Patient safety and the human toll of inaction

March 2nd through the 8th was National Patient Safety Awareness Week — I don’t really know what that means either.  We seem to have a lot of these kinds of days and weeks — my daughters pointed out that March 4 was National Pancake Day — with resultant implications for our family meals.

But back to patient safety and National Patient Safety Awareness Week. In recognition, I thought it would be useful to talk about one organization that is doing so much to raise our awareness of the issues of patient safety.  Which organization is this?  Who seems to be leading the charge, reminding us of the urgent, unfinished agenda around patient safety?

It’s an unlikely one: the Office of the Inspector General of the Department of Health and Human Services.  Yes, the OIG.  This oversight agency strikes fear into the hearts of bureaucrats: OIG usually goes after improper behavior of federal employees, investigates fraud, and makes sure your tax dollars are being used for the purposes Congress intended.

In 2006, Congress asked the OIG to examine how often “never events” occur and whether the Centers for Medicare and Medicaid Services (CMS) adequately denies payments for them.  The OIG took this Congressional request to heart and has, at least in my mind, used it for far greater good:  To begin to look at issues of patient safety far more broadly.

Taken from one lens, the OIG’s approach makes sense. The federal government spends hundreds of billions of dollars on healthcare for older and disabled Americans and Congress obviously never intended those dollars pay for harmful care.  So, the OIG thinks patient safety is part of its role in oversight, and thank goodness it does.

Because in a world where patient safety gets a lot of discussion but much less action, the OIG keeps the issue on the front burner, reminding us of the human toll of inaction.

While the OIG has had multiple important reports in this area, the watershed one was their eye-opening November 2010 report. If you haven’t read at least the executive summary, you should.   The OIG looked at care for a national sample of Medicare beneficiaries and what it found was unexpected:  13.5% of Medicare beneficiaries suffered an injury in the hospital that prolonged their hospital stay, caused permanent harm, or even death.

An additional 13.5% of Medicare patients suffered “temporary” harm — such as an allergic reaction or hypoglycemia — things that are reversible and treatable, but quite problematic nonetheless.  Taken together, these data suggest that 27% of older Americans suffer some sort of injury during their hospitalization — much higher than previous numbers.

There are three more statistics from the OIG report that should give us all pause.  First, they estimate that unsafe care contributes to 180,000 deaths of Medicare beneficiaries each year.  This is a stunningly high number.  Second, Medicare pays at least an additional $4.4 billion to cover the costs of caring for these injuries.  And finally, about half of these events are preventable based on today’s technology and know-how.

I suspect that if we actually make safety a priority, many more events would become preventable over time.   And yet, although hospitals are supposed to identify, study, and track adverse events, the OIG says it mostly isn’t happening.  At least not in any systematic way.

This is all old news, of course, so on to new news. The OIG just released another excellent report, this time on harm in skilled nursing facilities (SNFs).  While we have paid a lot of attention to acute hospitals, we have generally paid far less attention to what happens when patients leave.  And, about 20% of Medicare patients, after discharge, go to a SNF.

So, the OIG went looking at SNF care, and what they found is both unsurprising and quite disappointing. During their SNF stay, 22% of Medicare beneficiaries suffered a harm that prolonged stay, caused permanent harm, or even death.  And, an additional 11% suffered temporary harm that could be reversed with a medical intervention.

Physician reviewers considered 59% of these events to be preventable and these physician reviewers “attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care.”  And these adverse events add an additional $2.8 Billion to Medicare spending.  And remember, none of these financial calculations include the financial harm patients suffer because of lost work, family members having to take time off to provide additional care, etc.

It’s been 15 years since To Err is Human and patient safety has gone from a niche topic to something far more mainstream.  We now recognize that safety is a huge problem.  However, over the past few years, we have seen consistently disappointing data that we aren’t making much progress.  It has caused many people to stop trying.

Of course, we can’t publicly admit that we are giving up when the human toll is so high.  So, instead, we are encouraging “voluntary reporting” that ignores most errors, using metrics to assess performance that don’t really reflect the safety of underlying care, and putting tiny incentives in place that aren’t meaningful enough to really change behavior.  In 5 years, when we talk about the 20th anniversary of the To Err is Human report, will we wonder again why we have made so little progress?

The path forward, although difficult, is pretty clear.  I’ve previously described a set of proposed solutions but in a nutshell, I think we should do three things.  First, measure and monitor adverse events in a systematic and robust way.  This is increasingly possible with EHRs and we have described how before.  Second, make safety data public.  It will catalyze professional ethos, create real competition for safety, and force hospitals to get better.  Third, put big incentives on the table so that there is a clear business case for safety.

