results and may be applied to many aspects of the health care planning process, health education, and quality improvement efforts.     

Depressive symptom severity,contributing factors,and self‐management among chronic dialysis patients

Despite the high prevalence of depressive symptoms in patients receiving chronic dialysis, there has been inadequate attention to patient‐related barriers to management of depressive symptoms, such as factors identified by these patients as contributing to their symptoms, and how they responded to the symptoms. Participants (N = 210) in an ongoing longitudinal observational study of multidimensional quality of life in patients receiving chronic dialysis completed a battery of measures monthly for 12 months. For each patient at each measurement point, an event report was generated if he or she scored outside of the normal range on the depressive symptom scale (Center for Epidemiologic Studies Depression Scale‐Short Form [CESD‐SF] ≥10) or expressed suicidal ideation. Of the 210 participants, 100 (47.6%) had a CESD‐SF score ≥10 at least once resulting in 290 event reports. Of these 100 participants, 15 (15%) had also reported suicidal ideation in addition to having depressive symptoms. The most frequently stated contributing factors included “managing comorbid conditions and complications” (56 event reports, 19.3%), “being on dialysis” (50, 17.2%), “family or other personal issues” (37, 12.8%), and “financial difficulties” (31, 10.7%). On 11 event reports (3.8%) participants had been unaware of their depressive symptoms. On 119 event reports (41%) participants reported that they discussed these symptoms with their dialysis care providers or primary care providers, while on 171 event reports (59%) symptoms were not discussed with their health‐care providers. The prevalence of depressive symptoms is high and many patients lack knowledge about effective self‐management strategies.     

Developing a patient complaint tracking system to improve performance

BACKGROUND: Assessing patient satisfaction exclusively through close-ended scaled survey questions may not provide a complete picture of patients' concerns. Only recently has the role of complaint data as a management tool received attention. FORMATION OF THE TEAM AND THE DATABASE: The Complaint Management Team was created in January 1997 at Hartford Hospital (Conn) to develop a coding and reporting mechanism for complaints (negative comments) gathered from patient surveys. Developing the codebook was an evolutionary process. A database was designed to collect three separate complaints and the verbatim text associated with the code. REPORTING: Department-specific, location-specific, and organization wide reports are generated. Quarterly department-specific reports are used to trend the incidence of complaint themes, identify specific locations with problems, and initiate improvement efforts. OVERALL FINDINGS: Since March 1997, most complaints have fallen into five major categories--accommodations (environment), quality of care (care and treatment), respect and caring (humaneness or attitudes and behaviors), timeliness, and communication. The hospital's real estate department has completed a project focused on increasing patient satisfaction with parking. Two projects are still in progress; one is focused on increasing patient satisfaction with respect and staff caring attitude/behaviors, and one on improving satisfaction with the level of noise on the units. DISCUSSION: Approximately 4,000 survey complaints are coded every year. One limitation of the database is that all sources of complaints received throughout the organization are not yet captured. Another limitation is that the outcomes measurement section has exclusive access to the database. CONCLUSIONS: The patient complaint tracking system enables staff, managers, teams, and departments to develop improvement efforts based on quantitative and qualitative data.     

Effecting and leading change in health care organizations

BACKGROUND: Understanding change is crucial to implementing quality improvement (QI) initiatives. Widespread change will be required to correct what many consider to be outmoded and deficient systems of care. This article summarizes the current literature--within both health care and the fields of business and management--regarding how change occurs at the individual and organizational levels. Part 1 focuses on changing clinician behavior, which is instrumental to any effort directed in the health care setting. Part 2 examines the culture of change. Part 3 addresses issues of leadership, along with the necessary steps to guide change in an organization. Part 4 summarizes key elements of change. Finally, Part 5 provides three case examples of QI initiatives reported in the recent literature to illustrate how the application of the knowledge of change management can assist in the successful implementation of QI programs. KEY ELEMENTS OF CHANGE: The knowledge base regarding successful change in health care organizations can be summarized in eight crucial strategies or principles: (1) develop a vision for change, (2) focus on the change process, (3) analyze which individuals in the organization must respond to the proposed change and what barriers exist, (4) build partnerships between physicians and the administration, (5) create a culture of continuous commitment to change, (6) ensure that change begins with leadership, (7) ensure that change is well communicated, and (8) build in accountability for change. CONCLUSION: A knowledge of change management can help leaders of QI programs in health care organizations successfully apply these concepts to bring about much-needed transformations in health care.     

Using quality function deployment to capture the voice of the customer and translate it into the voice of the provider.

