Making Sense of the ‘Iowa Patient Safety Study©’

Confronting problems we have in healthcare today and fulfilling our vision for the future begins with having the courage and willingness to do the ‘right thing.’ Too often, however, doing the ‘right thing’ runs contrary to how we are incentivized to perform. As we know, incentives drive behaviors – both good and bad.

In his book, “Mistreated: Why We Think We’re Getting Good Healthcare and Why We’re Usually Wrong,” Dr. Robert Pearl appropriately wrote: “The design of our healthcare system – how it’s structured, reimbursed, technologically supported, and led – determines how the people in it will behave.” This sentence clearly articulates the inherent problems found in a haphazardly-designed system that now comprises almost one-fifth of the U.S. economy.

I have learned a great deal from our recent “Iowans’ Views on Medical Errors – Iowa Patient Safety Study^©.” Five large takeaways from this study include:

1. Nearly one-in-five Iowa adult patients experienced medical errors in the past five years, either for themselves or for someone close to them.
2. When a medical error occurs, six-in-10 Iowa patients are not notified of the error by the responsible healthcare provider.
3. Most Iowans who experienced medical errors desire to report the error because they want to prevent the same error from happening to someone else. This runs contrary to conventional belief that patients desire to report medical errors primarily to receive compensation for the harm they received.
4. Iowans strongly feel that medical errors must not be hidden from the public and should be reported, both to the patient and to an appropriate regulatory agency.
5. Iowans believe medical errors are mostly caused by overworked staff, lack-of-care coordination and poor communication.

Reading between the lines on many of the survey findings, here are some of my general thoughts on what we can learn from this report:

• Medical errors are a national public health crisis, and Iowa is certainly not immune from this persistent epidemic.
• Making healthcare safer is difficult largely because healthcare organizations operate in a very complex healthcare system. They use a myriad of inoperable electronic health-record systems that are not fundamentally equipped to allow for effective communication between providers. Most importantly, strong incentives to push appropriate patient care in the right direction is sorely lacking. Because of this, delivering efficient and safe healthcare appears to be more problematic than putting a man or woman on the moon.
• Surveyed Iowans are not necessarily blaming individual workers who devote their worklife to the medical profession, but rather, they tend to believe that well-meaning medical professionals are trapped in a subpar delivery system.
• The patient ‘perspective’ must be actively pursued to measure the outcomes of the care they receive, and this experience can help reveal the prevalence of medical errors. The future of healthcare will be determined as much or more by patients as by physicians.
• Zero-tolerance of preventable medical errors should be the norm, rather than exception – Most everyone knows that this problem is happening, but little has been done to determine the extent of this problem and how to make it unacceptable in the future. When errors occur, provider care systems are largely silent on this topic, often failing to share prompt, open disclosure and a full apology to harmed patients. This primarily happens because providers wish to avoid the possibility of malpractice lawsuits and maintain a pristine public reputation. Patients, on the other hand, have reasonable expectations that are woefully unmet after an error occurs. They likely feel thrust into a confrontational situation while still being in a fragile state of health. In short, if we don’t demand safe care, they don’t supply it. In 2017, commercial passenger airlines had zero deaths due to accidents…because that industry has a zero-tolerance approach to preventable errors. The medical industry can learn greatly from other industries.
• Organizational culture is critical to the success of delivering safe care. The environment in which medical staff work – such as hospitals and clinics – can provide the necessary organizational culture to ensure the healthcare delivered is as error-free as humanly possible. Medical staff should not be afraid to report medical errors when they do occur. Safety improvement initiatives will only succeed when leadership, safety culture programs, fundamental communication practices, commitment to transparency and patient engagement are fully-aligned with the objective of greater patient safety.

Thought leader and author Frank Sonnenberg describes trust quite succinctly, “Trust is like blood pressure. It’s silent, vital to good health, and if abused it can be deadly.” To have an efficient and effective healthcare delivery system, trust will be required at all levels and by all participants. This means that, at their most vulnerable time, patients should not be taken advantage of by those who are given this trust – especially when medical errors occur.

If we can put a man on the moon in 1969 using technology dated 50 years ago, why can’t preventable medical errors be tracked and mostly eliminated today? We must first have the moral will to succeed, and then design and install correct incentives to ensure the desired behaviors and outcomes.

The re-design of our healthcare system requires the grit we used when launching a rocket to the moon. In healthcare, however, its more about human (and organizational) behavior than rocket science.

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