Spotlight on medical errors evokes stakeholders' involvement
The study authors concluded medical error-related deaths are not being properly documented on death certificates due to limited ICD-10 codes, the study authors concluded. “There are only a few codes where the role of error can be inferred," they stated.
Rick Pollack's, president and CEO of the American Hospital Association (AHA), responded to the study’s findings in a press release stating, “No matter the number, one incident is one too many."
"Hospitals are constantly working to improve patient safety," Pollack added. "But there is more work to do and hospitals are committed to quickly adopting what works in every step of care provided."
A 2012 article in the Journal of Health Care Finance estimated the economic impact of medical errors could be as high as $1 trillion a year - a big incentive for hospitals to focus on safety.
The Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services (HHS) recently estimated that hospital-acquired conditions (HACs) dropped 17% between 2010 and 2014, saving 87,000 lives and nearly $20 billion in healthcare costs. Yet there still remains a host of medical errors to address.
Some of the top medical errors range from medication errors, hospital acquired infections such as methicillin-resistant Staphylococcus aureus (MRSA), catheter-associated urinary tract infections, bed sores to blood clots and surgical-site infections.
Medication errors – costly and challenging
Medication errors top the list because of their high frequency.
The Office of Disease Prevention and Health Promotion estimates that adverse drug events (ADEs) account for 1 in 3 of all hospital adverse events, affect 2 million hospital stays per year, and prolong hospital stays by 1.7 to 4.6 days. In outpatient settings, ADEs account for more than 3.5 million doctor visits, one million ER visits and approximately 125,000 hospital admissions.
These errors come with a high price tag. A National Priorities Partnership brief estimates inpatient preventable medication errors cost approximately $16.4 billion a year and outpatient cost about $4.2 billion.
However, “due to the lack of current and reliable data, the $21 billion opportunity in wasteful healthcare spending represents a conservative estimate of the cost of preventable medication errors,” the brief stated. Some of the suggested solutions included care coordination strategies, interdisciplinary teamwork, and computer technology to reduce these errors.
“It’s one of the more challenging errors to measure because it’s not always clear when something happens to a patient it’s because of the medication,” said Erica Mobley, director of communications at the Leapfrog Group, a nonprofit organization which promotes healthcare safety.
Mobley's group uses a “proxy measure” that evaluates Computerized Physician Order Entry (CPOE) systems. These systems have alerts programmed into them to detect errors, such as if someone prescribes an adult dosage for a pediatric patient.
Brigham and Women’s Hospital Chief of General Medicine Dr. David Bates and his team developed the CPOE system in 2004, and have shown in a 1998 study that the technology reduced preventable adverse drug events by 55% from 10.7% to 4.9% per 1,000 patient days. In a more recent study also conducted by Bates’ team, serious medication errors fell by 88%.
Yet when the Leapfrog Group compiled data from a hospital survey using their simulation tool with dummy patients to test system alerts, the results, released in April, were surprising.
“We found, based on our simulation tool, that the systems did not flag 40% of potentially harmful orders, but more concerning, didn’t flag 13% of fatal orders," Mobley said. "That really indicates hospitals have these systems, which is good, but they’re not always working as they should and there needs to be a lot more work to be done to make sure they are effectively preventing medication errors,” he added.
Part of the problem may be in the customization of the systems, which involves conforming to a hospital’s formulary, the types of patients they treat, and medications they are likely to prescribe. “There’s a lot of work to implement these systems effectively," Mobley concluded. "It appears that not all hospitals are taking all the steps to do so.”
Creating a culture of safety
One of the areas that many experts agree needs to improve is the culture of safety. Dr. Michael Hicks, executive vice president for clinical affairs at the University of North Texas Health Science Center (UNTHSC), which recently announced the launch of the Institute of Patient Safety, told Healthcare Dive that medical students need to be better educated in patient safety.
“Part of this is about creating a culture of safety in healthcare, where clinicians of all types work together within hospitals, health systems, and the community at large to develop common systems and procedures around delivering safer care," Hicks said.
Patient safety will be added to the curriculum at the new medical school being created. “The science and culture of patient safety must be woven into the fabric of clinical education if we are going to be successful in creating a patient safety culture,” Hicks added.
However, this can be challenging in a hospital environment, according to Mobley, because there may be some hesitation by staff to speak up. “We look for hospitals that have a strong culture of safety…so every staff person is empowered to speak up if they sense something is wrong," she said.
"You’ve heard of stories of nurses not wanting to say anything because of intimidation by a surgeon or doctor…but once the culture of safety is in place, we see an overall reduction of errors in that hospital.”
Transparency of data and hospital scoring
AHRQ provides tools for hospitals to establish a culture of safety, which range from TeamSTEPPS, a customizable communications training program for clinicians to reduce patient safety risks, to a Hospital Survey on Patient Safety Culture that examines patient safety from a staff perspective.
