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Real Hospital Metrics We Need to Know

Real Hospital Metrics

Each year, about a quarter of a million patients are estimated to be fatally harmed due to preventable medical errors in U.S. hospitals. This mid-range estimate is used in our ‘Silently Harmed’ white papers and was recently reported in May by Dr. Martin Makary of Johns Hopkins. Given this startling (and probably conservative) number, here are a few critical (yet simple) hospital-specific, patient-safety culture metrics that would be helpful for the unsuspecting public.

Most often, these metrics are only available to specific participating hospitals and the Agency for Healthcare Research and Quality (AHRQ) – the federal agency whose mission is “to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable…”

The AHRQ sponsors the development of patient safety culture survey tools for hospitals, nursing homes, ambulatory outpatient medical offices, community pharmacies and ambulatory surgery centers. As an example, the hospital survey was designed to assess hospital staff opinions concerning patient safety issues, medical errors, and event reporting. Though not mandatory, these instruments can be used by hospitals and other providers to make the following assessments of their organizations:

  • Raise staff awareness about patient safety.
  • Diagnose and assess the current status of patient safety culture.
  • Identify strengths and areas for patient safety culture improvement.
  • Examine trends in patient safety culture change over time.
  • Evaluate the cultural impact of patient safety initiatives and interventions.
  • Conduct internal and external comparisons.

 
Since 2007, approximately 30 percent of U.S. hospitals have administered the safety survey to their doctors, nurses and other healthcare workers. Survey data is collected every two years. In order to trend their results over time using the AHRQ database, hospital-specific surveys may only be up to two years old. For the most recent survey year (2016), a total of 680 hospitals submitted data, comprising approximately 448-thousand hospital staff respondents.

Four answers worth knowing

As a prospective hospital patient, I would want to know what percent of surveyed staff members responded “yes’’ to the following four questions:

    1. Would you have your surgical procedure at the hospital (or the department/unit) in which you work?
    2. Do you feel comfortable speaking up when you have a safety concern?
    3. Does the teamwork here promote doing what’s right for the patient?
    4. Are your managers and administrators responsive to your patient-safety concerns?

 
In order to elicit honest responses from hospital staff, confidentiality is extremely critical. If staff members feel that confidentiality is lacking, the survey becomes a meaningless ‘gamed’ response and is possibly more harmful because the rose-colored results may mislead the public. If we, the public, had access to these comprehensive and revealing standardized results every two years, we would have an easier way to assess which hospitals are safer than others.

Think about it. Would you want to seek care from a hospital where only one-third of its staff would choose to go for their own care? By making choices that are important to you and your family, hospitals would be incentivized to invest in a part of healthcare (safe care) that has been grossly neglected for decades.

Teamwork = Effective Care

One cannot underestimate the importance of teamwork when seeking appropriate and effective care. Evidence of a safe workplace culture is present when each member within a specific hospital department or clinical area:

  • Is comfortable being a patient within that care unit.
  • Feels comfortable speaking up when there is a safety concern.

 
A well-coordinated team thrives on strong communication protocols. This culture-of-safety ensures that medical errors will eventually be reduced, much the way teamwork required in a cockpit is designed to reduce pilot errors.

Not all hospitals are the same. In fact, not all departments within the hospital are the same. It’s the teamwork culture-of-safety that exists and continues within each unit of each hospital that makes the difference. The right culture will be sustained despite the turnover that invariably happens due to retirement, job-changes, etc.

Hospitals (and their associations) often debate which metrics should be used to hold them ‘accountable.’ They cite many methodological reasons why such metrics should be avoided or embraced. Some of these concerns may be legitimate. But perfect is often the enemy of good. For me, simplistic answers to the questions above will ultimately determine whether the care we seek is what we were hoping to obtain.

There is nothing wrong with keeping it simple.

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Healthcare Costs and Wages in Iowa
the Faceless and Nameless Among Us

Healthcare Costs and Wages in Iowa - the Faceless and Nameless Among UsWhether it is a morning jog or perhaps a bike ride, I find great pleasure in determining the measureable progress I have made both in distance and time.

