• Patient safety lags, years after study shows 98,000 needless deaths Tuesday, December 8, 2009

    To Err Is HumanIt was ten years ago this month that the Institute of Medicine of the National Academies issued its landmark report, “To Err Is Human.”

    That report “arguably launched the modern patient-safety movement,” according to University of California, San Francisco, medical professor Dr. Robert Wachter.  The oft-quoted report estimated as many as 98,000 people die in U.S. hospitals each year as the result of preventable medical errors. That report recommended a “four-tiered approach” for better hospital safety. 

    Ten years later, how are hospitals doing?

    Wachter, who is associate chair of the UCSF Department of Medicine, gives safety efforts a grade of B- in a paper published in the January 2010 issue of Health Affairs.  That’s slightly better than the C+ Wachter gave on the fifth anniversary of “To Err Is Human” in 2004.  In the abstract to his latest paper, Wachter writes:

    Relatively few health care systems have fully implemented information technology, and we are finally grappling with balancing “no blame” and accountability.  The research pipeline is maturing, but funding remains inadequate.  Our limited ability to measure progress in safety is a substantial impediment.

    Wachter is especially disappointed in the lack of improvement in hospitals’ information technology, which he says has been “stunningly slow” with a “glacial adoption curve,” especially compared to the use of information technology in other areas.  He says only 2 percent of hospitals have fully integrated IT systems, including electronic medical records and electronic entry of treatment instructions (such as prescriptions) by physicians.

    But Wachter says if you had asked him when “To Err Is Human” was published how much progress would be made over the next ten years, he would have underestimated what has actually been accomplished.  As he writes on his blog:

    …as I wander around my own medical center, signs of progress are unmistakable.  Our safety enterprise is much more vigorous than it was five years ago (it was nonexistent 10 years ago).  Despite some major IT snafus, we are using an electronic health record, and it is a far better way of communicating information than via snippets of chicken scratch penned on dead trees.  During a weekly two-hour meeting, we analyze serious errors and review progress in fixing the unsafe conditions we uncover.  Our residents and students are (mostly enthusiastically) participating in new safety and quality curricula.  We are measuring safety outcomes such as healthcare-associated infections and reporting these results regularly at the highest levels of the organization.  All good stuff.

    The estimate of as many as 98,000 deaths a year resulting from preventable errors has been described as “equivalent to two 737s crashing every day.”  Some health care executives have objected to that comparison, but Wachter embraces it.

    Although some have critiqued the “crash-a-day” spin as hyperbolic, I continue to believe it was masterful.  Something was necessary to shake us out of our collective inattention, and it took the Jumbo Jet analogy to do it.  (And just consider what our response would be if, in fact, a commercial airliner crashed for “just” two or three days in a row!)

    A story on the anniversary of “To Err Is Human” on the HealthLeaders Media web site says there are still many “significant challenges” to improving patient safety, among them reducing the number of medication errors.

    Allen Vaida, a pharmacist and executive vice president of the Institute for Safe Medication Practices, says: “We have made great strides in understanding that medication errors are an issue, but we still have a long way to go.” Vaida says hospitals should implement barcoding of medications. 

    “Only 5-20% of hospitals now do it.  We should be striving for 100%,” he says. Second, he says, “we have to do a better job learning from others.  Too many hospitals see tragic mistakes that happen elsewhere and say, ‘That happened in California.  I’m in Ohio.  It doesn’t happen here.’

    “We need to realize we’re in a risky business, and ask the question, ‘Could that happen here?’ “

    J.G. Preston


  • Patient safety 10 years after “To Err is Human”
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  • Latest California hospital penalties include five patient deaths
  • Latest round of California hospital errors include patient deaths
  • Las Vegas Sun finds 969 preventable injuries at local hospitals over two years

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