Healthcare Executives Need to Do More and Show More for a Safer Health System

HealthLeaders Media Staff, May 21, 2009

Almost 10 years ago, the Institute of Medicine released one of its most talked-about reports ever—the pivotal "To Err Is Human: Building a Safer Health System"—which stated the alarming idea that at least 44,000 people and perhaps as many as 98,000 each year were dying in hospitals as a result of medical errors that could have been prevented.

At the time of its release, the report generated a firestorm of controversy: Was this figure a mistake? How could this be happening in our nation's hospitals? Congressional hearings, television show and magazine articles continually cited this figure—trying to make sense of it. And after a decade, we would have assumed that we had finally met this issue head-on.

Or have we? A new report released this week by Consumers Union says we may not have progressed as much as we thought. In fact, it says a review of the current scant evidence reveals that preventable medical harm accounts for approximately 100,000 deaths a year—accounting for one million deaths over the past decade.

Many hospitals are likely to be debating that finding. Since 1999, many have instituted organization-wide initiatives to improve patient safety. They have found ways to reduce hospital- acquired infections or prevent falls or ensure the right patient gets the right medication at the right time. Many have instituted programs such as hand washing or marking the correct body part for surgery that they know are making a difference in the way they deliver care.

But Lisa McGiffert, director of Consumers Union's Safe Patient Project and co-author of the report, "To Err is Human—To Delay Is Deadly," sees it differently when using a broader view.

"We know that there has been fragmented progress—different projects here and there to get hospital infection reporting," McGiffert said, "but they are very fragmented and they really aren't giving a complete picture of patient safety in the country, which is certainly not where the IOM committee envisioned we'd be 10 years later."

The IOM goal was to have findings substantiated—to get to the level where providers across the country could say "where we've reduced preventable medical harm by X percent," she said. But that has not happened. No central repository exists to show changes nationwide. "So not only do we not know if we're any better off. We have every indication that we are worse off."

So rather than push the Consumers Union report aside, maybe healthcare organizations should be taking a closer look at what it is recommending. For instance, it suggests:

Creating accountability through transparency. The IOM recommended creation of two national reporting systems to help reduce errors—a mandatory and public reporting system for encouraging accountability, and a voluntary and confidential reporting system to help healthcare providers learn from their mistakes.

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