Our obligation to provide safe and effective care is one of the most sacred trusts given to us—by our community, our friends, and our families.
“Medical Errors May Be the Country's
Third-Leading Cause of Death”
—The Advisory Board Company, Sept. 24, 2013
This was one of several attention-grabbing headlines for stories reporting on a recent study’s estimate that preventable adverse events (PAEs) cause as many as 440,000 patient deaths a year.a Put another way, PAEs account for “roughly one-sixth of all deaths that occur in the United States each year,” the study’s author, John T. James, PhD, writes.
James’ estimate is far higher than that published by the Institute of Medicine (IOM) in its groundbreaking 2000 report, To Err Is Human, which stated that up to 98,000 people a year die from preventable medical errors. But James’ research has the support of two influential patient safety experts who shared their views with ProMedica.b Lucien Leape, MD, a renowned pediatrician and Harvard professor of health policy who co-founded the National Patient Safety Foundation expressed confidence in James’s estimate, noting that the IOM used crude methods to arrive at its estimate. David Classen, a lead developer of the Institute for Healthcare Improvement's Global Trigger Tool, emphasized the need for the media to update the numbers reported to reflect James’ estimate because of the gravity of both patient suffering and the enormous financial costs that result from preventable adverse events.c Leape and Classen concur that the media should stop citing the 98,000 figure.
So the number is now 440,000 lives lost annually—a staggering loss of life. Unfortunately, statistics like these appear to have done little to move our profession to take action, as many leading experts and national agencies state that improvements over the past decade have been negligible. Why is this?
Connecting Patient Safety with Value
Consider the following equation:
Value = Clinical quality + safety + patient experience
Cost of care
What will it take for our organizations to seriously fund patient safety efforts, recruit experts in safety science and high-reliability design, train our caregivers in methods that eliminate harm, reengineer our internal processes to be error proof, and to eliminate these types of deaths once and for all?
Perhaps, as leaders, we’re too far removed from the front line of care delivery. Perhaps we’ve never seen or felt the emotional impact experienced by a patient and their family. It seems to me that we need to creatively capture the hearts and minds of every leader and caregiver to make an impact on safety. The impact needs to be heartfelt and register at an emotional level, using examples that hit very close to home.
With this in mind, I recently facilitated a hospital board retreat. The topic was “The Board’s Role in Quality and Safety.”
During the retreat, I reviewed the lives of three people who were affected by the care they received in healthcare organizations that had very good reputations.
The first slide showed a picture of a thriving 81-year-old grandmother. She was sitting on the deck of a lodge, watching elephants gathered around a drinking hole in South Africa. The trip was an 80th birthday gift from her sons—and it was a birthday she nearly missed. She had experienced many medical errors in her lifetime, but the one that nearly caused her to miss this birthday celebration was a heart test reading that was initially reported as “normal.” Two days later, she had a heart attack and underwent urgent bypass surgery. The initial reading of the heart test was found to be incorrect; in fact, the test showed significant coronary artery disease. This misreading nearly cost the woman her life.
The second example showed a happy grandfather enjoying time with his new granddaughter. His life was taken by a nursing medication error. He had just been in an auto accident and was in the hospital for observation. Except for some bruising, he was expected to make a full recovery and return home in a few days. But he had heart failure, and he was on nitroglycerin patches to help treat it. When it was time to switch to a new patch, the nurse applied the new patch, but didn’t remove the old patch. Too much nitroglycerin caused his blood pressure to drop to dangerous levels and his kidneys to fail. Because of his advanced heart failure, his physicians felt his kidneys would not recover and that dialysis would be pointless. He passed away several days later due to the medication error.
The third individual was a man in his 70s who was taking pleasure in a very active and enjoyable retirement with his wife. He was a victim of colon cancer. How can a person die from colon cancer if he or she gets regular screenings, as recommended by the U.S. Preventive Services Task Force? Well, he didn’t receive the screenings. His family practice physician never referred him for the appropriate tests.
“Who were these people?” I asked.
They were my mother … my grandfather … my father.
Medical errors happen very close to home, and everyone’s at risk. They don’t just happen in another state or at that hospital down the street, but right in our own institutions, where we care for our neighbors and family.
The Need for Leadership on Safety
As we embark on our mutual goal to create the safest healthcare delivery system possible, we must do everything within our power to ensure that our services are error proof.
I implore you to lead and contribute to patient safety programs in your institutions. It will take all of us, but together, I know we won’t fail. Our friends, our families, and our communities are counting on us. They have entrusted us with their care and their lives, and we have accepted this responsibility with open arms. It is a most sacred trust. Let’s not let them down.
As healthcare leaders, we can take five action steps to improve safety in our organizations.
Make safety the number one strategic priority. This commitment should be visible not just on paper, but also in word and deed.
Be visible and vocal leaders for safety improvement. We should discuss the need for improved safety during every meeting, and talk about it on executive safety rounds. Let’s make safety a core value of our organizations.
Adequately resource the safety work. Every hospital I’ve consulted with in the past five years is under-resourced—not only for improving quality, but also for improving safety. For whatever reason, our organizations have been unwilling to fund an adequate number of FTEs to get this job done. We can’t afford to wait any longer. And we don’t need a stronger business case than this: 400,000 people lose their lives each year due to medical errors.
Openly and transparently report medical errors. Create an environment where staff are rewarded—not punished—for reporting errors and incidents. The more we know about our systems and processes, the better they will become. Our goal is to create an environment that is so reliable, there will be zero errors and zero harm.
Learn from other industries. Retain experts from the nuclear and/or aviation industries to guide safety efforts. These experts know how to build highly reliable systems, and several groups have successfully translated the strategies and tactics into the medical environment.
John Byrnes, MD, is chief medical officer, Sisters of Charity of Leavenworth Health System, Denver, and a member of HFMA’s Colorado Chapter.
a. James, J, “New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care,” Journal of Patient Safety, September 2013, .
b. Allen, M., “How Many Die from Medical Mistakes in U.S. Hospitals?” Sept. 19, 2013.
c. The IHI Global Trigger Tool provides a method for assessing the incidence of adverse events in an organization.
Publication Date: Monday, December 02, 2013