Rightfully so, the spread of the coronavirus (COVID-19) in our country and abroad remains at the top of daily headlines. From quarantines, stock market slumps, flight cancellations and a shortage of supplies such as face masks and hand sanitizers, this is a huge concern around the world. According to the World Health Organization (WHO), COVID-19 “…is a new virus to which no one has immunity.”
At the date of this writing (March 9), about 3,900 people have died from COVID-19 (mostly in mainland China), and there are now more than 111,000 global cases, with infections in more than 70 countries and territories. Additionally, three Iowans have tested positive with the virus. The U.S. death toll is at 22 and climbing. Without question, we must remain urgently focused on this very dangerous and deadly epidemic.
But we should also be mindful that we have been in the middle of another epidemic for decades that greatly impacts each of us – preventable medical errors. According to a national report in 2016, up to 250,000 Americans die each year in our hospitals due to preventable medical errors, roughly 700 needless deaths each day. Another 2013 estimate is at over 400,000 deaths, or about 1,100 each day. The 2017 Iowa Patient Safety Study that HHRI performed revealed that one-in-five patients in Iowa experienced a medical error within the past five years – with about 60 percent occurring in Iowa hospitals.
Patient Safety Awareness Week is this week (March 8 – 14) and it recognizes the importance of patient safety in all healthcare settings. Tackling preventable medical errors to ensure patient safety is a monumental goal, requiring multi-layered ‘solutions.’ Any worthwhile approach must begin with two essential words, patient-centric.
The general public assumes that medical errors are comprehensively monitored by appropriate state-based and federal agencies. Unfortunately, this is not the case. A January 2018 Des Moines Register editorial correctly stated, “Without concrete data on medical errors, we don’t know how many people are affected or whether any efforts are successful in reducing mistakes.”
Until employers and the general public demonstrably insist medical errors be accurately tracked and improvement shown, little will be accomplished. There are two paths for Iowa to learn more about the prevalence of medical errors and to gauge success in reducing these errors. One path is through the Iowa legislature, requiring new reporting requirements by medical providers, while the other path is through a public-private partnership that enables grass-roots initiatives to organically develop. Both paths would require heavy lifting.
PATH 1: LEGISLATIVE EFFORTS
The legislation process is wrought with many potholes that would hinder progress, much of which are politically-motivated with lobbying agendas that represent the provider community and their best interests. Possible approaches through state-based legislation may include:
#1: Mandate Adverse Event Reporting System
Pass legislation to mandate the reporting of adverse events (medical errors) by Iowa medical providers. According to a 2014 report by the National Academy for State Health Policy, 28 states and the District of Columbia have variations of authorized adverse event reporting systems, while the remaining 22 states do not. Iowa does not have such a reporting system.
- Purpose: By having a robust reporting of adverse medical events in Iowa, this critical data would allow healthcare organizations and regulatory agencies to evaluate causes, revise and create processes to reduce the risk of future errors. This information, when honestly and fully reported, can help medical organizations more clearly understand the root causes of what happened, regardless of the outcome of the error, and to identify the combination of factors that caused the error or near-miss to occur.
- Public Desire for Reporting System: The Iowa Patient Safety Study© found that 88.5 percent Iowans, whether they experienced a medical error or not, believe the provider community should be required to tell patients if a medical error is made during the treatment. Additionally, at least three-quarters of Iowans ‘strongly agree’ that hospitals, physicians and nursing homes should be required to report all medical errors to a state-based agency.
- Push-Back by Provider Community: Organizations such as the Iowa Hospital Association, Iowa Medical Society and their surrogates will argue that Iowa DOES have an adverse-event reporting system in place – a voluntary one. Perhaps true, but voluntary reporting provides little value to seriously understand the true scope of the medical error problem in Iowa. Much of what is shared with the public is grossly under-reported and misleading. This behavior of withholding critical data is more provider-centered than patient-centric. It does not help the public discern the frequency of the problem and whether improvement – if any – has been made. Having a state-mandated reporting system in place, however, does not ensure that medical providers will comply with these reporting requirements. Largely due to insufficient regulatory enforcement provisions found within states, mandatory reporting laws often result in undercounting and underreporting of accurate and comprehensive data. Effective enforcement provisions of such a mandate is critical to success.
#2. Mandate HCAHPS Survey of Iowans that Includes Medical Error Experience
Currently, participating U.S. hospitals randomly survey patients using a provider-endorsed questionnaire known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). This standardized national survey uniformly measures and publicly reports discharged patients’ perspectives about their recent hospital stay, such as: their communication with doctors/nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, pain management, discharge information and overall hospital rating. However, this standard tool does not include critical questions about medical errors while hospitalized.
Iowa lawmakers could pass legislation to mandate that hospitals (along with their research partners) survey patients about medical error experiences they had during the hospitalization and require those results be made public. A logical (and efficient) approach would be to include those questions in the HCAHPS survey.
#3. Establish a Central Database in a State Agency
This effort could be separate or be part of mandating an adverse reporting system in Iowa. Patients, unfortunately, are the most underused resource when measuring the outcomes of the care they receive. Iowa and many other states do not have a centralized repository for patients to report medical errors. Pursuing the feasibility of a state-wide, incident-reporting system for patients and families can encourage patient engagement as a priority for patient safety efforts. As found in the Iowa Patient Safety Study©, patients want errors to be prevented in the future and need to know a system is in place that will work toward that end.
PATH 2: NON-LEGISLATIVE EFFORTS
As mentioned earlier, mandating medical providers to report adverse events has serious limitations, not the least being that laws seldomly correct or modify behavior to report these events. To serve as a counter-balance to insufficient provider reporting, Iowa may consider doing one (or both) of the following that will incite public opinion to nudge provider correction:
#1. Implement an independent, statewide random-sampling survey of patients who recently received care from Iowa medical providers.
From this public-private partnership, critical insight would be obtained regarding the prevalence of medical errors that would allow for future improvements. Pursuing this process would yield critical information on medical errors in Iowa that are based on both factual and scientific processes that include the patient experience and perspective. The cost to perform this annual or bi-annual survey could be jointly borne by public and private organizations with the results made available to the public. Aggregate data results could incrementally be shared with the public, but after a few years of this research, provider-specific data would be available to the public. As Supreme Court Justice Louis Brandeis famously wrote, “Sunlight is said to be the best of disinfectants.”
#2. Survey State of Iowa Employees Only
This option is a scaled-down version of the previously mentioned state-wide survey. Learning more about the experiences of State of Iowa employees and their family members would provide additional insight on how medical errors can potentially impact healthcare costs and productivity issues for a large common employer. Based on the findings, this group could serve as the harbinger for expanding to a larger statewide program sometime later.
By using verifiable facts, Iowa can begin to assess and correct a serious long-term problem that has been largely ignored. Iowa can lead the nation on patient safety practices and desired health outcomes, both of which will help control healthcare costs and enhance productivity of its residents. For this to happen, on-going data gathering will be necessary to learn how prevalent this problem is and whether progress is being made to improve patient safety. If providers are unwilling to share the adverse events on a comprehensive basis, it only makes sense to rely on retrieving the insight and experience of patients receiving this care. This process allows for a more patient-centric approach.
The COVID-19 epidemic is now upon us, requiring a vigil readiness with coherent practices. So too, we must be vigilant with patient safety practices.
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