BACKGROUND: Health care has a number of historical barriers to capturing the voice of the customer and to incorporating customer wants into health care services, whether the customer is a patient, an insurer, or a community. Quality function deployment (QFD) is a set of tools and practices that can help overcome these barriers to form a process for the planning and design or redesign of products and services. The goal of the project was to increase referral volume and to improve a rehabilitation hospital's capacity to provide comprehensive medical and/or legal evaluations for people with complex and catastrophic injuries or illnesses. HIGH-LEVEL VIEW OF QFD AS A PROCESS: The steps in QFD are as follows: capture of the voice of the customer, quality deployment, functions deployment, failure mode deployment, new process deployment, and task deployment. The output of each step becomes the input to a matrix tool or table of the next step of the process. CASE STUDY EXAMPLE: In 3 1/2 months a nine-person project team at Continental Rehabilitation Hospital (San Diego) used QFD tools to capture the voice of the customer, use these data as the basis for a questionnaire on important qualities of service from the customer's perspective, obtain competitive data on how the organization was perceived to be meeting the demanded qualities, identify measurable dimensions and targets of these qualities, and incorporate the functions and tasks into the delivery of service which are necessary to meet the demanded qualities. DISCUSSION: The future of providing health care services will belong to organizations that can adapt to a rapidly changing environment and to demands for new products and services that are produced and delivered in new ways.     

Using a SANE interdisciplinary approach to care of sexual assault victims

BACKGROUND: Many hospitals have recognized the need to develop policies and procedures for female sexual assault victims' prompt access to emergency medical care and for collecting law enforcement evidence. At Lehigh Valley Hospital (Allentown, Penn), care in the emergency department (ED) for sexual assault victims was covered by oncall obstetricians and gynecologists. Although many aspects of rape management were in place, a busy ED with varying levels of physician response and exposure to the process of rape management contributed to a lack of standardized, objective, timely, and compassionate medical management of sexual assault victims. DEVELOPING THE PROGRAM: The Sexual Assault Nurse Examiner (SANE) interdisciplinary approach to care of sexual assault victims was implemented in May 1998. Community education and awareness projects emphasized prevention of sexual assault and domestic violence, as well as minimization of trauma for victims by promoting services that provide a supportive, caring, and healing environment. RESULTS: Comparing a baseline group of 130 sexual assault victims with 39 patients who were evaluated after the SANE approach was implemented indicated increased clinical interaction and significant improvements in quality indicators, such as completeness of evaluation and information gathered relevant to medical-legal issues. DISCUSSION: Law enforcement staff developed a more collaborative relationship with SANE examiners through the interdisciplinary team approach. Collaborative relationships were initiated with several other hospitals in the hospital's integrated delivery system to help offset some of the program's training, continuing education, and on-call costs and to allow for joint outcomes collection. The SANE program became a core ED service in July 1999.     

Nanotechnological approaches for the development of herbal drugs in treatment of diabetes mellitus – a critical review

Diabetes mellitus (DM) is a chronic illness that requires continuing medical care and patient self‐management education to prevent acute complications and to reduce the risk of long‐term complications. The number of people with diabetes is increasing due to population growth, ageing, urbanisation and increasing prevalence of obesity and physical inactivity. Apart from currently available therapeutic options, many herbal medicines have been recommended for the treatment of diabetes. Herbal drugs are prescribed widely because of their effectiveness, less side effects and relatively low cost. Several pharmacopoeias have provided parameters to maintain quality and standardise procedures in identification/authentication of herbal inputs and their products. Available literature related to folklore medicine used in the treatment of diabetes extended to nanoformulation of herbal drugs up to date was cited. The use of bioactive compounds leads to new hope to improve the life expectancy and health status of the population for the formulation of novel drugs. Recently, many studies have shown that nanotechnology has the potential to be used in different biological and medical applications, mainly as targeted drug delivery systems to minimise and delay the chronic effects of diabetes. Herein, the authors presented a thorough review of the available herbal medicines and the possibilities of developing their nanoformulations in the treatment of DM.Inspec keywords: drugs, drug delivery systems, nanomedicine, reviews, diseases, patient careOther keywords: nanotechnological approaches, herbal drugs, diabetes mellitus treatment, critical review, chronic illness, medical care, patient self‐management education, long‐term complications, risk reduction, ageing, urbanisation, obesity, physical inactivity, pharmacopoeias, standardise procedures, herbal inputs identification‐authentication, folklore medicine, bioactive compounds, health status, biological applications, medical applications, targeted drug delivery systems, chronic effects, herbal medicines     

Patient-centered measurement at an academic medical center.

