It has been well over a decade since the landmark report To Err Is Human was released by the Institute of Medicine. That study said preventable medical errors caused up to 98,000 deaths each year. Those findings established medical error as one of the leading cause of death in the United States.
The study rocked the medical community because until then, hospital leaders believed some errors and infection were inevitable. We all accept that “accidents do happen.” But most of us acknowledge that many are preventable. Apparently that’s not the case with all hospitals.
A controversial report released the other day by the Leapfrog Groupnoted that even now “about 400 people die every day – the equivalent of one large jetliner crashing and killing all aboard– because of hospital errors.”
By my calculations, that’s 146,000 unnecessary deaths every year, almost 50 percent more than when the IOM report came out.
In a first-of-its kind initiative, the Leapfrog Group graded over 2,600 hospitals across the country using publicly available data on patient injuries, medical and medication errors, and infections.
Nearly half earned a ‘C,’ including many renowned medical institutions. They aren’t happy with the results. The adversarial relationship between Leapfrog and the hospitals can’t help. The Leapfrog Group, the health-care quality watchdog founded in 2000, represents the interests of large employers who purchase healthcare and are demanding safety improvements in hospitals.
The Wall Street Journal “Health Blog“ said some hospital leaders took issue with the use of self-reported questionnaires in the rating methodology. One chief quality officer complained that much of the data was at least one year old.
But To Err Is Human came out in 1999. So I question why one year would make a difference?
“Safety appears to be something all hospitals can choose,” says Leah Binder, president and CEO of the Leapfrog Group.
We agree to some extent. Because obviously some hospitals—the ones with the “A” grade — are choosing to do all they can to correct the problems. But in many cases, hospitals just aren’t aware of the options they have, or perhaps don’t believe the problems can be fixed.
For example, the IOM said the fragmentation and decentralization of the health care system was a key contribution factor to preventable error. Operating in silos “may create unsafe conditions for patients and impede patient safety efforts.” At TeleTracking, when we enter an engagement with a hospital or health system to fix capacity management problems, the first thing we typically address is decentralization. When we demonstrate the benefits of centralization in terms of patient flow and revenue generation, hospital leaders are generally receptive to reorganization their processes.
Another case in point involves the periodic exposure of housekeepers and transporters to infection because they aren’t forewarned about entering an isolation room. This happens across the country with more frequency than anyone would care to admit. So the employees who travel most widely through any hospital can become infection carriers, along with their equipment. To address this problem, TeleTracking embedded features in its software that automatically alert everyone who needs to know that they are about to encounter an infected patient and to prepare accordingly. Yet very few hospitals avail themselves of these features.
Overcrowding has been proven to spread infection, yet only 20 percent of U.S. hospitals today employ automated capacity management systems to alleviate that problem. Asset tracking software can now detect how well employees comply with hand-washing directives, yet that capability is used in only a small percentage of hospitals.
So there is an educational component about the latest technologies and process improvement initiatives available to improve patient safety and quality, to be sure. The question is, are enough hospitals choosing to seek out that education? Or do they still believe that medical errors are just part of the “healing” process.
~ Valerie Fritz