The same can be said about reviewing data from our past studies that cover a longer period of time. Doing so helps gauge a better understanding of trends occurring within benefits, specifically as it relates to health insurance components. As we are keenly aware, what we pay for our health insurance and the healthcare we receive continues to nip at take-home pay and the ability to afford other necessities, such as food, clothing, housing, etc.

A recent study commissioned by 25 local Iowa United Way associations indicated that for almost a third of Iowans (31 percent), the income they receive does not allow them to cover the basic costs of living. In fact, two parents working full-time in this state would need to collectively earn $23.34 per hour over a 40-hour week to cover basic household costs. With cities, counties and states debating what specific minimum wage amount should be acceptable (and affordable), this topic will not go away anytime soon.

Knowing that components of health insurance plans, such as premiums, deductibles and out-of-pocket maximums continue to push northward, this also impacts family budgets and whether they have adequate health coverage. By ‘adequate,’ I am referring to cost-sharing responsibilities that may overwhelm lower-earning Iowans. According to the Kaiser Family Foundation, Iowa happens to have a lower-than-average rate of uninsured (six percent). Nonetheless, even those who do have coverage continue to experience higher cost-sharing arrangements that may cause people to seek less care – which is a plausible reason we see moderation in the growth of health cost spending.

With this in mind, I want to take a quick look ‘back’ on trends for a few health insurance cost components confronted by Iowans with employer coverage. Covering a six-year period (2009 – 2015) from our annual ‘Iowa Employer Benefits Study©,’ we learn that the average weekly wage from the Iowa Workforce Development (IWD) rose annually by 2.6 percent, while premiums increased during that same period by 9.2 percent prior to any plan designs changes made to lower the increase. Altering plan designs typically result in higher cost-sharing for employees, something that employers are reluctant to do. After alterations, the average annual premium increase was 5.5 percent, still over twice the weekly wage increase.

In addition to premium inflation, Iowan’s with employee-only coverage have experienced increasing deductibles by eight percent annually, from $1,061 to $1,662. The total cost-sharing exposure Iowan’s pay for medical costs (e.g. out-of-pocket maximums) increased by 6.1 percent annually from $2,210 to $3,151. Finally, employees with single coverage have contributed 6.2 percent more annually through payroll deduction for their cost of the employer-sponsored coverage.

Here is a summary of the six-year history.

Average Annual Increase in Iowa (2009 –As payment responsibility for medical costs continues to shift from employers to employees, a new dynamic of patients becoming the ‘new payer’ profoundly impacts the receivables for the provider community, specifically hospitals. Though not new information, this fact can and will change how financing options may evolve from providers to help patients navigate their financial obligations and ensure that patients are well educated about the cost of their care. Insurance companies, for their part, may also explore innovative financial solutions to help their insureds assume payment responsibilities – possibly a foray into a new market of opportunities.

Trends found in this six-year period will most likely continue well into the future, and the evolution of how we pay for our healthcare will require off-the-beaten-path solutions to establish new funding mechanisms for an increasing number of patients.

Over time, the compounding of these trends will affect more Iowans, revealing that many will no longer be faceless and nameless, rather, they may become us.

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The Lure of Opioids

The Lure of Opioids

One medical topic clearly on today’s radar is the use (and abuse) of opioids – medications that are often used to relieve pain, such as: hydrocodone (e.g. Vicodin), oxycodone, morphine, codeine and other related prescription drugs.

It is relatively easy to become addicted to opioids. Like many others, I have been prescribed various opioids (typically Vicodin) in the past when having lower back pain or a dental procedure that required pain management. Thankfully, I used only a very small portion of the prescribed pills during each incident, which resulted in the accumulation of many ignored (and expired) bottles in our medicine cabinet.

