“People need to become activists to make hospitals safe for all of us. If each day a 747 airplane crashed, killing all 500 people aboard, we’d be outraged. But more than that many people die of medical errors each day and society ignores it.”
~ Lori Andrews, bioethicist, legal activist and author
Making patient safety one of her crusades, Ms. Andrews was appalled at the unconscionable number of easily preventable medical errors and deemed them utterly unacceptable.
Andrews and her team shadowed staff at teaching hospitals and found a much higher rate of easily preventable medical errors than was reported in the literature. In fact, some 46 percent of patients experienced at least one error during their care, and 18 percent of patients suffered serious harm due to such errors.
Although Andrews didn’t find the disparity especially surprising, what did trouble her was the feeble, half-hearted attempt of the hospitals to address and reduce their errors. Andrews is emphatic about the need for health care consumers to agitate for improved quality of care and patient safety. Until that happens, we aren’t likely to see any improvement in care, and will continue to pay the price, emotionally and financially, for treatment errors which are easily avoidable.
In 2008, these mistakes resulted in more than 2,500 preventable deaths. Financially, such errors cost the country at least $17 billion, according to Jim Toole, chairman of the Society of Actuaries. The report documented 10 categories of medical mistakes as comprising the bulk of serious miscues, with the top five comprising 55% of total costs. In 2008, the list was as follows:
- 1. Pressure ulcers—374,964 errors, $10,288 per error and $3.858 billion total.
2. Postoperative infections—252,695 errors, $14,548 per error, $3.676 billion total.
3. Mechanical complication of a device, implant or graft—60,380 errors, $18,771 per error, $1.133 billion total.
4. Postlaminectomy syndrome—113,823 errors, $9,863 per error, $1.123 billion total.
5. Hemorrhage complicating a procedure—78,216 errors, $12,272 per error, $960 million total.
6. Infection following infusion, injection, transfusion, vaccination—8,855 errors, $78,083 per error, $691 million total.
7. Pneumothorax—25,559 errors, $24,132 per error, $617 million total.
8. Infection due to central venous catheter—7,062 errors, $83,365 per error, $589 million total.
9. Other complicaitons of internal (biological) (synthetic) prosthetic device, implant and graft—26,783 errors, $17,233 per error and $462 million total.
10. Ventral hernia without mention of obstruction or gangrene—53,810 errors, $8,178 per error and $440 million total.
Why is this happening? Caregivers and medical facilities have a vested interest, if not active compassion, for their patients’ welfare. Certainly those adverse events which could easily be avoided should have been minimized years ago. Why are hospitals not attempting to learn from their mistakes to prevent future errors? What is the dynamic driving this deadly phenomenon? We know that doctors and nurses suffer from hospital-generated patient overload. We know hospitals fight for financial survival as more uninsured patients fill beds and more patients are unable to pay their medical bills due to a savage recession.
And we also know that the numbers of errors did not measurably decrease between 2002 and 2007, despite the Institute of Medicine’s 1999 determination that perhaps as many as 98,000 deaths and 1 million injuries resulted from medical errors each year. Although this report purportedly spurred new efforts to improve patient safety, there has been no significant progress.
What is being done about this? The Obama Administration has launched a $1 billion effort to recognize, reduce and prevent the lack of quality control. Stated goals include:
- Increasing patient training and self-care skills before patients leave the hospital.
- Sharing plans of care across inpatient and outpatient settings.
- Standardizing communication exchanged between physicians and other health professionals caring for patients.
- Improving medication reconciliation and safe medication practices.
- Establishing that the health professional initiating a handoff maintains responsibility for the patient until he or she receives confirmation that the transfer is complete.
Communication between physicians is key. Your role as your own advocate includes insisting that the primary care doctor stays informed of admission, progress and release. Watch for updates as this effort goes forward — it is part of the healthcare reform legislation passed last year, and has the potential not only to save lives but money which would be better spent on health and healing.