Medical Errors and Patient Safety
"Health care in the United States is not as safe as it should be - and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.
Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide."
"A variety of factors have contributed to the nation's epidemic of medical errors. One oft-cited problem arises from the decentralized and fragmented nature of the health care delivery system - or "nonsystem," to some observers. When patients see multiple providers in different settings, none of whom has access to complete information, it becomes easier for things to go wrong.
From 1999 Institute of Medicine report "To Err is Human - Building a Safer Health System"
Medical information is becoming increasingly complex and for various reasons (time constraints, stress of multitasking, too many patients, not enough staff, learning curve with health IT, lack of awareness, etc.), health care professionals do not always explain information in a way that patients can understand. Health care professionals may not even know when patients do not understand, nor do patients ask their providers to explain complicated information (perhaps due to embarrassment or fear of questioning the "experts").
Types of Medical Errors
SOURCE: Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.
A few Developments in Process Improvement: (Shi & Singh, 2013)
- Clinical Practice Guidelines :In response to findings of small area variations, various professional groups, MCOs, and the government have embarked on the development of standardized practice guidelines
- Cost-Efficiency : This occurs when the benefit received is greater than the cost incurred in providing the service
- Critical Pathways: These are outcome-based and patient-centered case management tools that are interdisciplinary and that facilitate coordination of care among multiple clinical departments and caregivers
- Risk Management: This is a proactive effort to prevent adverse events related to clinical care and facilities operations, and is frequently focused on avoiding medical malpractice.
Practitioners predict that quality will "trump finances" in communities throughout the US.
97 percent believe that all hospitals will have governing boards with special committees on hospital quality and patient safety by 2014. Many believe that "zero tolerance" will be used instead of basing goals on average industry standards. Many also expect that hospitals will adopt programs developed by the aviation and manufacturing industries to improve communication and reduce medical errors, and that senior management bonuses will be determined by achievement of quality outcomes over achievement of financial goals. The pay-for-performance model of reimbursement will make patient care safer.
Watch the following video on patient safety to put human faces into the maze of technology, critical pathways, clinical guidelines, and cost efficiency initiatives. Consider where carefully framed theories, rules, and regulations wane and reality takes over.
Joint Commission Speak Up: Prevent errors in your care, Monday, March 07, 2011
Improving Health Care Together
"Learn about Joint Commission Resources (JCR) and its work with the Partnership for Patients initiative. Launched in December 2011, the initiative brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in a shared effort to make hospital care safer, more reliable, and less costly."
Podcast: on Medical Errors
Health care providers are people. Human error is bound to happen. We have systems in place to minimize error, but they are not enough to prevent all mistakes. No one goes to work wanting to harm a patient. There is increasing recognition that a health care provider involved in a serious medical error is a 'second victim.' For more information on this topic visit the Institute for Healthcare Improvement (IHI) web site: www.ihi.org
Danielle Ofri is a writer and a practicing physician at Bellevue Medical Center in New York City. In this installment of the Narrative Matters series from Health Affairs she presents her experience with a medical error and related this to disclosure, apology and the role of shame. Click the source link below to view the links to the podcasts.
To listen to the podcast click: https://itunes.apple.com/us/podcast/danielle-ofri-ashamed-to-admit/id407251174?i=89380209&mt=2
A discussion of the American health care system also needs to consider access and quality issues, and it stands to reason that the health and health care of a person with low health literacy (who is unable to understand health information or medical instructions about medications or diet) will be compromised as a result. And—after seeing the impact of time and staff shortages, cost reductions, tougher regulations, etc., on our health providers—is it any wonder that they may not even be aware their patients don't understand the materials and handouts they are being given?
Consider the connection between health literacy, patient safety, and medical errors. Patients who know how to ask questions of providers, and providers who know how to answer patients in plain language, can go a very long way to improving the health care of our population.
Some excellent web sites that provide comprehensive information on health literacy include the US Department of Health and Human Resources (HRSA) site: