Just one year ago (February 2016), Heartland Health Research Institute (HHRI) published a series of white papers, ‘Silently Harmed – Hospital Medical Errors in the Heartland.’ ‘Silently Harmed’ was intended to demonstrate what the national estimated preventable adverse events (PAEs) may mean to Iowa and six states contiguous to Iowa. Using a handful of U.S. studies that evaluated preventable mortalities, HHRI settled on approximately 250,000 patients dying annually in U.S. hospitals due to preventable mistakes.
Just two months after ‘Silently Harmed’ was published, The Leapfrog Group estimated over 206,000 avoidable deaths occur in hospitals annually. A month later in May, a report released by Makary and Daniel estimated preventable deaths in U.S. hospitals to be greater than 250,000, similar to the HHRI estimate. The Makary-Daniel report made national headlines by suggesting “medical errors are the third leading cause of death in the United States.”
Another report has now been released in the March 2017 edition of the Journal of Patient Safety suggesting that “approximately 200,000 preventable hospital-related deaths each year in the United States is not unreasonable.” This report is authored by Kavanagh, Saman, Bartel and Westerman.
What I found to be most interesting in the recent report by Kavanagh et. al include the following:
- Patient Perspective – Any insinuation from the medical community that preventable medical errors should be discounted due to patient age, health or life choices are baseless. If a terminal patient dies prematurely due to a medical error, this is still an unacceptable occurrence. As the article correctly states, “Medicine does not have the moral authority to discount or disregard days, weeks, or months of life.”
- Voluntary and Non-Audited Reporting – Voluntary and non-audited reporting mechanisms greatly under-report adverse events, preventable harm and fatalities. “The 2010 Office of Inspector General Report found diagnostic codes ‘absent or inaccurate’ in seven of eleven Medicare hospital-acquired conditions, and in 93 percent of the time, incident reports were not submitted.” In fact, “since 2005, an average of less than 1000 sentinel events have been voluntarily reported to The Joint Commission per year from the hospitals that have undergone their accreditation process…Officials at The Joint Commission estimate that less than 0.1% of events have been reported.”
- Cultural of Safety – Having a ‘culture of safety’ serves as the hospital’s foundation from which to build new internal systems and policies that prevent patients from being harmed. “What ties the occurrence of preventable adverse events and mortality together is the willingness and determination of facilities to adopt a culture of safety and invest in patient safety. The adoption of preventive protocols is further hindered by the United States’ fragmented, nonuniform healthcare systems composed of facilities with differing philosophies and administrative structure.”
- Put Your Money Where Your Mouth Is – Some in the healthcare industry ignore current studies on medical harm and believe we must wait for more perfect data before it can be shared with the public. “The onus should not be on consumers but on the healthcare industry to generate comprehensive data to demonstrate that their product is safe.”
One example on just how grossly under-reported adverse events are in our hospitals, just look at a recent article in the Minneapolis Startribune. The article indicated that Minnesota hospitals reported only 336 ‘adverse events’ during the last year, including operations on the wrong body parts and disabling medication errors. The report included four adverse events that resulted in deaths — three from patient falls and one from a medication error — and 106 that led to severe injuries. This type of reporting runs contrary to national reports on adverse events in U.S. hospitals. In May 2016, the Agency fo Healthcare Research and Quality stated, “According to the most recent data, nearly 4 million adverse events occurred in U.S. hospitals in 2013…we can project that about 170,000 people died in 2014 as a results of an adverse event or medical error.” This estimate is for Medicare-eligible patients only. Based on 585,000 hospitalizations in Minnesota in 2012, HHRI estimated that roughly 146,000 patients are seriously harmed in Minnesota each year, while over 4,200 patients are fatally harmed annually.
Creative reporting of such important metrics continues to be allowable in this country.
Most agree that we need better data to avoid further speculation of this epidemic. Playing horseshoes and hand grenades to determine the number of patients harmed is no longer good enough. After all, if we don’t know the extent of the problem, how can we determine whether the new delivery and payment systems will solve it?
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