For many, the continued use of opioids to control pain may quickly evolve into a habit, and eventually, addiction. Without seeking and receiving appropriate rehabilitation for opioid addiction, accidental deaths happen far too often. In 2014 alone, the number of opioid deaths due to overdose in the United States was 28,647, a number that exceeds the size of Marshalltown, Iowa’s 16th most populated city. A 14 percent increase from 2013, this number represents an age-adjusted rate of 9.0 Americans per 100,000.

Iowa Opioid Fatalities

The Kaiser Family Foundation analysis shows that 158 opioid fatalities occurred in Iowa during 2014. With an adjusted death rate of 5.3 Iowans per 100,000, Iowa ranks considerably below the U.S. average. The adjusted rates of fatalities per 100,000 for each of Iowa’s six neighboring states are listed below:

  • Nebraska – 3.2 (56 fatalities in 2014)
  • South Dakota – 4.1 (33)
  • Minnesota – 6.0 (318)
  • Illinois – 9.4 (1,205)
  • Wisconsin – 11.1 (627)
  • Missouri – 12.0 (696)

The below-average rates for Iowa, Nebraska, South Dakota and Minnesota leads one to ask, “What are these states doing differently?” Have these states implemented actions preventing individuals from becoming addicted and treating those who are addicted? Do they have narcotics detectives and emergency medical technicians who help guide individuals to treatment rather than arrest them? Some states have indeed implemented programs to address this emerging topic of national concern.

The Center for Disease Control and Prevention (CDC) recently released guidelines to help physicians prescribe opioids appropriately and responsibly. The opioid crisis should not just be the concern for providers who prescribe opioid medication. In fact, everyone has a role to play mitigating this epidemic, including those addicted and their family members, those who treat the addicted, educators, law enforcement agencies, and the efforts of a well-coordinated community. As two authors commented in a recent Health Affairs publication, the opioid crisis is “a multi-faceted problem [that] requires a multi-faceted solution.”

For each of us, a frequent reconnaissance of our medicine cabinets to ‘search and safely dispose’ is a good first step to eradicating opioid misuse and abuse.

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Codman – A Medical Pioneer

Ernest Amory Codman

Dr. Ernest Amory Codman

Henry Ford was one. So was Eli Whitney, Thomas Edison, and more recently, Steve Jobs. Each developed their own niche through new areas of thought, research and ingenuity and are now synonymous with the title, ‘pioneer.’

‘Medical Outcomes’ Pioneer

Another pioneer was a Boston surgeon by the name of Dr. Ernest Amory Codman. Unfortunately, his work was considered unpopular among his peers, so by the time he died in 1940, he had little fame or fortune. He died penniless without even a headstone on his grave.

Born in 1869, Codman made contributions to anesthesiology, radiology, duodenal ulcer surgery, orthopedic oncology, shoulder surgery, and the study of medical outcomes. But his biggest contribution was founder of what is known today as ‘outcomes management’ in patient care.

Codman became the first American doctor to follow the progress of patients through their recoveries. Using “End Result Cards,” he kept track of every patient he treated, along with demographic data, diagnosis, the treatment rendered, and the eventual outcome of each case. He would follow up with patients at least one year after treatment to determine the outcome of his work.

Unlike his peers, it was his lifelong passion to establish an ‘end results system’ to track patient outcomes. Clinical ‘misadventures’ would be identified and provide additional insight to improve the care of future patients. But this was not enough for Codman. He also believed that all information stemming from this work should be made public so that patients could make educated decisions on which physicians and hospitals to seek care.

This happened over a century ago!

While on surgical staff at Massachusetts General Hospital (MGH), Codman also became a member of the Harvard faculty and instituted the first morbidity and mortality conferences. MGH had little interest in Codman’s pursuit of health outcomes, and he subsequently lost his staff privileges. Not deterred, and exhibiting characteristics of a honey badger, Codman established his own hospital to pursue the performance measurement and improvement objectives he believed would progress medical outcomes management.

