The problem of patients dying or being harmed because of preventable medical errors in U.S. hospitals remains one of grave consequence that is not getting enough attention, according to the chairman of the Senate Subcommittee on Primary Health and Aging, which met Thursday with a panel of patient safety leaders
to spotlight the issue.
Speakers at the hearing expressed concern that 15 years after the eye-opening Institute of Medicine
report “To Err is Human” drew attention to the issue, improvement has been limited, sporadic and inconsistent.
If the question is “are patients clearly safer in U.S. hospitals today than they were 15 years ago?”, “the unfortunate answer is no,” said Dr. Ashish Jha, a Harvard School of Public Health professor whose research focuses on improving quality and reducing costs. “We have not moved the needle in any demonstrable way overall,” he said. “No one is getting it right consistently.”
Subcommittee chairman Sen. Bernie Sanders convened the panel to bring awareness to what some say is now the third leading cause of death in the U.S. after heart disease and cancer. He noted a study in the Journal of Patient Safety
, which estimated that the number of premature deaths associated with preventable harm to patients may be closer to 400,000 a year, more than four times higher than the 1999 IOM report (PDF)
, which estimated as many as 98,000.
The author of the recent report, John James, founder of the Houston-based advocacy organization Patient Safety America, was among the presenters. Other speakers included Dr. Tejal Gandhi, president of the National Patient Safety Foundation; Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine; Lisa McGiffert, director of the Safe Patient Project at the Consumers Union; and Joanne Disch, a professor at the University of Minnesota School of Nursing.
Sanders—who at one point alluded to the current system in hospitals as dysfunctional, profit oriented and not patient centered—asked what is needed to encourage change.
Patient-safety experts emphasized the need for reliable data, metrics and monitoring systems that can consistently provide accurate comparisons on outcomes; for accountability and incentives that are aligned to encourage a focus on safety; and the need for federal legislation
through the health equivalent of the Federal Aviation Administration or National Transportation Safety Board. They also stressed fundamental system redesigns that make safety a part of the culture of the institution, among other needs.
A culture where people are afraid to speak out about errors won't get a hospital very far on any initiative, Gandhi said. Disch added that leadership has to back their words with resources—from technology to staffing—to ensure staff have the tools to make the changes. Pronovost said he found from his work on CLABSI that leadership efforts that “owned the problem” and established a clear chain of accountability were most successful.
And Jha said leadership efforts can't wait for incentives. “Until we get to the point where the CEO of the hospital is lying awake at night worrying about patient safety, I don't think we're going to move the needle,” he said.Follow Sabriya Rice on Twitter: @MHSRice