BACKGROUND: Harborview Medical Center (Seattle, Wash) has collected patient data on operations since 1988 and has participated in the University HealthSystem Consortium's (UHC; Oak Brook, III) patient satisfaction measurement program since 1996. The patient feedback program is intended to provide data suitable for the quality improvement process and benchmark Harborview's performance against that of other academic medical centers (AMCs). USE OF PATIENT FEEDBACK AT HARBORVIEW: The Picker Institute Adult Inpatient survey's seven dimensions of care are used to disseminate the patient data and focus the action plans. The areas with the largest problem scores and the highest correlation with overall satisfaction are identified, and then specific actions are devised to address those areas. For example, patient satisfaction data collected in May 1997 led the quality council to highlight information and education as an area for improvement for both inpatients and outpatients. Patients reported that they often got answers they could not understand. Also, they did not always get enough information at discharge to feel comfortable about going home. A Discharge/Transition Center CQI (continuous quality improvement) team was charged with developing a discharge/transition process that ensures continuity of care for patients as they move throughout the system. In addition, a hospitalwide Patient and Family Information team has been working on improving information delivery by developing both patient-friendly processes and useful educational materials. FUTURE DIRECTIONS: Harborview will continue to gather feedback through not only more targeted, specific surveys but also focus groups, which have been conducted around specific issues such as diabetes care, clinical pathways, pain management, and teen health.     

Using the Internet to teach consumers about quality care

BACKGROUND: The Internet is an important source of health information for consumers. Patients can learn about their diagnoses, review treatments and medications, and locate other health information for themselves and their families. Information about quality care can also be found on the Internet. Few consumers, though, use these Web sites for learning about quality care. SEARCH FOR WEB SITES ON QUALITY CARE: In 2000 the investigators searched the Internet and generated a list of approximately 90 relevant Internet documents under the broad heading of quality health care. They then pared the list to 34, by using the Health Information Technology Institute (HITI) criteria. TESTING OF INTERNET DOCUMENTS BY CONSUMERS: In the second phase of the project, 5 of the 34 Internet documents were tested by a convenience sample of 32 consumers. Most of the participants had experience in using the Internet, although generally not in the area of quality care. They found the Web sites easy to use and indicated that the Internet resources would help them assess the quality of care they receive from physicians, nurses, and others. DISCUSSION: Web sites need to be evaluated to ensure that the information they provide is accurate and current, among other criteria. All patients should understand their health benefits and the importance of making informed decisions about their health care, as well as how quality care is measured, how to use quality reports, how to choose providers and hospitals, how to assess the quality of their own care and be more involved in it, and what they should do when faced with new diagnoses.     

Promoting patient safety: is technology the solution?

BACKGROUND: On April 30, 2001, the Cleveland Clinic Foundation and Cleveland Clinic Health System Quality Institute sponsored a 1-day conference focused on technology in patient safety. PATIENT SAFETY-A CALL TO ACTION: Kenneth W. Kizer focused on ten high-priority patient safety strategies identified by the National Quality Forum-including implementing recognized "safe practices", recognizing and dealing with professional misconduct, and supporting efforts to create a nonpunitive environment for health care error reporting. CULTURAL IMPLICATIONS OF INTRODUCING NEW TECHNOLOGY: Randolph A. Miller described a computerized clinician order-entry system used to provide decision support, reduce excess test ordering, introduce cost savings, and meet regulations for inpatient radiology and cardiology tests. USING BAR CODES TO ELIMINATE MEDICATION ERRORS: Jeff Ramirez reported on the Veterans Health Administration's use of bar coding technology for point-of-care validation of medication administration, which has resulted in improvements in response time; the efficiency of the dispensing, delivery, and administration process; and patient care. HOW TO MAKE COMPUTERS TEAM PLAYERS: The knowledge base exists to design computers as team players that expand human expertise and help health care practitioners better create safety. Yet David D. Woods challenged the audience to anticipate the changing shape of iatrogenic risk as a result of increasing dependence on automation in health care. TECHNOLOGY AND MEDICATION SYSTEMS: Mark Neuenschwander spoke about automating various steps within the medication use system, through computerized prescriber order entry and bedside scanning. FUTURE TECHNOLOGICAL POSSIBILITIES: Charles Denham suggested how technology may aid health care professionals in their care of patients, such as in using predictive modeling to identify the risks of therapeutic intervention.