A postmortem on the patient safety movement

Are patients better off than they were ten years ago?

Just over a decade ago the Institute of Medicine (IOM) released its celebrated report on patient safety, To Err is Human.  Many credit that report, which was released with great fanfare, with launching the patient safety movement.  So it’s appropriate to assess the movement’s impact eleven years later.  How did we do?

On November 25 the New England Journal of Medicine published a study on trends in patient harm during a six year period in the middle of the decade of the patient safety movement, with much talked about and disappointing results.  The report, which showed no improvement in treatment related adverse events over the study period, raises questions about whether the movement even had an impact at all.

I was not surprised at the findings and, in fact, blogged last year my opinion that the movement was a failure.  It’s appropriate now to examine some of the reasons.  But before we get too pessimistic lets acknowledge some positives.  Long before the birth of the patient safety movement the field of anesthesiology had made great strides, implementing systems improvements which markedly reduced  the rate of perioperative complications.  And in the decade just past there were a couple of isolated success stories, namely the use of check lists to reduce central line infections and perioperative complications.

So why has the movement has so little impact overall?  To answer that question it is helpful to examine more closely its history.  In its 1999 report the IOM claimed that 44,000 to 98,000 Americans were killed in hospitals each year as a result of medical mistakes.  But the IOM’s methods were not transparent and its analysis was suspect.  A spate of scholarly articles soon challenged the findings.  The lead author of the Harvard Medical Practices Study, on which the IOM’s figures were largely based, even wrote an editorial expressing regret about how the findings of his study had been distorted.  Even patient safety leader Robert Wachter, one of the biggest boosters of the IOM report, admitted that it was a remarkable piece of spin.  But it didn’t matter.  The notion that hospitals were killing up to 98,000 Americans each year took on a life of its own.  To borrow an expression from Wallace Sampson (who was writing about the widespread acceptance of unscientific complementary and alternative medicine) “with the press wowed and the academics cowed” the horse was already out of the barn.

The myth of 98,000 deaths from medical mistakes was perpetuated, and with far reaching negative  consequences.  The IOM report and the ensuing media hype paved the way for implementation of Medicare’s no pay for adverse events policy, in which often unavoidable complications, such as patient falls and pressure ulcers, were administratively defined as medical errors.  The culture of patient safety soon morphed into a culture of provider blame.  Even the trial lawyers took notice and adopted a new legal standard for adverse events.

Patient safety experts have told us that a blame free atmosphere where transparent, open analysis of adverse events can take place is essential to an effective systems approach to patient safety.  The IOM report backfired.  It had the opposite effect, producing a culture of blame in which any adverse event is someone’s (and hopefully someone else’s) mistake.  What is ironic is that many of the IOM’s own recommendations were based on a blame-free culture of transparency.  It’s little wonder, then, that a Consumer’s Union report from last year found that almost none of them were carried out.

So are patients better off than they were a decade ago?  Yes, thanks to medical progress and innovation which year by year make us smarter and offer better options for diagnosis and treatment.  What about the future of the patient safety movement?  It may yet succeed, but first medical experts and policy makers need to perform a root cause analysis on the failures and missteps of the past decade.

Robert Donnell is a hospitalist who blogs at Notes from Dr. RW.

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