From 1911 to 1916, Codman recorded and published 123 errors on 337 patients hospitalized in his care. The cause of errors ranged from lack of knowledge and skill to poor surgical judgment and an absense of care or equipment. He sent copies of his annual hospital reports to major U.S. hospitals challenging them to document their outcomes. But hospitals would not follow his lead. Undeterred, Codman made his reports available to the public allowing patients to be well-informed when seeking care from hospitals.

At a local medical society meeting one evening, Codman blatantly displayed a cartoon (drawn by a friend) showing an ostrich with its head in the sand kicking up sand and golden eggs, explaining that the ostrich represented surgeons and hospital administrators whose only interest was in mining financial rewards – not improved care. From this, he was asked to resign from the society. Shunned by his peers, many of whom no longer referred patients to him, his views were widely ignored by the medical profession.

Through his work, he was a founder of the American College of Surgeons that later became known as the Joint Commission on Accreditation of Healthcare Organizations.
Ahead of his time, Codman once wrote, “We believe it is the duty of every hospital to establish a follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians.”

Had his peers not ignored his actions and views on improving patient outcomes, one might easily conclude that the rapid advancement of medical outcomes would be light years ahead today.

Since his death, Codman’s impact on the medical profession is viewed quite differently. In 2014, over a century following Codman’s efforts to reform the medical world, a group a physicians raised money to establish a granite and bronze memorial at Codman’s gravesite.

Doing the right thing to benefit the public takes immeasurable courage. Constructing and implementing a contrarian approach may seem disruptive – especially to your peers. These so-called disruptions may eventually reveal themselves as new areas of thought, research and ingenuity. Through his struggles, there’s no doubt that Dr. Ernest Amory Codman was a true medical pioneer.

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Autopsies – The Ultimate Medical Audit

AutopsySixty years ago, about half of all patients who died in hospitals were autopsied to determine the cause of death – which also advanced the knowledge of medicine. In fact, autopsies were considered routine. For some family members, autopsies provided a sense of closure that was desperately needed during an emotional time.

By 1971, this practice changed dramatically when a decision by The Joint Commission – a federal organization that accredits healthcare facilities – dropped the autopsy requirement rates for community hospitals and teaching facilities, which were 20 percent and 25 percent, respectively. Simply put, the practice of performing autopsies on a regular basis was no longer in vogue.

At the time, hospitals were simply performing autopsies to comply with this requirement – not to gain medical insight. Largely due to autopsy cost, which were generally paid by hospitals, medical providers pressured the commission to eliminate the requirements altogether. The commission eventually relented, as it was determined that too many hospitals were performing shoddy autopsies that revealed little additional information to advance the understanding of diseases and the effectiveness of various treatments.

Today, approximately five percent of patients who die in hospitals receive an autopsy. As many as 40 percent of hospitals don’t perform autopsies at all. Many of the autopsies that are performed – such as for the musician, Prince – are to discover any evidence of foul play or suspicious circumstances, perhaps requiring a government-assigned coroner or a medical examiner to review the case. Due to the nature of educating medical students, teaching hospitals are more likely to undertake autopsies than non-teaching facilities. But the decline in autopsies most assuredly means the death certificates are not likely to be as accurate when determining the cause of death.

At a family’s request – and their own expense – autopsies can still be performed. But due to sensitivity and cost issues (an autopsy can run $1,500 or more), most grieving families shun autopsies. Health insurance companies do not cover the cost of autopsies because it does not relate to the health or well-being of a living person.

Moving beyond the cost and sensitivity issues, autopsies do provide a great deal of value to the medical world. Studies show that doctors make diagnostic errors in about 25 percent of cases. These errors remain unknown due to the absence of autopsies, consequently resulting in incorrect information used on death certificates.

In 1998, the Journal of the American Medical Association reported that autopsy results revealed that clinicians misdiagnosed the cause of death up to 40 percent of the time. Other studies indicate that 10- to- 30 percent of autopsies performed reveal previously undiagnosed conditions, many by unreported medical errors. It would be intriguing to know whether fewer medical errors occurred in hospitals when autopsies were more prevalent. Unfortunately, we don’t have such data to definitively render such comparisons.

