To Our Federal Government
Preventable medical harm is one of the greatest unmet healthcare challenges of our time but is mostly ignored by the federal government and the public is unaware of the threat. In 1999 a report by the Institute of Medicine estimated that up to 98,000 patients die in U.S. hospitals in any given year from medical errors. By 2016 the estimate had ballooned to between 250,0001 and 400,0002.
Even though medical errors are believed to harm millions of people each year, including nearly 25% of all hospitalized patients3, cause approximately 9.5% of all hospital deaths4, and are recognized by most medical experts as the 3rd leading cause of death5, the federal government does not recognize medical errors as a cause of death6, does not have a standard definition of what constitutes a medical error7, and its various departments do not collect data related to them. As a result, they are unable to research medical errors or formulate effective solutions. This also impedes the ability of the healthcare industry and others in the private sector to develop solutions.
This call for action does not address the immense financial harm to the affected patients, families, businesses, and our country. The federal government must no longer ignore a threat that kills hundreds of thousands and causes misery and hardship for millions of Americans each year.
We ask the federal government to:
- Establish a national standard definition for medical error that is acceptable to both patients and medical professionals.
2. Collect data on all deaths that stem from medical errors, develop effective preventative solutions, and disseminate them to the healthcare industry and the public.
3. Include death due to medical error on the CDC Leading Causes of Death report.
The volume, severity, frequency, and root causes of preventable harm that result in hospital deaths are not all routinely collected or reported by hospitals. As a result hospitals and their physicians, as well as the healthcare industry in general, are unaware of the trends. The aggregation and distribution of the basic metrics of preventable harm would improve patient safety by allowing medical staff to learn from mistakes that have been made.
We ask the federal government to:
4. Require hospitals to conduct a comprehensive analysis that fully informs the medical team and hospital when a medical error may have caused or contributed to the death of a patient, and record the data.
5. Require hospitals to collect the basic metrics for all preventable harm resulting in death and distribute the data to all medical staff on a regular and ongoing basis.
Hospitals are black holes to patients. Medical errors and their subsequent injuries and deaths are not reported locally or easily accessible. Even though the majority of hospitals are non-profits and receive benefits from the federal government, there is a serious lack of transparency. When hospitals lack transparency, patients are put at risk by being denied the opportunity to make an informed decision about their safety. They assume they will be treated safely because the medical oath says ‘do no harm’ but past estimates of preventable deaths suggest otherwise, and no recent studies have been done. Medical professionals are human and make mistakes. Viable solutions to preventable harm can’t be developed until the true extent of the problem is determined, and that isn’t possible until the relevant data is collected and assessed.
Hospital patients and their advocates could stop many errors from happening (the American Patient Rights Association has developed a Patient’s Hospital Safety Guide app), but because there is little to no transparency, and the federal government has failed to inform or educate the public about the seriousness of the problem, people don’t realize it is an issue they should be concerned about, or that they’re at risk of being harmed with each hospitalization. The patient is forced into a position of blind trust and when harmed becomes an unwitting victim. Information on hospital safety that is currently available to the public from CMS (such as Hospital Compare) and organizations that base their ratings and grades on its data, cannot be relied upon because CMS allows multi-unit hospital systems to report data on a systemwide basis, rather than for each individual hospital. Independent rating/grading organizations do not report this problem with the data.
We ask the federal government to:
6. Implement a Medicare (CMS) system to capture all deaths due to medical error by hospital, reportable through a publicly accessible system. (This is an ongoing system of capturing, identifying, and conducting an audit soon after, for all deaths.)
7. Require hospitals to provide data to CMS on all medical errors that result in injury or death.
8. Require hospitals to provide transparency on the safety of their environment based on all global triggers8 through an easily accessible daily public report.
9. Implement meaningful incentives for hospitals to provide the data necessary to create the above reports and meaningful penalties for those that fail to report.
We learned from the pandemic that if people realize there’s a direct threat to their lives, and if they’re informed of the numbers of people dying locally, they can be motivated to take action to protect themselves. It was necessary to have daily information on the number of deaths, to prevent even more people from dying. Similarly, people could be motivated to take action to protect themselves when admitted to a hospital if: 1) they were aware that there is a risk of death as a result of an error during their treatment; 2) information is available on how many people have died at their local hospital due to an error; and 3) they have information about how they can protect themselves.
The number of avoidable deaths due to medical errors could be reduced by providing patients with the information they need to mitigate their risk of being harmed at their local hospital. With adequate and appropriate information, patients can become a part of their medical team. A patient’s active involvement in their safety adds an extra layer of protection to the patient.
We ask the federal government to:
10. Provide an easily queried, publicly accessible reporting system of all deaths due to medical error with a simplified report, by hospital and type of error.
11. Provide public education about what patients can do to protect themselves against hospital medical errors and continual public awareness campaigns about the importance of such protection and how to learn about it.
Healthcare represents approximately 18% of GDP9,10 but patients are not represented or involved in matters dealing with their safety at a national level. This is significant. The public would be best served by an independent board or agency that solely represents the interests of patients and is established to develop and implement solutions designed to improve patient safety.
We ask the federal government to:
- Establish an independent board or agency to represent the interests of patients concerning their safety and develop viable solutions to reduce preventable harm in healthcare.
Prepared by
American Patient Rights Association
The American Patient Rights Association (APRA) is a nonprofit consumer organization of people seeking safe and fair health care. APRA is developing solutions to the preventable physical and financial harm that is occurring to millions of Americans each year as a result of the failures of our healthcare system. One example is the Patient’s Hospital Safety Guide, an app developed in cooperation with leading medical experts to save lives.
Copyright © 2023, American Patient Rights Association. Americanpatient.org.
______________________________
1,4,5,6 Makary and Daniels (2016). Medical error—the third leading cause of death in the US. BMJ 2016;353:i2139.
2 James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-128.
3 Bates, Levine, et al. (2023). The Safety of Inpatient Health Care. NEJM 2023; 388:142-153.
7 Grober, E. D., & Bohnen, J. M. (2005). Defining medical error. Canadian Journal of Surgery, 48(1), 39.
8 Quality Measures Fact Sheet – CMS Patient Safety Indicators PSI 90 (NQF #0531)
9 Berwick, D. M., & Hackbarth, A. D. (2012). Eliminating waste in US health care. JAMA, 307(14), 1513-1516.
10 Vancar, P. (2023). U.S. Health Expenditure as Percent of GDP 1960-2021. Statista 2023.