In patient safety, compelling stories are waiting to be told Date: 01/06/20
By Michael L. Millenson
The modern patient safety movement would not exist without media attention.
Prominent stories about medical error played a central role in the political impact of the landmark Institute of Medicine (IOM) report, "To Err is Human," which came out in late November 1999. (See sidebar.) The IOM estimated that up to 98,000 Americans die from preventable harm in hospitals each year and another 1 million are injured.
Physicians did virtually nothing about patient safety for decades, as I pointed out in a 2004 medical journal article, despite repeated warnings about treatment-caused deaths and injuries. Instead, it was “the public shaming of the profession that has occurred as a result of stories about medical errors in the news media [that] has played a key role in … adoption of innovations in error prevention.”
The good news is that today every hospital is doing something to improve safety. The bad news is that a commitment to reducing harm to the greatest possible extent – so-called “zero preventable harm” – is still uncommon, partly because too many clinicians still wear blinders about error prevalence and preventability. Patient safety stories remain relevant and important. What follows is an overview of some opportunities.
That bad doctors are allowed to practice remains a troubling problem. What "To Err" highlighted was the systemic issues (e.g., protocols for identifying the right surgical patient) that are responsible for the vast majority of harm.
Medical error studies using different definitions and methodologies have produced a wide range of death estimates. My advice is to cite either the upper range of the IOM estimate (which has become uncontroversial) or what is the closest I’ve seen to an “official” estimate. That’s a statement by the Department of Health and Human Services (HHS) in its strategic plan that “preventable medical errors potentially take 200,000 or more American lives each year.”
Note the word, “preventable,” which is important. Also, note, that the underlying research refers to errors in hospitals. We’re only beginning to understand deaths and injuries in that environment. (That glaring ignorance could itself be a story.)
Finally, 1990s-era analogies about hypothetical 747 crashes are as outdated as your Boyz II Men CD. Instead, you can compare the daily death toll from medical error to the 346 deaths in six months from two crashes of the 737 Max (as I did, here).
Stories about systemic efforts to keep patients safe typically may involve three different groups.
The IOM called for an independent patient safety agency. Instead, a Center for Patient Safety was created within what’s now the Agency for Health Care Research and Policy (AHRQ). The initial fiscal year (FY) 2001 appropriation was $50 million. Since then, not counting extra money earmarked for medical liability reform research (near and dear to the hearts of doctors), funding for what is now the Center for Quality Improvement and Patient Safety peaked at $72 million in FY 2019, according to an AHRQ spokesman. It was down 10% in the FY 2020 budget request, to about $65 million, but stayed constant after government funding was renewed through a Congressional continuing resolution.
By way of context, just one major malpractice suit in Illinois involving a brain-damaged boy produced a settlement of $50 million. Or, to use a different comparison, the safety center budget comes to less than 4% of the $1.8 billion in state funding announced by HHS in September to combat the 70,000 deaths a year from opioid overdoses.
What do those budget constraints mean for patient safety? What’s being funded, and what’s being left undone? That’s a story still untold.
In 2011, the Centers for Medicare & Medicaid Services (CMS) began its Partnership for Patients. (If you want to know why it’s CMS and not CMMS, see my “beat” on the ampersand.) CMS reported that the program paid nearly a half-billion dollars to groups such as the Hospital Research and Education Trust, part of the American Hospital Association, to work with individual hospitals to achieve significant reductions in “hospital-acquired conditions.” Another half billion or so went to reduce readmissions.
When I spoke with AHRQ recently, agency estimates of avoided harm through what is called the Network of Quality Improvement and Innovation Contractors amounted to a staggering 107,000 lives and $26 billion saved. (I simplified here because of some methodological changes by AHRQ.)
But there’s a problem. While a 2015 investigation by The Washington Post column, The Fact Checker, concluded that AHRQ’s “research seems solid” (I agree), there’s no way to match up AHRQ’s calculations, which refer to entire country, with the work of the Partnership hospitals.
So, is this an extraordinary, cost-effective and life-saving program that should be expanded, or would closer examination show that a half billion dollars didn’t buy much?
That question remains an open one in part because of this topic’s political invisibility. The last Congressional hearing on patient safety occurred in 2014, when members of a Senate subcommittee heard testimony that hospital patients were no safer than they were 15 years before. The hearing was convened by subcommittee chair Sen. Bernie Sanders.
In recent years, the American College of Healthcare Executives, the American Hospital Association and the Joint Commission have all proclaimed their commitment to “zero preventable harm,” sometimes in tandem with nonprofits such as the National Patient Safety Foundation (now part of the Institute for Healthcare Improvement). New patient safety groups have sprung up, such as the Patient Safety Action Network and the Patient Safety Movement Foundation.
At the same time, however, the patient safety cause seems largely to have abandoned by Consumer’s Union and the Public Citizen Health Research Group.
Are hospitals’ voluntary efforts producing verifiably significant results? What are doctor groups doing? These questions can be asked of local organizations, not just national ones.
Two decades after "To Err," one needn’t point to negligence or incompetence to make the point that patient safety cannot be allowed to become “sidetracked” by other priorities. In a recent Health Affairs blog post, I discussed how harming patients can be profitable, and how some institutions may be using return-on-investment criteria for patient safety efforts that compare the profitability of a bed filled by a patient who was harmed with the profitability of filling that same bed with a different patient! (An empty ICU bed might have to be available to schedule a profitable procedure such as heart surgery.)
While it has become a cliché that “there is no mission without a margin,” those two goals need not collide when it comes to patient safety. The ranks of those who have made zero harm a strategic priority include safety net hospitals, community hospitals, academic medical centers and large health systems. Unfortunately, these pioneers have generally received little to no public recognition.
For instance, St. Louis’s BJC HealthCare reduced patient harm by more than half in just five years. That was the IOM’s original goal for the entire nation. In another five years, harm events declined even further, down a stunning 75%. Ten years after the IOM report, by comparison, a major study found almost no progress.
One more quick point. Enthusiasm for price transparency notwithstanding, a bargain is no bargain if you end up seriously injured or dead. (Or, as my mother-in-law memorably put it, “Cheap is cheap.”) It’s easy to examine the safety information local hospitals provide on their websites; in my experience, some Big Names provide Little Information. If a hospital tries to object that publicly available information from other sources is outdated or misleading, ask for more recent and more accurate data. Regulations and laws specify public disclosure minimums, not maximums!
The patient safety story that likely reached the most Americans in 2019 was a brief part of an Aug. 9 segment on "The Daily Show," with on-air and online audience of about 9 million people. In it, host Trevor Noah praised efforts to address medical error such as checking prescriptions “to make sure you don’t have an overdose.”
Unfortunately, this brief review came in the context of making the larger point that some groups try to prevent accidental deaths, but gun makers do not.
“Doing better on safety than the gun lobby” is not the same as, “First, do no harm,” and a passing mention on a hybrid humor-public affairs show is not the same as real reporting.
In patient safety, compelling local and national stories are still waiting to be told.
Michael L. Millenson is the author of the book, "Demanding Medical Excellence: Doctors and Accountability in the Information Age," the president of Health Quality Advisors LLC and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. Earlier in his career, he was a health-care reporter for the Chicago Tribune.