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Hospital Safety: Is There Progress?

HospitalSometimes history does repeat itself. Back in the 19th century, going to the hospital or even being treated by a physician was often the way to a fast death. Because no one understood how germs spread from patient to patient, doctors did not wash their hands. The notion that operations needed to be performed under sterile conditions was not yet thought of. More Civil War soldiers died from dysentery and wound infections than died on the battlefield. Giving birth at home under the care of a midwife was usually much safer than going to a hospital, because there were fewer germs. Moreover, even though doctors didn't know much, they knew more than everyone else, so few people questioned their judgment. In short, medicine was primitive and dangerous.

Let's fast forward to the 21st century, when we know about germ theory and the importance of sanitary practices. We also know a lot about how to communicate effectively and raise issues in nonthreatening ways. Yet, people continue to die in hospitals by the thousands because doctors and other hospital staff members do not adhere to well-understood protocols for protecting patients' safety. Although there have been miraculous improvements in medical understanding, execution of those improvements is still limited by simple human frailty - the desire to cut corners and an unwillingness to speak honestly and accept input.

How Many Deaths From Medical Errors Annually?

How many patients die today because of hospital errors caused by poor communication and failure to adhere to protocols? It is not always clear for a variety of reasons. First, hospitals are reluctant to report negative outcomes. Second, the direct cause of a patient's death may not always be obvious medical error, although additional digging may reveal mistakes that led to the condition that caused the patient's death or serious illness. In other words, medical mistakes can be part of a string of dominoes, with each one affecting the other.

Despite often imprecise statistics, we can say with confidence that far too many people die in U.S. hospitals because of medical errors. Here are some numbers that reveal both the lack of clarity about preventable hospital deaths and the enormity of the problem. For example, in 1999, the Institute of Medicine estimated in a ground-breaking report, "To Err Is Human," that 98,000 people died because of hospital errors. In 2010, the U.S. Department of Health and Human Services estimated that 180,000 people died as a result of hospital errors.

Hospital Lobby Disputes Figures

Things became more complicated in 2013. A study reported in the Journal of Patient Safety showed that between 210,000 and 440,000 hospital patients suffered preventable harm that resulted in their deaths. If this is indeed the case, then hospital deaths are either the sixth or the third leading cause of death in the United States, behind only heart disease and cancer.

The American Hospital Association, not surprisingly, disputes these numbers. However, independent reviewers contacted by ProPublica noted that the methodology used to arrive at these figures was sound. Four studies conducted between 2002 and 2008 showed that there were "serious adverse outcomes" in up to 21 percent of hospitalizations.

Importance of 'To Err Is Human' Study

That 21 percent represents only a portion of error-caused deaths, according to one of the authors of the 1999 study, Dr. Lucian Leape, a Harvard University pediatrician. He believes that the most recent number range is correct and that 440,000 is the more accurate number. Because "To Err Is Human" continues to inform the debate about patient safety, it is important to examine it in some detail.

The report began by defining medical errors and providing examples that included adverse drug events, incorrect transfusions, surgical injuries that included wrong-site surgery, deaths related to the use of restraints, falls, burns, pressure sores and treating the wrong patient. Such errors were most likely in intensive care, operating rooms and emergency departments.

The report also discussed the financial costs of errors such as these. The number was staggering: Between $17 billion and $29 billion each year is spent needlessly or lost altogether because of medical mistakes. These losses include lost income and decreased household productivity and the cost of additional care because of conditions caused by errors. Less tangible costs included the loss of trust in the American health care system and diminished patient and employee satisfaction.

Most Common Errors Listed in 'To Err Is Human'

The report also listed the most common errors that resulted in adverse outcomes. These included:

  • Diagnostic errors that included delays, failure to use appropriate tests, use of outdated tests or treatment and failure to act on test results
  • Treatment errors that included mistakes when performing an operation, errors when administering other treatment, mistakes in calculating the dose or means of administration of a medication and avoidable delays
  • Inadequate monitoring and follow-up that also included failure to use treatment that would prevent further complications
  • System failures that included failure to communicate and equipment failure

The most important conclusion of the study was that most errors are not caused by individual recklessness, but by systemic failure. The study also recommends a way to address these systemic failures: Make it harder for people to make mistakes and easier for them to do things correctly.

