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

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.

Since 1999, progress has been made mostly on voluntary, confidential systems that do not create any external pressures for change. Twenty four states do not have any medical error reporting requirements in place; those states that do require error reporting do not disclose facility-specific information to the public about mistakes. The report suggested a facility-specific reporting of medical harm that is "mandatory, validated and public."

Measuring the problem. The IOM, noting in 1999 that there was no unifying effort to improve healthcare, called for the creation of a Center for Patient Safety within the federal Agency for Healthcare Research and Quality (AHRQ) to coordinate and monitor improvements. However, 10 years later, no national entity exists to comprehensively track patient safety—hindering the ability to tell if improvements have been made.

While AHRQ is attempting to do this, its efforts have been hampered by the lack of reliable medical error reporting. In its May 2009 report, the AHRQ noted that patient safety actually declined by almost 1% a year in the six years after the IOM report was issued in 1999. Ironically, AHRQ still points to the IOM's 1999 report as the best estimate of the magnitude of medical errors, according to the Consumers Union report.

Raising standards for competency in patient safety. The IOM recommended a bigger focus on patient safety by regulators, accreditors, and purchasers. It also called for periodic examinations of doctors and nurses to assess their competence and knowledge of safety practices.

During the past decade, many ideas in patient safety standards have come from the private sector. While these efforts are noteworthy, the results have been fragmented—making it difficult to promote and measure national improvement.

The report noted that the Joint Commission has attempted to use the accreditation process to ensure competency and adoption of its National Patient Safety Goals at hospitals. However, the Commission does not publicly disclose individual hospitals' progress in adopting these goals; its efforts to monitor patient safety sometimes have been criticized.

In the last 10 years, most of the patient safety work done by providers has been on the "confidential side for learning." said McGiffert. "Maybe they've learned something but we sure don't know what the results are."

As the debate over healthcare heats up in Washington, Congress should make sure that improving—and monitoring—patient safety is a central part of any reform legislation it adopts, she adds. Keeping in mind these important issues, hospitals and healthcare organizations—even those that have made big strides is addressing patient safety issues—should see what the Consumers Union report says about transparency and raising standards.

"That is what the public wants to see. You can tell us all you want—that you're doing better," McGiffert said. "But show us the evidence. That's what this report is about."