Remember the Institute of Medicine’s 1999 report, “To Err is Human” which revealed that as many as 98,000 people die in hospitals each year as a result of medical errors? The institute set a five-year goal of reducing that number by half. In response, accreditation bodies, payers, nonprofit organizations, governments, and hospitals launched major initiatives and invested considerable resources to improve patient safety.
Yet adverse events reported since have ranged from 100,000 to 400,000 a year, so it is fair to say we have not reached the goal.
Dr. James Jones, an advocate for patient safety, has a different take on the problem. “Trying to achieve a specific, quantitative reduction may be less important than simply applying the lessons already learned to ensure the safety of patients in our health-care system,” he said recently.
We need action on the part of providers, legislators, and people who will one day become patients. Yet the action and progress on patient safety is frustratingly slow.
On Dec. 10, I attended a National Academy of Medicine symposium in Washington, reflecting on the 15th anniversary of “To Err is Human.” We have seen some gains in preventing certain infections, for example, central-line catheter infections have been reduced by 80 percent across the country and don’t even happen in some hospitals. Yet we still have 120 adverse events per 100,000 hospital admissions each year. Each year, there are 4,000 surgical near-misses or adverse events, such as wrong-site surgery, the wrong procedure, or sponges left in a patient.
Every preventable adverse event reflects an unnecessary death or injury. Leaders of various agencies have spent 15 years forming committees, generating guidelines, and mandating public reporting, all at a cost to each of us but with poor outcomes.
This failure is due to the fact there is not adequate agreement, consensus, or validation for our measurement process.
We also have not really bought into the idea of patient engagement or empowerment, even though we know that when patients are educated and know how to advocate for their care, risks are reduced.
During this symposium, we were shown slides of patient engagement websites. Several studies have shown patients don’t use these sites, mostly because they don’t know about them or find them too hard to navigate.
We have published several papers that show patients will become engaged if they receive explicit direction, knowledge, and their health-care providers encourage patients to ask questions.
Matthew McHugh from the University of Pennsylvania provided the most sobering data at the conference. He surveyed more than 20,000 bedside nurses and found the majority of them would not always recommend their own hospitals to family or friends. Most believed their management did not respond to patient safety issues and they therefore were uncomfortable reporting safety violations.
Until we change the culture of our health-care system, patients and families must be their own advocates so they don’t end up saying, “If only I’d known.”
Maryanne McGuckin, Dr.ScEd, FSHEA, a former faculty member of the University of Pennsylvania, is president of McGuckin Methods International, member of the World Health Organization's Global Patient Safety Challenge, and author of “The Patient Survival Guide: 8 Simple Solutions to Prevent Hospital and Healthcare Associated Infections.”
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