It stands to reason that autopsies may provide additional learning for physicians and hospitals during weekly or monthly peer review meetings, allowing for new initiatives and policies to emerge that will avert future medical errors. Such evaluations can only come from the autopsy table.

Resuscitating the slow death of the autopsy may actually be a solution to learning more about the frequency of fatal medical errors and to advance the scientific knowledge of medicine. With at least 30 percent of health costs being considered ‘wasted’ cost, why not divert a small portion of this waste to reveal truths we must eventually confront?

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Preventable Fatalities in Hospitals
Gathering the Right Statistics

Silent Death: Approximately 252,000 patients die annually in hospitals due to preventable medical mistakes.

Silent Death: Preventable medical errors in hospitals.

A recent report published in The BMJ by Dr. Martin Makary and Michael Daniel, both from Johns Hopkins University School of Medicine, generated a great deal of national exposure from the mainstream media – and for good reason. We have known for years that fatalities due to preventable mistakes made in U.S. hospitals are enormous. In fact, medical errors are the third-leading cause of death in this country, behind only heart disease and cancer. But the number of medical-error fatalities are seldom reported or collected by local and national health officials.

The report estimates that about 251,000 patients die annually in hospitals due to preventable medical mistakes. However, this is considered to be a low estimate because the authors tracked only errors documented in health records, and included only hospital patients. For many obvious reasons, mostly due to malpractice and reputation concerns, medical errors are grossly underreported.

In addition to the report, the authors published a letter directed to the U.S. Centers for Disease Control and Prevention (CDC) suggesting that death certificates have serious limitations by not listing the preventable complications that contributed to the death of patients. The authors, no doubt, agree with our ‘Silently Harmed’ white papers which state “preventable harm in hospitals appears to be an epidemic, and until it is exposed and meaningful reporting methods are embraced and enforced, we have no clear process to measure improvement.”

The United States currently uses a collection system on national health statistics that does not track medical errors. Death by diagnostic and medication errors, communication breakdowns and other system errors are not counted nor included on the death certificate. This is because U.S. health statistics are based on International Classification of Disease (ICD) codes, instituted in 1949.

Bob Anderson, chief of the CDC’s mortality statistics branch, told National Public Radio recently that such reporting would be hard to change “unless we had a really compelling reason to do so.”

This particular comment struck a raw nerve with me. I can think of at least 251K+ ‘compelling’ reasons to change how we track mortality statistics in this country!

When will we finally break away from our adherence to past practices and realize that for medical outcomes to eventually improve, we must accept and embrace new priorities that will address the third-leading cause of death in the United States? For real progress to take hold in healthcare, we must first confront the brutal facts by gathering pertinent measurable statistics to serve as concrete benchmarks for future improvement.

Now that would be compelling!

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Disparate Views on Patient Safety Progress

Patient Safety Progress - a Matter of Perspective When it comes to patient safety progress in the U.S., are we better off today than we were 17 years ago, when the Institute of Medicine’s seminal report “To Err is Human” was published?

Depending on the source (and their particular perspective), the answer to this question can vary widely.

As outlined in our ‘Silently Harmed’ white papers, the measurement of medical errors within hospitals is, quite frankly, abysmal. However, there are pockets of success – such as infection rates – that have dropped in hospitals. This past December, the Agency for Healthcare Research and Quality (AHRQ) issued findings that indicate decreases in infections, medicine reactions as well as other complications from 2010 to 2014 that have resulted in 2.1 million fewer incidents of harm – and 87,000 fewer fatalities.

In Iowa, an editorial by Dr. Tom Evans in the Des Moines Register acknowledged that preventable medical errors do exist – but that “significant improvements” have been made over the past 10 years. Further, data suggests that adverse drug events were virtually eliminated (99.9 percent), pressure ulcers were reduced by 89.4 percent, central line-associated infections decreased 34.7 percent along with many other improvements that were made in less than four years. These “downright impressive” results brought an avoidance of 3,310 adverse events, 15,603 fewer days in the hospital, and more than $50 million in cost savings.