Possible Ways to Reduce Deaths From Medical Errors

This sounds great, but how does one accomplish this type of change? The report had three broad recommendations:

  • Establish a single national agency charged with developing and distributing information and tools to improve knowledge of patient safety
  • Develop a national error reporting system so that practitioners throughout the country could learn from the mistakes of others
  • Raise national performance standards - "good enough" is not good enough

In addition, the report contained a recommendation for local organizations and practitioners: Develop a culture of patient-focused safety and make sure that it is supported by designing jobs to include safety responsibilities; making working conditions safe for patients and staff; standardizing equipment, supplies and procedures; and developing ways to prevent care providers from relying solely on memory. It is not enough to make these improvements, however; patient safety must be constantly monitored.

What happened as a result of the 1999 report? In 2008, one writer bemoaned the lack of progress toward adopting these recommendations and meeting the 1999 report's goal of a 50 percent reduction in medical errors within five years. However, the same author noted that at least awareness of the problem had been raised considerably, and some things had changed for the better. One of the most important changes was the distribution of information about an approach to teamwork based on the system used by airplane flight crews.

How TeamSTEPPS Could Reduce Negative Outcomes in Hospitals

This system, TeamSTEPPS, (Team Strategies and Tools to Enhance Performance and Patient Safety) is designed to improve communication that in turn leads to greater safety. The process has strict protocols for handling emergencies, asking questions, providing input and stopping a procedure already underway. When expected of all employees and used correctly, the process saves lives. However, every doctor, nurse, custodian, cook and aide needs to be trained in how to use this approach. Providing and completing this training has been a challenge for many hospitals.

Why TeamSTEPPS Is Not Used Universally

Fast forward from 2008 to 2015. TeamSTEPPS is not used in every hospital and health care setting. According to one news story, the main roadblock to implementing this important improvement in communication and safety is doctors. This is not that surprising. Many physicians - especially surgeons - are rock stars, used to doing things their way and possessed of healthy egos that allow them to undertake the riskiest of jobs - cutting into another person. However, the same characteristics that make them good surgeons and doctors can also make them prima donnas, unwilling to collaborate and not eager to consider that they may be wrong.

One news story in an industry journal, Hospitals & Health Networks, reported that when required TeamSTEPPS training is provided, doctors are often conspicuously absent from the room. The explanation offered in the article was that doctors are loathe to collaborate due do their competitive nature . They needed to be to get into medical school, get the best internships and residencies, and land the most prestigious jobs. Moreover, they often believe that a patient's safety lies entirely in their hands, something that was not far from the truth a generation ago.

Clinging to Autonomy

Medicine has changed, however, with many responsibilities pushed down the hierarchy to save money and use resources effectively. Doctors are no longer the only people with medical knowledge. Having autonomy is one of the things that doctors cherish as partial payment for the enormous responsibilities they shoulder.

Giving up that autonomy is very difficult for some. One speaker at a TeamSTEPPS training conference observed that one way to obtain buy-in from physicians is to create a sense of urgency. Doctors often don't see a communication problem. After all, like most of us, they believe that they communicate well. To remain full members of a medical team, however, they need to acknowledge the problem and agree to try the solution. Once this happens, said the conference speaker, TeamSTEPPS becomes their idea and they become its champions.

In other words, progress may be slow, but progress has been made. According to a report from the Agency for Health Care Research and Quality, in 2014, 1,500 hospitals had adopted the program throughout their organizations. Master trainers numbering 5,000 have trained over 300,000 front-line hospital staff members.

Many Believe That Not Much Has Changed, Despite Heightened Knowledge of the Problem and Ways to Correct It

Progress has been slow in some areas. For example, a Cleveland news outlet recently reported that seven northeastern Ohio hospitals were penalized under the Affordable Care Act provisions designed to lower rates of hospital-acquired infections. The hospitals include University Hospitals Ahuja Medical Center, MetroHealth System, St. Vincent Charity Medical Center, Akron General Medical Center, Summa Health Systems Hospitals, Lutheran Hospital and Cleveland Clinic. Along with more than 700 hospitals nationwide, these facilities will receive a one percent reduction in their Medicare reimbursements rates because they were in the worst-performing quartile of hospitals evaluated for infections and complications.

Determining whether efforts to reduce infection rates have borne fruit overall depends on how the statistics are presented. For example, the raw number of hospital deaths is different from the rate of hospital deaths. Also, there are different types of hospital deaths. For example, there appears to be some progress in reducing the number of hospital-acquired-infections, or HAIs. However, congressional testimony in 2014 indicated that overall, not much has changed and that hundreds of thousands of patients continue to die needlessly in U.S. hospitals.