healthcare biggest problem: accidental patient deaths caused by medical errors

Ignored As An Election Issue, Deaths From Medical Errors Have Researchers Alarmed

We learned Tuesday that health care is a big concern for voters, with exit polling from CNN, NBC and other major outlets showing 40 percent of Americans picked health care as their most important issue. Yet neither political party is taking on health care’s most visceral problem: accidental patient deaths caused by medical errors.

Medical errors are the third leading cause of death in America. More than 500 people likely died of avoidable medical errors on Election Day alone. This horrendous problem first drew a national spotlight 18 years ago, when the Institute of Medicine published a report suggesting upwards of 100,000 Americans died each year from preventable medical errors. Since then, advances in measurement have revealed an even higher estimated body count. A 2016 analysis suggested preventable patient deaths likely total more than 250,000 a year and an analysis by our organization, conducted by Johns Hopkins, estimates employers waste $8,000 per inpatient admission on the costs of avoidable errors.

The November issue of influential peer-reviewed policy journal Health Affairs is devoted to the latest patient safety science, and it contains plenty of bad news. Nurses – our first line of defense in hospitals – do not believe we have made enough progress reducing medical errors, with 35 percent  giving their own workplace an unfavorable rating for patient safety. Medication errors are a persistent problem, and researchers are now investigating a new category of safety concerns: diagnostic errors that affect at least 12 million patients a year, with 4 million suffering serious harm. One study found serious problems with psychiatric patients’ safety, including a long list of serious abuse complaints obtained only through a Freedom of Information Act request.

Fortunately, there is also evidence that some medical professionals are learning cutting-edge techniques to address patient safety challenges.

For instance,  engineers are modeling data analytics to hardwire better quality into the health care environment. In addition, researchers are looking at the built environment for solutions that will better routinize important safety practices like hand hygiene at the patient bedside. One study offers a nuanced perspective on communication practices that help address complications as early as possible and there are new recommendations for using technology to address medication errors. In another study, researchers implemented a system that tracks errors in real time, so they can be addressed before they do further harm. The technology even predicts patients who are at highest risk of future error in order to head off future problems. Lastly, a case study from South Carolina found that a checklist used in the operating room lowers the patient death rate—but it takes more resources than anyone ever imagined to make it work.

Many hospitals have made progress in addressing medical errors, including reducing infection rates and other hospital-acquired problems. And thanks to a remarkable little federal agency that Congress continually threatens to de-fund—the Agency for Healthcare Research and Quality (AHRQ)—we now have significant research on best practices for improving patient safety.

At a briefing by Health Affairs this week, researcher Thomas Gallagher suggested that the biggest hurdle preventing hospitals from improving patient safety is transparency – medical professionals simply do not want to admit mistakes.  This challenge becomes increasingly evident as we try to account for the bodies harmed by medical errors.

We rely on antiquated systems for counting incidences of mistakes and problems, and when better systems come along, we don’t use them for reporting. A new study by University of Michigan Medical School researchers underscores this problem. The Centers for Medicare & Medicaid Services (CMS) publicly reports the frequency of severe pressure ulcers by hospital or hospital system. Pressure ulcers are bedsores that have progressed to open wounds affecting cartilage or even bone. They should never happen. Medicare monitors these ulcers through claims data, but the study suggests this method may undercount them by a factor of 10 or more. CMS uses chart review, not claims data, to monitor other bedsores. The study suggests this method catches about 20 times more incidences compared to claims data. This raises many questions. Why are claims data so inaccurate? After all, claims are bills, so theoretically they should be more accurate. And why isn’t Medicare using the most advanced possible method of tracking this important issue?

The sad reality is that we have only just begun to understand the depths of the patient safety problem, and it is likely worse than what we’re seeing. A recent survey of seriously ill people and their families by The Commonwealth Fund, The New York Times and Harvard’s T.H. Chan School of Public Health, found that one quarter of patients suffered a serious medical error. No other industry tolerates a one-in-four failure rate. Even daredevils won’t take that level of risk.

It is heartening to know so many clinicians and researchers are working to address these problems, but they need more support from our leaders. We know elected officials aren’t paying attention. How?  My organization grades hospitals on safety and finds no difference in the report cards of red states and blue states.

We cannot develop effective solutions without knowing where we currently stand. Congress can help, starting with increased funding for AHRQ and for measurement enterprises such as the National Quality Forum that help us understand the full scope of the problem. Patient safety is a critical health care issue for every American, because none of us ever knows the moment when we will face an urgent health problem that will land us in the hospital. So all of us want hospitals to succeed.

I run an organization called The Leapfrog Group with a membership of highly impatient business leaders fed up with problems with injuries, accidents, and errors in hospitals. I can’t stand the sight of blood but I’ve worked in healthcare over 20 years, including a rural hosp…

4 Responses

  1. Want to cut down on the amounts of opiates prescribed? Maybe find some way to decrease the medical errors that leave people with a life time of pain!

  2. I love the “look to tech to solve the medication errors” problem. There’s at least one teeny problem…the old GIGO. I know just trying to fix my medication list at my PCP has been on ongoing problem for years: every appointment, they hand me a list. Every appointment, I edit the list. Somehow, the edits never, ever end up in the system. They have had me as being on a couple of meds I’ve never taken, couple more I stopped years ago. I’m sure if the changes were ever correctly entered, the list would be correct. But between lack of tine, lack of training, lack of care/interest, it somehow never happens. I’d bet one way to decrease medical errors would be to change the profit-driven model of “shovel thru as many patients as possible for maximum bucks” was altered. When med personnel are forced to see 15 or 20 people an hour for 8-10 hours a day, and then do another 4-5 hours worth of asinine insurance company paperwork, there’s no way on Earth they’re not going to screw up. And that’s just at a plain ole PCP practice.

    As for as getting the guv’mint outta health care…how is purely profit-driven care any improvement? We need a new paradigm.

  3. Ditto on ,”Jan,” comment….However,,,as far as errors,,,,u have only counted what u have been told are errors,,,,by the same people who have a vested interest in covering up errors,,,so,,jmo,,,I would double that number,,,,Being a victim of a severe medical error,literally involving Mayo Clinic,,St.Lukes,,in Milwaukee and some very ,”upper Doctors,,ie on the board type doctors,,,,they will doo anything to cover up a severe error,,no matter how much they destroy another person ablity to live life in less physical pain,,I have witness actual test being re-done w/my name on it,,but not my body,,I have witness medical records deleted,and I have witness medical record completely alter’d to cover up a huge error,,Now a days,,the doctors I have met on my case,,don’t give a rats asss about ethics,,,just money,their professional image,,even if they have kill,lie about a patient medical history to make themselves look innocent,,even though they are guilty as sin!!!Beware patients,, some doctors will literally lie to your face,delete records,change image testing and put your name on it,,,rather then let their error be revealed,,If I had 500 $$$,I’d have thee alter ultra sounds,the original surgeon and medical director handed over to a data recover agency to prove exactly that they will put your name on a test,w/someone else’s,body, say on ultra sounds,..Point being some doctors will do anything to cover-up their severe medical errors,,,no matter how much it hurt the patient physically,maryw



    Sorry for the all caps—I just get so upset.

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