Such public messages appear to be a good start, but make no mistake, we should refrain from performing a celebratory dance in the end-zone as if a game-deciding touchdown was scored. Continuing our football analogy, some notable national experts may suggest that the ball has advanced only a few yards, but far shy of reaching a new set of downs.

The fact is, when it comes to actually reporting adverse events, we don’t know what we don’t know. In other words, we can only measure what is being reported.

A recent report from Leapfrog Group and Castlight Health finds that computer systems in hospitals fail to flag 13 percent of potentially fatal mistakes, while about 40 percent of the most common medication errors were not caught when tested. In 2014 alone, the Centers for Disease Control and Prevention (CDC) indicates that a life-threatening bacterial infection, called Clostridium difficile (C. diff) has sickened over 100,000 American hospital patients. The CDC reports this particular infection has increased by four percent between 2013 and 2014, while other research suggests that 450,000 people, both inside and outside of U.S. hospitals, are affected by this infection each year, resulting in 29,000 fatalities.

I have periodically heard that patient safety experts in academia are not living in reality, as they tend to use their own theoretical acumen and measurements that seldom match up with the ‘real world’ of care delivery. Perhaps this may be true in some cases, but many of these same ‘academia’ experts also practice medicine for a living and have a great deal of passion to ‘simply do the right thing.’ They avoid projecting a false sense of security that our care is safer than it really is. Doing so can be disingenuous – if not grossly misleading.

A short list of highly-accomplished individuals that are on the forefront of patient safety in the U.S. and worldwide include: Dr. Ashish Jha, Harvard School of Public Health; Dr. Martin Makary, Johns Hopkins University; Dr. Peter Pronovost, Johns Hopkins; Dr. Atul Gawande, surgeon at Brigham and Women’s Hospital (Boston); Dr. Lucian Leape (retired from Harvard); Dr. Robert Wachter, UCSF Medical Center; etc. This list is long and impressive. They are not fearful about holding up the mirror to other clinicians and provider systems and challenging them to measurably improve their outcomes based on what is most important to patients.

On March 23, ProPublica held a webcast forum to discuss the value of the Surgeon Scorecard that became available to the public in 2015. Given the lack of specific risk-adjusted data we have on individual clinicians, it was interesting to hear arguments on both sides about the evolution of clinician scorecards available for public use. Toward the conclusion of the forum discussion, Dr. Jha was asked to summarize the progress of patient safety since the IOM report went public 17 years ago. This particular comment was quite revealing:

But at the end of the day, are we measurably and meaningfully safer today than we were 17 years ago? Personally, I would argue the data suggests we are not. We are not meaningfully safer than we were.

Again, time to ‘huddle-up’ and find new ways to advance the ball down the field. Let’s hope that a celebration will eventually take place in our collective future!

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A Documentary Film about Medical Errors

Documentary Film about Medical Errors - To Err is HumanDuring the last two decades, I have spent considerable time researching key factors that influence and impact healthcare costs, primarily due to my work with employers who relied on our guidance and strategies to obtain employer-sponsored health coverage.

It was through this work that I increasingly became familiar with the name, Dr. John M. Eisenberg. I would soon learn that Dr. Eisenberg was not only a physician dedicated to his profession, but was highly distinguished throughout his career while advancing evidence-based research in healthcare at the policy, practice and management levels. One of the many accomplishments he had in his short life was serving as director of the Agency for Healthcare Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy and Research.

Without a doubt, Dr. Eisenberg was a worldwide pioneer on patient-safety issues, as he authored more than 150 articles dedicated to policy and scientific initiatives relating to the safe delivery of quality care that Americans trust they receive. Unfortunately, this passionate man who truly made a dent in our healthcare-related universe, died from a brain tumor in 2002 at the age of 55. Dr. Eisenberg was essentially a rock star within the medical world, as he was highly respected by his peers. In fact, the National Quality Forum (NQF) annually recognizes individuals and organizations that improve patient safety and healthcare quality through the establishment of the John M. Eisenberg Patient Safety and Quality Awards. These awards are being presented at NQF’s Annual Conference on April 7-8, 2016, in Washington, DC.

