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Medical Errors Third Leading Cause of Death, Senators Told

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   July 18, 2014

At a Senate subcommittee hearing, hospital quality experts urge lawmakers to establish measures to halt preventable medical errors in hospitals, which kill as many as 400,000 people each year.

The Centers for Disease Control and Prevention's role in quality of care should be greatly expanded to reduce many more types of patient harm, several leading healthcare quality leaders told members of the Senate Subcommittee on Primary Health and Aging Thursday.

"There's no reason to think what [the CDC] has been able to do around [healthcare-associated infections] they can't do in other areas like venous thromboembolism and medication errors, and they can partner with the U.S. Food and Drug Administration," said Ashish Jha, MD, founder of the Initiative on Global Health quality at the Harvard School of Public Health.

"The CDC has a phenomenal track record (through the National Healthcare Safety Network reporting program), this is a public health problem, and the CDC is our public health agency. They have a central role to play."

Peter Pronovost, MD, senior vice president for patient safety and quality at Johns Hopkins Medicine, urged the panel to "charge the CDC with developing monitoring and transparently reporting incident rates on the top causes of harm. They [the NHSN] do it for hospital-acquired infections now and they know how to do it for others."

Subcommittee chairman Sen. Bernie Sanders, (I-VT), called the hearing to publicize statistics showing that preventable medical errors in hospitals kill as many as 400,000 people each year, making it the third most common cause of death in America.

"That will come as a great surprise to most people," Sanders said. "But it hasn't received anywhere near the attention it deserves."

Besides giving a greater role to the CDC, Pronovost said that at a federal level, there needs to be standards for the reporting of healthcare quality and cost, measures similar to those created for the banking industry by the Securities and Exchange Act.

CDC Expanding Quality of Care Efforts

"Right now, we have no guarantee that the measures we're reporting on are accurate." The healthcare system, he said, "is the equivalent of Boeing building a plane with many subcontractors, and the makers of the landing gear said to Boeing: 'I don't want to send a signal to the cockpit to tell you if the landing gear is up or down, you're going to have to guess.' And Boeing says, 'No problem. We'll still buy it. Even though it will cause deaths."

Asked by Sanders if infection rate information is publicly available, Lisa McGiffert, director of the Safe Patient Project for Consumers Union,highlighted the wide-ranging policies for reporting among state health departments.

"When it comes to surgery, it probably depends on what state you're in whether [infections from] the surgery you're getting are going to be published. In Washington State, they publish hip and knee implant surgery [rates] so you're in luck there. But you're not in luck in Texas and the federal government doesn't require that yet."

Tejal Gandhi, MD, National Patient Safety Foundation President, said that there is no way to force hospitals to share what they learn from their mistakes with other organizations.

"If my hospital figures out how to solve a problem [regarding a common medical error], that doesn't naturally leave the four walls of my hospital. So things get reinvented (at other hospitals). We need better mechanisms to make sure that sharing across organizations happens when these events do occur."

Jha and Pronovost both stated that the problem is lack of leadership, with Jha emphasizing his own research that CEO salaries are not tied to quality measures.

"Until we get to the point where the CEO of the hospital is lying awake at night worrying about patient safety, I don't think we'll really move the needle beyond these leading organizations, which are going to do it no matter what incentives are there."

Pronovost said that quality leaders are borrowing a tactic from the nuclear industry that uses peer-to-peer review, in which hospitals with zero infections were asked how they did it.

"What we found was that there was no magic bullet, but what there was was a clear chain of command…It was zero if the nurse manager owned the problem, and it was zero if we asked the rates and they knew them. It was zero if the there was a culture where nurses could question doctors for not using a checklist."

Asked whether patients in U.S. hospitals are fundamentally safer today than they were in 1999, when the Institute of Medicine's landmark report, To Err Is Human, quantified the number of patient deaths from medical mistakes, Jha replied, "the unfortunate answer is 'no.'

"We have not moved the needle in any meaningful or demonstrable way, although overall, in certain areas things are better and certain areas things are probably worse."

John James, founder of Patient Safety America who testified that his son died of three avoidable medical errors, quantified the number of deaths from medical errors at four times what the IOM report said.

James advocated for a national patient safety board, and a national patients bill of rights. Those rights would include the right to know:

  • The safety record of any clinic, nursing home or hospital
  • Costs of tests and elective procedures in advance
  • When drugs are prescribed off label
  • That the teams of healthcare professionals are evaluated through 360-degree performance reviews

"In my opinion, patient safety is not going to improve substantially until the playing field between patients and the healthcare industry is leveled by an enforced bill of right," he said.

As progress moves toward more transparency in acute care settings, Gandhi, a former chief of quality and safety at Partners Healthcare in Boston, said medical errors occurring in ambulatory centers, from primary care offices to ambulatory surgical and dialysis centers, should not be overlooked.

"The safety issues in each of these settings differ and little is known about what they are. We need better data" to understand the frequency and causes of prescription errors, why tests are not ordered or not sent to physicians and patients, why doctors sometimes don't follow-up on those results, and why patients don't always take their medications as they should.

"We can not just tell clinicians to try harder and think better. We need better systems to minimize cognitive errors… such as computerized algorithms or decision support," Gandhi said.

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