First, do no harm
More than ten years ago, the Institute of Medicine’s report To Err Is Human spotlighted the enormity of suffering and loss caused by medical errors—up to 98,000 deaths and more than one million injuries each year. The report sparked responses from all corners of the health care world, including the Medicare-funded hospital patient safety initiatives that we have guided as Oregon’s Quality Improvement Organization. We are proud to have supported the Surgical Care Improvement Project/Heart Failure Initiative (and recognize its high performers in this issue), and to have helped spread the use of the Surgical Safety Checklist as part of the Oregon Institute for Healthcare Improvement Network.
Despite these successes, the past few months have brought sobering reminders of the patient safety challenges that lie ahead.
- In November, the Office of Inspector General for the U.S. Department of Health and Human Services released a study indicating that one of every seven (13.5%) hospitalized Medicare beneficiaries was harmed by an adverse event during their stay. Another 13.5% experienced temporary harm events; for some, these events were “temporary” only because the harm was addressed in the course of a longer stay for another condition. These adverse and temporary harm events contributed to an estimated 180,000 deaths a year and added more than $4.4 billion to federal health care costs—and 44% were deemed preventable by physician reviewers.
- In December, the New England Journal of Medicine published a 6-year retrospective study of 10 hospitals in a highly engaged state (North Carolina), using the Institute for Healthcare Improvement’s Global Trigger Tool for Measuring Adverse Events. Among 2,341 admissions records reviewed, the study identified more than 25 “harms” per 100 admissions. Although the study period overlapped IHI’s widely subscribed 100,000 Lives and 5 Million Lives campaigns, the reviewers found no significant decrease in overall rates of harm over the 6 years.
Many hospitals are doing many things right, and multiple stakeholders have been working hard to support their efforts. What more can we do?
- Recognize our biggest opportunities for improvement, and build upon them. The OIG reviewers found that events related to surgery or procedures were less likely to be preventable than events such as hospital-acquired infections. Hospitals and their stakeholders are renewing their focus on preventing central-line associated bloodstream infections (CLABSIs). However, a 2010 study in 250 hospitals found that merely having policies requiring a bundle of evidence-based preventive behaviors was not enough to reduce CLABSI rates; the rates fell only when an intensive care unit monitored actual compliance with the required behaviors and achieved at least 95% compliance. Hospitals like Regions Hospital in St. Paul, MN, that have made these bundles a daily routine have documented dramatic reductions in CLABSI rates.
- Use internal monitoring of “Present on Admission” indicators within the hospital’s QI team to learn which harms are happening after patients arrive—and learn from other providers that have been able to reduce these problems.
As in other fields of endeavor, progress in patient safety will depend on strong leadership at the top of each health care organization. Boards and executive suites are ultimately responsible for creating a work culture that empowers all staff to learn from errors and to adopt methods others have found reliable for avoiding harm. Hospital leaders must continue to take a proactive role in defining organizational goals to reduce harm, and in ensuring that their organizations meet those goals.
Q-News, Issue 26
© 2011 Acumentra Health. All rights reserved.
Portions of this material were prepared by Acumentra Health, Oregon’s Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.