At NShore Patient Advocates, it is a phenomenal understatement when we say that we are passionate in our pursuit of preventing medical error for our clients. Preventing medical error was one of the founding objectives in the creation of the company, and continues to be a driving force today. Ours is not a novel goal, however. Today, we’re going to take a look at a report on preventable medical errors that rocked the world of medicine and changed how health systems operated forever.
“Errors…are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals.” -Quote from the To Err Is Human report
In November of 2009, the Institute of Medicine published a landmark report entitled To Err Is Human: Building A Safer Health System. What is the institute of Medicine (IOM)? They are a non-profit organization, a division of the National Academy of Science, a group of super smart individuals that work independently of the federal government to “to provide evidence-based research and recommendations for public health and science policy”. Most importantly, they provide their results to Congress, where changes can begin to be instituted. The IOM’s Quality of Health Care Committee looked at two prior studies of medical errors and extrapolated the data to the 33.6 million annual hospital admissions in the United States. The results were shocking: they estimated that anywhere from 44,000-98,000 of hospitalized patients die each year due to preventable medical errors. That is more deaths per year than motor vehicle accidents, breast cancer, or AIDS. They somberly concluded:
“It is not acceptable for patients to be harmed by the health care system that is supposed to offer healing and comfort–a system that promises, “First, do no harm.” -Quote from the To Err Is Human report
In addition to the priceless cost of the loss of life, medical errors are very expensive to hospitals and to society, estimated at $12 to $29 billion dollars a year. How come such a high figure? The losses are staggering: more medical care to treat the results of the errors, loss of household income, loss of productivity, and disability. What type of preventable medical errors, you might ask? Well, preventable medical errors come in many different forms. You can probably recall some shocking news reports: having the wrong limb amputated, or treating the wrong patient. Here are a few more examples: medication errors, diagnostic errors, treatment errors, falls, mistaken patient identity, and pressure ulcers. (You may be wondering what a pressure ulcer is; they truly are a huge deal in a bedridden patient. Pressure ulcers are a breakdown in the skin that occurs in patients who are unable to move themselves around in bed. When you can’t shift your body on your own, the bony parts of your skeleton will exert continuous pressure on the skin overlying the bone, restricting blood flow to that part of the skin and leading to death and ulceration of the skin and underlying tissues) Are you shocked by these figures? Sadly, we are not at all surprised by these figures (we actually believe these estimates to be low).
The IOM concluded that errors were not due to a specific group of people in a hospital; they were largely the result of problems in “systems, processes, and conditions” that “lead people to make mistakes or fail to prevent them.” They found that preventable errors occurred due to a multitude of reasons, including fragmented care—patients seeing different physicians at different facilities who don’t communicate with each other. Medication errors were a huge piece of the problem. Patient safety–another big problem. They also pointed the finger at our legal system in which medical providers are very reluctant to report errors out of a fear of lawsuits, the result being that lessons can never be learned from the mistakes of others.
Their recommendations were broad.
They included initiating a voluntary medical error reporting system (that would complement the mandatory reporting system already in place in 29 states) with laws enacted by Congress that would prevent the subpoena of these error reports, thus removing the fear of lawsuits as a barrier to admitting error. The thinking was that if even minor errors where no harm was done were disclosed, the disclosures would “help detect system weaknesses that can be fixed before the occurrence of serious harm, thereby providing rich information to health care organizations in support of their quality improvement efforts. “
They suggested that health systems develop a “culture of safety” and simplify equipment and processes (much like other industries such as the aviation industry which has experienced tremendous success with their focus on system safety) Issues of licensure, certifications and training as part of the improvement processes were discussed as well.
Most interestingly, they said that patients themselves should be a part of the culture of safety as well, especially as it relates to medications. Patients should know what medications they are taking, their appearance, and their side effects, and that they should also be educated to speak up if they notice “medication discrepancies” or if they are experiencing medication side effects. We couldn’t agree more!
The Committee did not feel that all was lost, however. They optimistically quipped:
“It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives, and meet the challenges ahead.” -Quote from the To Err Is Human report
Hang on to your seat when you read this: The committee recommended a goal of a 50% reduction in medical errors over the next 5 years!!
This article is the first of a four-part series looking at medical error. To follow the series click here.
Teri Dreher, RN, CCRN, iRNPA , Owner/CEO of NShore Patient Advocates
With over 36 years of clinical experience in Critical Care nursing, home-based health care and expertise as a cardiovascular nurse clinician, Teri is well acquainted with the complexities of the modern healthcare system. She has served as a nursing leader, mentor, educator, and consistent patient advocate throughout her career in some of the best hospitals across the country. Her passion to keep the patient at the center of the model of nursing care led her to incorporate North Shore Patient Advocates, LLC in 2011, serving clients throughout the northern suburbs of Chicago.