At one Nashville hospital in 2017, a patient was mistakenly given a powerful paralytic drug instead of a light sedative, resulting in their death. A few years later, at a different hospital in Nashville, a patient caught fire in their bed due to improper defibrillator use.
Despite decades of advocacy and training efforts led by entities like the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, the industry has long struggled to reduce or eliminate sentinel events, the unanticipated occurrences in a healthcare setting that result in a patient's serious injury or death. More severe care errors, known as “never events,” include those that shouldn't ever happen in healthcare, such as wrong-site surgeries, medication errors, patient self harm and criminal activity.
Related: Reports of serious adverse events rose in 2022: Joint Commission
There hasn't been much improvement over the years. In 2018, 25% of Medicare beneficiaries experienced at least one instance of harm during their hospital care, compared with 27% of patients in 2008, according to a 2022 Office of Inspector General report. The study found that 43% of the adverse events could have been prevented through better care.
As part of its report released last month on patient safety, the President’s Council of Advisors on Science and Technology advocated for more federal oversight and public reporting of high-priority harms such as patient falls, misdiagnoses and wrong-site surgeries. To receive federal funding from CMS, hospitals generally are required to track, analyze and address certain adverse events as a condition of participation under the Quality Assessment and Performance Improvement program.
The report also encouraged agencies like CMS to incentivize hospitals’ use of evidence-based solutions to prevent the harms, with penalties for not addressing the incidents in the right way.
Some health systems have already made significant progress by addressing root causes of adverse events like poor communication and staff burnout.
Improving clinical communication
In medicine, communication is too often like a game of telephone—fractured and inefficient, with clinicians relying on sticky notes, white boards and printed documents to coordinate critical aspects of patient care, said Subha Airan-Javia, hospitalist physician and clinical informatician at Philadelphia-based Penn Medicine.
As a result, patients experience harm in the form of missed, delayed or incorrect treatment, she said.
Several Penn Medicine hospitals have implemented a digital workflow and collaborative care platform called CareAlign that is constantly updated with patients’ vitals, labs, handoff notes and electronic health record data, providing clinicians with a single source of real-time information. Since the platform was rolled out in 2016, a majority of Penn Medicine clinicians using the technology have reported they were able to prevent what could have been an error or sentinel event.
CareAlign also has contributed to Penn Medicine’s improved patient experience scores and performance on quality metrics, like the number of unplanned readmissions within 30 days.
Changing safety processes
At WellSpan Health, based in York, Pennsylvania, one of the first steps to decreasing the number of adverse events was to involve nursing leaders, infection preventionists and physicians in the creation of easy-to-follow, evidence-based, standardized care processes.
“We spent a lot of time educating people that almost every significant event is the result of a poorly designed process versus an individual error,” said Dr. Mike Seim, the system’s senior vice president and chief quality officer. “If it happened to one person, it could probably happen to multiple people.”
When the work started in 2019, the goal was to shift clinicians’ mindsets to reporting potential causes of harm early and solving the problems, Seim said. At daily huddles, staff can provide input on any patient safety concerns that will get passed on to facility leaders and system executives, he said.
If an adverse event occurs, the facility has a “stop the line” call with hospital leaders and other staff to contain the issue. Immediate short-term changes are then implemented to make sure the error doesn't happen again, Seim said.
In the case of a medication error, for instance, the drug might be removed from a cabinet where other medications are stored so they aren’t mixed up by accident.
The number of reported safety events has doubled in the past three years, to 40,000 in 2022, and serious events decreased by more than 50%.
Becoming a high reliability organization
Hospital leadership must commit to a goal of zero harm, employ performance improvement tools and create a space where staff can speak up about things that might negatively affect the organization, according to the Joint Commission’s high reliability framework.
Sanford Health, based in Sioux Falls, South Dakota, has instilled a sense of responsibility in employees to lessen adverse events, encouraging workers to ask questions and learn from shortcomings in communication and patient care, said Dr. Jeremy Cauwels, chief physician.
Across the health system, all daily huddles and clinical floor meetings begin with a story about an adverse safety event, Cauwels said.
Like Wellspan, Sanford Health also reports its adverse events to staff to track progress and accomplishments. Recently, one of Sanford Health’s medical centers set an internal record by going 70-plus consecutive days without a serious safety event, Cauwels said.
“It’s really just a culture of transparency,” he said. “You have to be willing, from the CEO all the way down, to say that we are going to talk about the [adverse] events that happen within our walls and we're going to do everything we can to prevent them.”
