It has been over 10 years since the publication of the Institute of Medicine's study on preventable medical errors: To Err Is Human: Building a Safer Health System. So how are we doing? Are there still nearly 100,000 patients dying in the U.S. each year due to preventable errors? I haven't heard anyone claim that this problem is solved yet.
The first story, above, indicates errors are still a major problem:
While patient safety in US hospitals is improving, “medical mistakes still occur at an alarming rate,” according to the sixth annual HealthGrades study of patient safety in American hospitals, released today.Between 2005 and 2007, medical errors cost Medicare over $6.9 billion and were responsible for more than 92,000 potentially preventable in-hospital deaths among Medicare beneficiaries, report Dr. Rick May and others at HealthGrades, a healthcare ratings organization in Golden, Colorado.
Keep in mind these are just Medicare patients. What percentage of all patients are on Medicare? I don't have that number handy… would really be interested to extrapolate 30,000+ Medicare patient deaths to the whole patient population.
Some more numbers:
More than 913,000 total “patient safety events” occurred, representing 2.3 percent of the nearly 38 million Medicare hospital admissions.Patients who suffered one of these mistakes had a one-in-ten chance of dying, the report indicates.
The AHRQ says there are about 29 million hospitals admissions each year in the U.S. At 0.23%, that would be a total of 66,700 deaths per year.
Are these incidents random events? It seems not — it behooves us, as patients, to find out which hospitals have better quality. You can do so at the HealthGrades website, but alas they sell the detailed reports (and no need for disclosure here, I don't take a cut for referring you to them). It seems difficult to, as a patient, draw valid conclusions from the data they show, but maybe that's the subject of another post (or for another blogger).
The investigators observed that, on average, Medicare patients treated at award-winning hospitals were 43 percent less likely to experience a medical error compared with those at bottom-ranking hospitals. “This finding of better performance was consistent across all 12 patient safety indicators studied,” the authors write.
At least things aren't consistently bad. So what are the “award winning” hospitals doing differently? It's got to be a matter of PROCESS, not people. I can't imagine the award-winning hospitals are hiring people who are smarter or more careful.
Errors with the highest occurrence rates were “failure to rescue,” defined as death among surgical inpatients with serious treatable complications; bed sores; postoperative respiratory failure; and serious postoperative infections.
There are some problems inherent in extrapolating the Medicare numbers, since those patients are older and, presumably, more likely to get bed sores. But still, this is a serious problem.
This related article also caught my attention:
This number was only the events that caused death or serious harm in Utah, not all errors.
Despite a years-long effort to cut down on one type of medical mistake – surgical errors – they remain Utah's top problem. There were 45 surgical errors last year, such as performing the wrong surgery on the wrong body part. One example: A gastrointestinal tube that was guided into a lung instead of the stomach.
“We're struggling,” said Iona Thraen, who reviews the mistakes as director of patient safety for the state health department.
Why are they struggling? It's not just Utah… why do the experts (I'm not pointing at myself as the expert) say many or most of these are preventable?
The standard practice is for hospital staff to manually count the sponges before and after surgery to ensure they are removed and confirm the removal with an X-ray, said Thraen. When reviewing the cases when sponges were left inside patients, the staff members are usually certain they counted and re-counted the material, she noted.
OK, you might wonder — how hard is it to have some standardized work that says you count and even re-count? Does the phrase “usually certain” set off red flags?
Counting — this is a form of visual inspection, done by a person — it's going to be prone to error. We're human. We make mistakes.
But do we have to make as many? The sidebar at the bottom of the article highlights a situation that might not be unique or rare:
During a routine inspection of McKay-Dee Hospital in Ogden last year, state health department surveyors cited the facility for compromising patient safety because surgical staff didn't count instruments before and after surgery. They did count sponges and needles.
Inspectors were told that staff only counted instruments during open-heart surgery and that surgeons were “reluctant to allow staff to perform instrument counts” because “it added more time to the surgical procedure,” according to the inspection report obtained by The Salt Lake Tribune.
Whoa. So when things like this are happening, as fancy RFID technology the only solution? The most cost effective solution?
How do you win the cultural battle that patient safety, not speed, comes first? Can you eliminate waste and take time out of the procedure rather than eliminating this step that impacts patient safety?
Seems like this, and many other medical mistakes, are cultural and social problems more than they are technical problems.
So I'll leave it on that. The LEI's John Shook has a blog post about looking beyond the technical for root causes of problems that fall in the social realm. Seems to fit here.
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