Health Leaders Comment
By Katherine H. Capps, for HealthLeaders.com, Nov. 19, 2001
Each year, between 44,000 and 98,000 patients die in hospitals as a result of mistakes made in their care - deaths from errors in medical management, rather than the underlying disease or condition of the patient (Institutes of Medicine, 1999; Brennan et al., 1991; Thomas et al., 1999). In fact, medical errors are the fifth leading cause of death in the United States. More people lose their lives to hospital errors than to breast cancer, AIDS or motor vehicle accidents.
In addition, medical errors are costly. Total national costs are between $17 billion and $29 billion (Thomas, et al, 1999; Johnson et al, 1992), including lost productivity, lost household income, and direct healthcare and disability costs associated with medical errors.
The National Health Leadership Council of the National Business Coalition on Health is a vehicle for leaders representing healthcare purchasers, providers, insurers and suppliers to discuss important aspects of healthcare, with a focus on advancing toward greater healthcare value. In January 2000, the NHLC met to discuss issues surrounding the 1999 IOM report that documented alarming systemic weaknesses in patient safety. The result of the meeting was a challenge to employers and stakeholder coalitions to take action and is summarized in the report, "Building Employer Leadership and Knowledge for Patient Safety."
Medical errors are deadly - and costly
According to the IOM report, between 3% and 4% of hospitalized patients suffer from medical errors, and about one in 10 results in death (Brennan et al., 1991; Thomas et al., 1999). The report also states that "two out of every 100 admissions experienced a preventable adverse drug event, resulting in averaged increased hospital costs of $4,700 per admission or about $2.8 million annually for a 700-bed teaching hospital." Everyone in the healthcare system shoulders this cost.
What causes medical errors?
Evaluation of the errors resulted in two key findings: errors occur because of system failures, and preventing errors means designing safer systems of care. Instead of finger pointing and individual blame laying, the IOC developed a four-part plan to improve patient safety, viewed as an integral piece of the healthcare quality puzzle. The four steps are:
*Set up a national center to provide leadership and research
*Establish both voluntary and mandatory reporting systems to identify and learn from errors
*Set standards for safety between various regulatory and market forces
*Implement safety strategies inside healthcare organizations
To implement lasting change, it is imperative that hospital cultures undergo substantial metamorphosis. Fear of reprisal must be replaced by an open environment where individuals feel comfortable about coming forward, revealing mistakes, and using "near misses" as an opportunity to learn and create better systems for healthcare delivery.
Stakeholders address the problem
Stakeholder partnerships are already working to identify systemic causes for medical errors and develop methods to increase patient safety. One of these is the National Patient Safety Foundation, established in 1997 as an independent non-profit organization, originally funded by the American Medical Association, 3M, CNA Insurance and Schering Plough. The group seeks to raise awareness of patient safety by funding initiatives that identify preventable error, increase education, reduce pressures and increase involvement, commitment and partnerships. Its greatest challenge is finding workable applications for its research findings.
The Partnership For Patient Safety (P4PS) is a network of professionals and committed organizations to develop and provide information, products and services that advance patient safety. With a focus on the role of business in patient safety, the group seeks to identify concrete ways coalitions can positively affect patient safety: through benefit plan design that incorporates patient safety standards in RFIs and RFPs; acknowledgement of patient safety issues in medical management; and change in consumer behavior reflecting better knowledge of patient safety concerns.
Accrediting organizations such as NCQA and JCAHO are also setting new standards relating to patient safety, specifically in reporting error events. Along with the stakeholder coalitions, these accrediting organizations recognize that patient safety is a subset of overall quality, and healthcare organizations must be more accountable for patient safety as well as other quality measures. Business coalitions across the country are also working to weave patient safety concerns into CEO vocabulary and to introduce new tools and principles in healthcare purchasing and employee education to reduce the number of medical errors. Several coalitions have focused on particular disease management areas to implement patient safety programs.
The role of business coalitions to promote patient safety
Clearly, patient safety is a front-burner issue for those who fully understand its scope. The role of communicating the urgency for improving patient safety lies not only with accrediting agencies and provider-based foundations, but with the purchasers of healthcare as well. Employers and employer coalitions are uniquely positioned to press the issue of patient safety as they engage in contracting negotiations. Strategic steps identified and fleshed out in the report, "Building Employer Leadership and Knowledge for Patient Safety," include:
Develop and support consumer awareness of safety issues
Support standardized voluntary and mandatory reporting efforts that will advance safety and quality issues
Support and demonstrate the creation of innovative financial models with the goal of rewarding providers for high quality, safe, affordable healthcare
Support and demonstrate the development of organizational indicators of safe practice to be used by consumers, purchasers and policymakers
Support the development and demonstrate the effective use of contractual standards for safety for use by purchasers
Although the medical errors problem has been researched and reported in professional circles for years, little except the occasional anecdotal tale has escaped to the general public. Communicating the breadth of the issue, first to CEOs, then to the general public, will do much to advance the cause and bring about the systemic changes necessary to prevent unnecessary death and injury. Perhaps as the public understands that two out of 10 patients in hospitals become victims of medical errors (many deadly), stakeholders will develop and implement revolutionary measures to improve patient safety.