There are lots of ways to do it and are well described.  And if we actually want to do this, we will have to reform our malpractice system so that these data can’t be turned into information for litigation. Finally, we need to move beyond hospital safety (despite having made so little progress in this arena) and start including safety in in a much broader context.  As the OIG points out, there are lots of safety problems in post-acute care as well.  That’s my wish list for what we need to do.

I’m not sure it’s right, and others surely have better ideas.  But we can’t be satisfied with our current efforts.  And, thanks to the OIG, we are fully aware of the size and scope of the problem.

So, during Patient Safety Awareness Week, we should all take a moment to thank the Office of the Inspector General at HHS for reminding us that patient safety remains a pressing concern.  Fixing it, of course, will require tough solutions and a lot of unhappy “stakeholders” who like the status quo.  But, as the OIG reminds us, the human and financial costs of waiting is very high.

Ashish Jha is an associate professor of health policy and management, Harvard School of Public Health.  He blogs at An Ounce of Evidence and can be found on Twitter @ashishkjha.

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  • PoliticallyIncorrectMD

    The reason we made so little progress in “patient safety” is because many (including the author of the article) keep confusing unsafe practices (which are unacceptable, but infrequent) with complications (which are common and expected). For those of us who are involved in practicing medicine as opposed to creating healthcare policy, it is well know fact that many / most medical interventions carry significant risk of complications. Nevertheless, they are used as long as the benefit from the intervention is likely to outweigh the risk. Perhaps we should abandon chasing costly and meaningless metrics and concentrate on creating realistic expectations by educating public on the realities of healthcare.

    • Dr. Drake Ramoray

      This is exactly right. I cannot recall if it was our hospital or CMS but at one time a hospital at which I had privileges wanted to treat pneumothorax after bronchoscopy (with or without biopsy) as a patient safety issue.

      As any pulmonologist will tell you this is a known risk of having the procedure. Sure techniques or care plans can/should be developed to reduce complications but they are mischaracterized as patient safety issues. I am not proposing any changes or even follow this issue currently, but I will always remember how upset the pulmonary guys were and how clueless the hospital admin was. It is one of my early memorable experiences, in the flesh, fresh out of fellowship that demonstrated the incompetence of people who don’t actually take care of patients, but effected real world practice. Inpatient diabetes management is another area, but I could probably write a whole book about that.

  • guest

    In other news, we have a healthcare system that spends millions, if not billions, of dollars per year to pay various administrators, regulators, bureaucrats and professors of public health to examine, investigate, track, monitor, regulate, audit and penalize the workers who actually take care of the patients in this country. What I want to know is this: if we took all that money and used it to pay for more doctors and nurses to do the actual work so that the healthcare worker:patient ratio in our healthcare organizations were more favorable, what kind of gains could we make in patient safety?

  • rbthe4th2

    I think what is being missed here is that there is not any attention turned to missed/delayed diagnoses. Check out patientgate – I’m sure that will help things when patients & doctors have a audio/visual recording of the encounter. Give patients meaningful avenues to correct issues & voice them, not just tokens. Those are just a start.
    I’d also like to see more access to medical resources. I use the same ones that the medical students and doctors use. So far, I’ve produced medical evidence pointing to specific diagnoses, where a number of doctors who didn’t want to partner with me, only blow me off & give me mental diagnoses when they didn’t see/read/check/verify signs/symptoms. There needs to be a way for meaningful reactions from the medical establishment to getting those attitudes & problems fixed, not after people are hurt or suffer because of a doctors’ lack of education or bias or inability to do a job. They’ll only cause more problems in the end.

    • guest

      That’s because there is no metric to track missed/delayed diagnoses, and furthermore, not to sound cynical, the people who are now driving the healthcare train (the insurers), aren’t too concerned about missed diagnoses. It’s just the patients (and doctors) who are, and as was pointed out to me today by an administrator in a different blog posting here, healthcare is now about administrators, researchers and policymakers, not about doctors and their work (taking care of patients).

      • rbthe4th2

        Pity I couldn’t give you 5 thumbs up for that.

  • PoliticallyIncorrectMD

    “There are three kinds of lies: lies, damned lies and statistics.”
    Mark Twain

    Lets take closer look at the numbers:
    Number of Medicare admissions per year (according to same report) = 1,000,000
    Number of daily interventions on single patient (labs, tests, procedures, medications; conservative estimate) = 100
    Number of average hospital days per stay (estimate) = 10
    Number of interventions per patient per stay = 100 x 10 = 1000
    Number of total interventions on Medicare patients per year = 1,000,000 x 1,000 = 1,000,000,000
    Number of events resulting in harm (rounded) = 10% x 1,000,000 = 100,000
    The likelihood of adverse event = 100,000 / 1,000,000,000 = 0.0001 or 0.01%

    Is that really that high?

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