This past February, within a week after the Des Moines Register published their editorial on lethal medical errors – an editorial that was prompted by the release of our Silently Harmed white papers – I received an email from an organization, Tall Tale Productions, located in Chicago. The author of the email, Mike Eisenberg, mentioned he had recently read the DMR article and consequently downloaded one of the Silently Harmed papers. Mike is Dr. Eisenberg’s son.

Mike, inspired by his father’s work, plans to direct a feature documentary on patient safety, tentatively titled, To Err is Human, using the same name from the seminal book released in 1999 by the Institute of Medicine. Expect to find stories of patients and families who were adversely impacted by medical errors, in addition to interviews with patient safety-experts who continue Dr. Eisenberg’s work. Tall Tale Productions is in the final stages of their campaign to raise money to underwrite the cost of this important film. To learn more about how to contribute to this documentary, you can contact Tall Tale Productions.

Seldom do I tout particular causes within my posts, but I made an exception this time. Patient safety is paramount to us all.

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Diagnostic Mishaps

DiagnosisOver 40 years ago, our family owned a 1975 Ford Granada that was very temperamental, dying at stoplights and stop signs for no particular reason. Much too often, we would take the car to the local Ford dealership, only to learn the cause of this problem could not be correctly diagnosed. Other than trading in the vehicle for a more reliable model, it seemed that running stop lights would be our only other viable option!

Since the release of our Silently Harmed white papers, one particular section has brought a great deal of intrigue and discussion from many people who have reviewed this paper and provided feedback. The section, ‘National Data on Common Adverse Events,’ addresses seven common adverse events found within our hospitals. Not mentioned within the seven, is misdiagnosis events, which are also very common – and harmful.

Indeed, according to the journal BMJ Quality and Safety, at least one in every 20 adults (about 5 percent) who seeks medical care in a U.S. emergency room or community health clinic, may walk away with the wrong diagnosis. The analysis estimates that 12 million Americans a year could be affected by such errors.

Of those mistakes, about half – or 6 million – could potentially cause harm, according to patient safety expert Dr. Hardeep Singh, who is the first to provide robust population-level data on the impact of the problem in outpatient settings. Patients with conditions as varied as heart failure, pneumonia, anemia and lung cancer could have serious problems that remain unrecognized by a doctor.

Other safety experts laud this finding as ‘hard evidence’ about the frequency of such mistakes. Some even argue that 5 percent is the minimum because these numbers overlook other error activity.

In 1997, the National Patient Safety Foundation (NPSF) commissioned a phone survey reviewing patient opinions about medical mistakes. Of the people reporting a medical mistake (42%), 40% reported a “misdiagnosis or treatment error,” but respondents did not separate misdiagnosis from treatment errors. Respondents also reported that their doctor failed to make an adequate diagnosis in 9% of cases, and 8% of people cited misdiagnosis as a primary causal factor in the medical mistake. Loosely interpreting these facts gives a misdiagnosis range of 8% to 42%.

The reasons why outpatient doctors misdiagnose patients can vary widely. Time with patients is more limited than ever and their symptoms are often complex and evaluated in what is described as “a fairly chaotic outpatient environment.” Many doctors lack the support and technical help that could free them to use consistent clinical reasoning. Adding more people to insurance coverage, a premise of the Affordable Care Act, can also stress the care delivery infrastructure, perhaps compounding an already fragile environment.

Just as Silently Harmed has attempted to grasp the number of hospital medical errors within each of the seven midwestern states, putting a population-level number on outpatient diagnostic errors can be a step toward generating greater awareness and resources to address the problem.

For patients, this important analysis should be a reminder that the doctor is not always right. Patients can play a key role in their own care by offering doctors a complete list of symptoms and a full-health history at the first visit. After the exam, they should be proactive about following up.

