By Leah Binder,
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. CMS monitors these ulcers through claims data, but the study suggests this method may undercount them by a factor of 10 or more. The agency 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 CMS 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.