Twenty years ago, the Institute of Medicine reported that 98,000 patient deaths per year stemmed from medical errors. But not enough has changed, and it’s even affected the leaders who are trying to improve healthcare.
Dr. David Blumenthal, a patient-safety expert and president of the Commonwealth Fund, lost his father about nine years ago due to a medical error. Martin Blumenthal underwent neurosurgery for a brain abscess at a prominent, but unnamed by David, teaching hospital in New York City about 10 years ago. While recovering in the neuro ICU the day after surgery, the 88-year-old retired businessman got out of bed, fell and suffered a traumatic brain injury. He died a year later.
David told Modern Healthcare reporter Harris Meyer that he doesn’t recall anyone at the hospital talking to him or his family about how the error happened or what the hospital would do to avoid similar events in the future.
“This was totally preventable, and it certainly deserved careful investigation and remediation,” Blumenthal said.
This week’s series “To Err is a Leadership Failure” examines the reasons why not enough has changed in the past 20 years. Maria Castellucci and Harris Meyer learned that part of the problem is inertia and another part lies in the very human nature to avoid that which makes us uncomfortable—admitting we’ve made a mistake.
Healthcare still has a prevalent culture of silence. Front-line workers worried about litigation or job loss cover up mistakes and leaders fail to address medical errors even in a preemptive fashion, almost as if not to jinx their luck.
A few months ago, the World Health Organization reported that 40% of patients in primary and outpatient care around the world are harmed by medical errors. Another 10% of patients acquire infections in hospital settings.
After the IOM report in 1999 estimated the cost in additional care, lost income and disability at $17 billion to $29 billion a year, stakeholders rallied. Both industry leaders and policymakers made promises. They organized task forces. They put money behind the efforts. Hospitals set bold goals and invested millions of dollars in technology and hundreds of hours in staff training to prevent surgical, diagnostic, medication and system failures.
Mistakes can be prevented, but that requires admission of guilt and an action plan that sets goals and holds people accountable if they don’t meet them. It also requires a change in the mentality of some providers, who might see patients in the aggregate instead of individuals, with families and friends who are left behind to grieve their loved ones and question their trust in the healthcare system.
It also might require healthcare leaders admitting they can’t do it on their own. In a recent op-ed in Time magazine, Kathleen Sutcliffe, a Bloomberg Distinguished Professor at Johns Hopkins University and co-author of a forthcoming book Still Not Safe: Patient Safety and the Middle-Managing of American Medicine, suggests that experts outside of medicine be consulted on improving patient safety.
“We live in an era of multifaceted problems that call for multidisciplinary approaches,” Sutcliffe wrote.
It wouldn’t be the first time healthcare learned something from other industries. Lean management first introduced by the automotive industry has made healthcare more efficient and improved patient care. Principles of retail-based customer service are being implemented by progressive healthcare leaders across the country to ensure patient satisfaction.
Few professions require the level of trust that’s necessary for healthcare to run smoothly. Patients must believe that the decisions made by the providers they choose are in their best interest, aren’t wasteful and are prudent. Providers rely on patients to adhere to medication and treatment regimes.
Life is too fragile a thing to take chances. And it’s true, to err is human. But to do as little as has been done in 20 years is inexcusable.