Trendspotter: If There’s A Will, Hospital Safety Can Be Improved

The studies are coming thick and fast on the dismal state of safety in American hospitals. It’s clear that little if any progress has been made in the decade-plus since the Institute of Medicine released its alarming report on medical errors, “To Err Is Human.” Yet our leading medical societies are relatively mute on the issue, while being quite vocal on the need to reform malpractice liability. Perhaps tort reform is a prerequisite for real progress on safety, but I think much more is involved.

The latest indication that hospitals remain dangerous places comes from a New England Journal of Medicine article published last week. Fittingly titled “Temporal Trends in Rates of Patient Harm Resulting From Medical Care,” the paper shows that in 10 North Carolina hospitals, there was no reduction in medical errors from 2002 to 2007. For the patient-days studied, there were 588 “patient harms,” including injuries resulting from procedures, medications, nosocomial infections, other therapies, diagnostic evaluations, and falls. These harms, nearly two-thirds of them preventable, occurred in one of every four admissions. Although few resulted in permanent injury or death, 43 percent of the harms were serious enough to require “initial or prolonged hospitalization.”

According to another recent study done by the government, one of seven Medicare patients who are hospitalized suffers harm during his or her inpatient stay. Altogether, adverse events in the hospital contribute to about 180,000 deaths a year, the study says. Of the 134,000 events recorded during a single month (October 2008), 44 percent were preventable.

The Joint Commission has put a priority on safety and has encouraged hospitals to report serious errors, known as “sentinel events.” But a recent investigation of Nevada hospitals by the Las Vegas Sun found that, of the 1,363 occurrences that fit the definition of “sentinel events” in 2008 and 2009, the hospitals reported only 402 to the Joint Commission. For example, the Nevada facilities reported only one central-line infection, but a Sun examination of billing records showed that 336 had occurred during that two-year period.

A similar situation has just been revealed in California, where 20 percent of the hospitals haven’t reported any significant medical errors to the state in three years.

Health policy expert David Nash, MD, says that the National Healthcare Quality Strategy called for in the Affordable Care Act could turn this big ship of medical errors around. According to Nash, the dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, the strategy is designed to unite public and private initiatives and build on the quality improvement programs already in place. Health and Human Services Secretary Kathleen Sebelius has asked providers for specific suggestions on how this might be done, and here’s what Nash advocates:

• Consolidation and reconciliation of the current performance data reporting requirements among various public and private agencies.
• An effort to standardize adverse events reporting across states and across hospitals.
• A commitment to developing and designating risk-adjustment methods to be used for comparing various patient outcomes across hospitals to enable benchmarking and progress measurement over time.

In addition, Nash supports “changing the culture of medicine” by requiring medical students to take courses on patient safety and making safety an integral part of CME. The American Association of Medical Colleges (AAMC) and the Institute for Healthcare Improvement, he says, are moving in this direction.

All of these are good ideas, but I think they’re too little and, by the time they have any effect, too late. I’d build upon the efforts of the new Center for Medicare and Medicaid Innovation (CMMI), which is supposed to develop and test new approaches to provider reimbursement. For example, hospitals are becoming interested in turning their physician practices into medical homes. Why not have CMMI test the idea of turning hospitals into medical homes where all care is coordinated and where one physician-perhaps a hospitalist-directs the team?

Perhaps CMS could also give hospitals incentives for reducing error rates and split up the bonuses among the nonphysician clinicians who provide the bulk of inpatient care. And hospitals could also get incentives for instituting surgical safety checklists, which have been shown to save lives.

It’s now abundantly clear that hospitals are not going to do the hard work required to make patients safer unless they’re acted upon by an outside force. The government could make a difference here-whether or not we get tort reform first.