There’s also a toolkit called Medications at Transitions and Clinical Handoffs (MATCH) that provides strategies to improve medication reconciliation processes for patients throughout the healthcare system, according to a recent AHRQ Views blog by Dr. Jeffrey Brady, director of the AHRQ Center for Quality Improvement and Patient Safety.
The Leapfrog group conducts an annual voluntary hospital survey that includes 30 different safety measures in two different domains, Mobley explained. The “processed domain” includes what systems and policies a hospital has in place to prevent errors and an “outcomes domain” which is the rate errors actually occur.
“Hospitals have to be excelling in both areas with low error rates to achieve an A grade,” Mobley said. “It’s not easy to achieve.”
Approximately 800 hospitals out of 2500 received an “A” grade in the latest survey.
For the first time, four national insurers (Aetna, Anthem, Cigna, and UnitedHealthcare) and one regional insurer (Health Net of California) united to write a letter asking 3,700 hospitals to participate in the 2016 Leapfrog hospital survey. Although the insurers had previously encouraged hospitals to participate individually, Mobley said, “we were excited to see them co-sign a letter.”
However, Medicare recently pushed back the launch of its star-rating plan of individual hospitals’ care after members of Congress, as well as several large medical groups, including the AHA, wrote letters questioning the agency’s method.
A recent Health Affairs blog questioned hospitals’ reluctance to share data and a lack of accuracy in data reporting. The post, written by author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age” Michael Millenson, concluded: “Although star ratings may be more suitable for hotels than hospitals, the hospital industry should still be held accountable for helping to build a “useful and helpful for patients" alternative. Hospital groups don’t have to wait for [the] government to lead their members to taking the specific steps needed to build a reliable, timely and complete report card the public can trust.”
Nancy Foster, vice president of quality and patient safety policy for the AHA responded to the Health Affairs blog, stating, “…hospitals and health systems have led the way in developing transparent reporting of quality and patient safety data.” However, she adds, “report cards must be designed with care.” The group has endorsed a set of principles for quality report cards to include:
- Clearly stated purpose with selected measures to fit this purpose.
- Demonstrate transparency by using a scoring methodology that can be replicated by others, identifies data sources, and describes limitations of data sources.
- Demonstrates validity by using statistical methods supported by evidence and field tested.
The answer is the balance between providing the right information that helps hospitals improve care and enables patients to make informed healthcare decisions, she said.
The role of patients and community
Patients and their family members have to be their own best advocates, said Hicks. “Even as healthcare reform continues to work to relieve some of this burden on families, the reality will remain that no one will be more motivated than the patient and family to create a safe environment."
Mobley agreed patients play a key role in preventing medical errors. “That’s one of the strongest messages we try to communicate with our safety scores," he said. "No hospital is perfectly safe and mistakes do happen and patients should be taking every possible step to protect themselves regardless of their hospital safety score.” Some of Mobley’s suggestions for reducing medical errors include having a family member as an advocate, speaking up when something doesn’t seem right, and having an updated medication list.
There’s still a great deal of work ahead regarding patient safety and all stakeholders are part of the solution as well as the community. Hicks said collaboration with the community will be important for the Institute for Patient Safety.
Dr. Michael Ramsay, president of the Baylor Research Institute and a member of the board of directors of the Patient Safety Movement Foundation, told Healthcare Dive technology also plays a key role in patient safety," Ramsay said. “This problem can only be beaten by all parties getting together to bring all resources to our patients."
In January, Sen. Sheldon Whitehouse (D-RI) introduced the Patient Safety Improvement Act of 2016 as hospital-acquired infections (HAIs) are getting more attention and efforts to prevent them have been ramped up. The bill would establish a grant program to support statewide collaborations to prevent HAIs and require hospitals to report HAIs to healthcare providers involved in a patient’s post-hospital care no later than 24 hours after diagnosis.
The Centers for Disease Control and Prevention (CDC) estimates 1 in 25 hospital patients acquire HAIs during their stay every year and 75,000 of them will die. “This is unacceptable and this bill is a significant step along the path to eliminating these preventable deaths,” Joe Kiani, founder of the Patient Safety Movement Foundation, said in a statement.
- The BMJ Medical error: the third leading cause of death in the U.S.
- Healthcare Dive Medical errors account for 251,000 U.S. deaths every year
- AHA Statement on the British Medical Journal Study
- Wolters Kluwer Economics of healthcare quality and medical errors
- AHRQ Saving Lives and Saving Money: Hospital Acquired Conditions Update
- The LeapFrog Group Preventing Medication Errors in Hospitals
- Healthcare Dive Patient Safety Institute Seeks to Reduce Medical Errors
- AHRQ Views AHRQ supports hospitals as they make care safer
- Health Affairs Blog Will hospitals help or hinder a better report card?
- AHA blog Striking a balance with transparency and usefulness