Unlike owning and operating a defective automobile, receiving a correct medical diagnosis from our trusted provider is critical to our physical and mental wellbeing. When it comes to our health, trade-ins are not optional.

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Tepid Improvement in Patient Safety Progress
But Massive Savings Are Possible

Healthcare Cost Savings - Tip of the IcebergAs our healthcare delivery system evolves, we must reach beyond the endless discussion and distractions over who pays and how much. The cost, compliance, coverage and political discussions are no doubt important, but these are inextricably linked to the safety outcomes of medical care we expect to receive – but, in too many cases, do not.

The patient safety dialogue has been buried from the general public under many other pressing national concerns:  the general economy, global terrorist activities, general elections later this year, immigration, Middle East unrest, gun control – as well as countless other issues.

In addition to covering more Americans, the premise of the Affordable Care Act (ACA) was to initiate new care delivery models that would eventually make healthcare more affordable and achieve better outcomes. The hope is that our healthcare ‘system’ is now on the path to recovery – we just need to give the initiatives time to work.

But is it really that simple?

If the Centers for Disease Control (CDC) were to include preventable medical errors in hospitals as a category, it would be the third leading cause of death in the U.S. – behind heart disease and cancer. Quite simply, the numbers for those seriously and fatally injured are massive. National estimates indicate that between 6.6 million to 11.5 million patients are seriously harmed in our hospitals – EACH YEAR. For those fatally harmed, the annual estimated range is 98,000 to 440,000 deaths.

Are improvements being made, and if so, by how much? The short answer is Yes, but…

The federal Agency for Healthcare Research and Quality (AHRQ) released a report in late 2015 indicating that hospitals have averted many types of preventable injuries (such as infections and medicine reactions) during the period 2011 – 2014, using 2010 as the base year. During this four-year period, officials examined 30,000 medical cases and, from this, extrapolated the number of complications that were possibly avoided. The cumulative results appear to be downright impressive: 2.1 million fewer incidents of harm, 87,000 fewer deaths and about $20 billion in healthcare savings.

No doubt, this is encouraging news. On the surface, the general public (and media) appear to have only tepid concerns about patient safety issues, most likely because the federal government, hospitals, grant-receiving medical provider collaborations, academia and other organizations are “all over” this national problem.

But these improvements only represent the proverbial ‘tip of the iceberg.’

Even Dr. Richard Kronick, director of the AHRQ, commented that these findings have yet to be fully understood and improvements most likely came from “low-hanging fruit.” In other words, these are the relatively easy problems. Problems in the past that should’ve been averted in the first place, but were not.

Loaded with curiosity, I decided to compare these improvements to national estimates of medical errors to understand how much progress was really made during this four-year period. Using the conservative estimate of 6.6 million patients harmed annually in hospitals, the 2.1 million averted conditions reported by AHRQ during the cumulative four-year period equates to an eight percent improvement. By using the high-end estimate of 11.5 million harmed patients annually, this reported improvement is under five percent. Keep in mind, that 2.1 million was a cumulative amount over four years, while the 11.5 million is EACH year.

As for preventable hospital fatalities, using the conservative 98,000 annual estimate that came from the Institute of Medicine in 1999 (which is now widely considered as being grossly low), about 22 percent of fatalities were averted. The high-end 440K estimate translates to a five percent fatality aversion.

Employers must understand that by averting preventable injuries, the potential cost savings are enormous, dwarfing the $20 billion reported by AHRQ. The cost savings per hospital-acquired condition found in the AHRQ report is almost $9,500. If we use this number, the potential annual cost savings by having all 6.6 million preventable injuries averted would be $63 billion annually. Should 11.5 million preventable injuries be averted, the savings would be estimated around $109 billion annually. This savings would translate into a sizeable benefit to communities, employers, employees and taxpayers. But this projected savings does not even approach the social costs associated with preventable medical errors.

Yes, progress in patient safety improvement is inching forward. But to move the needle beyond this anemic pace, this issue must become a top priority for the general public to force the care delivery system to be more transparent, effective, efficient and, most importantly, safe.

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