The Health Care Crisis: First We Need to Make Patients Safe - Part 1
Volume 2, Issue 16, June 2005, pp.16 and 17.
is “freedom from accidental injury due to medical care, or medical errors.”
“Medical error” is “the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim…
problems in practice, products, procedures, and systems.” Institute of Medicine
This is the first part of a two part article that will
outline the role that preventable medical accidents, injuries and diseases play
in the rising cost of health care, summarize the current state of efforts to
improve patient safety, and detail some changes that could be made in public
policy, health care financing and health care regulation that could make a real
difference both in lives and money saved.
Part 1 will provide information on the scope of the patient safety issue
and summarize the current state of efforts to reduce medical errors including
actions taken in Virginia. Part 2 will
suggest further actions that could be taken in Virginia to make health care
safer, save lives and reduce health care costs.
The national conversation on patient safety began with the
publication in 1999 of “To Err is Human:
Building a Safer Health Care System” by the Quality of Health Care in
America Committee of the Institute of Medicine (“To Err” or the IOM Report).
The IOM report shocked the nation with conclusions like
“At least 44,000 people, and perhaps as
many as 98,000 people, die in hospitals each year as a result of medical errors
that could have been prevented, according to estimates from two major studies.
Even using the lower estimate, preventable medical errors in hospitals exceed
attributable deaths to such feared threats as motor-vehicle wrecks, breast
cancer, and AIDS.” These numbers make medical error the 8th leading
cause of death in this country.
- Medical errors
“have been estimated to result in total costs (including the expense of
additional care necessitated by the errors, lost income and household
productivity, and disability) of between $17 billion and $29 billion per year
in hospitals nationwide.”
- Additional costs
are imposed on society by medical errors including costs associated with “lost
worker productivity, reduced school attendance by children, and lower levels of
population health status.”
Where are we now? The sad fact is that in the almost six years
since the report was published not enough has happened to reduce the number of
deaths or the consequent health care and other societal costs. While the medical community has gone from
denying the widespread nature of the patient-safety problem before the
publication of “To Err” to accepting
the importance of investments in improving patient safety, we are nowhere near
achieving the goal set out in the report of a 50% reduction
in medical errors in five years.
In fact, the
situation may be getting worse instead of better. A study cited in the second annual report on Patient Safety in
American Hospitals released by Health Grades in May 2005 reports that
“patient-safety adverse” events increased among Medicare beneficiaries between
1995-2003. Among other findings, Health
Grades determined that “hospital-acquired
infections rates worsened by approximately 20 percent from 2000 to 2003 and
accounted for 9,552 deaths and $2.60 billion, almost 30 percent of the total
excess cost related to the patient safety incidents.”
To put the number of deaths from
medical errors in perspective, the lower end of the estimated number of
preventable deaths caused by medical error, 44,000 per year, is the equivalent
of 110 Boeing 747’s crashing annually and killing all on board. As the 2005 Health Grades report points out,
“This also equates to three fully loaded jumbo jets crashing every other day
for the last five years.” Can anyone question whether the public would tolerate
that kind of death rate in the airline industry?
Speaking at the Commonwealth Fund
Quality Improvement Colloquium: Patient Safety Five Years After To Err is Human in November 2004, Robert
M. Wachter, MD, a leading authority on patient safety, gave this reason why we
have not made more progress:
We have not yet found
the right mix of financial, educational, research, regulatory, organizational,
and cultural activities and forces to catalyze the far-greater investment (in
money, time, and attention) that will be needed to make health care
In 2001 following publication of the
IOM report, the federal government announced $50 million in grants for research
into medical errors and patient safety.
The Agency for Healthcare Research and Quality now has a safety budget
of $60 million, but this pales in comparison to what the federal government
invests in innovation. The NIH research
budget for innovation is 500 times greater than the safety budget.
Virginia has taken some steps to
address the patient-safety issue since To
Err was published, but it is unclear what the effect of these actions has
The Virginians for Improving Patient
Care and Safety (VIPC&S) is a voluntary public-private partnership that was
formed shortly after the publication of the report. VIPC&S now includes
public agencies including the Virginia Department of Health along with representatives
of doctors, hospitals, health insurance purchasers, and health insurance
companies and associations. No
representatives of patients or individual consumers of medical services are
currently listed among the membership of the VIPC&S although the AARP was
listed as a member at one time.
VIPC&S adopted core principles for
addressing the IOM report in June 2000.
A principle goal of the organization is to ensure that any patient
safety reporting system adopted in Virginia does not involve public reporting
of safety data. VIPC&S believes
that any data reporting system must insure “strict confidentiality of
individual reports” and the use of data for “learning and improvement rather
In advocating a confidential reporting
system, VIPC&S is generally aligned with the views of hospital executives. Hospital
leaders have concerns about the impact of mandatory, nonconfidential reporting
systems on hospital internal reporting, lawsuits, and overall patient safety.
While hospital leaders generally favor disclosure of patient safety incidents
to involved patients, fewer would disclose incidents involving moderate or
minor injury to state reporting systems.
80% say that names of hospitals and professionals involved should be
A 2000 Study by Virginia Joint Commission on Health Care
recommended changes in Virginia law to encourage voluntary reporting of patient
safety data to patient safety organizations like VIPC&S. The Virginia Code was amended to provide
civil immunity to those providing data to such organizations. Virginia also has in place a mandatory
reporting program for certain health professions that requires hospital
administrators and others to report unprofessional or unethical conduct of
professional incompetence that has been strengthened recently.
There is also a patient level data reporting system, in
place since 1993, that requires reporting of
“external cause of injury” by hospitals. This data, aggregated by the Virginia Health Information is coded
in a manner that permits some analysis of the incidence of medial error, but no
regular public reports are made from this data. An analysis by the staff of the General Assembly’s Joint Health
Care Commission in 2000 concluded “for the
years 1997 and 1998, surgical misadventures and adverse drug effects occur in a
small, but perhaps slightly increasing percentage of inpatient
hospitalizations.” The staff also
highlighted some limitations of the data and found that “greater evaluation is
warranted concerning whether the VHI patient level data base could be used,
either in its present form or with some modification, as the basis for greater
screening and surveillance, from a public health and health care purchasing
perspective, of adverse medical events and medical errors in Virginia.”
Virginia has not expanded its mandatory reporting system or
published any analysis of existing data on medical errors since the Joint
Health Care Commission study in 2000.
Despite a recommendation by the AARP in response to the staff’s draft
report, there is no annual report to the public regarding the efforts of
VIPC&S to gain improvements in patient safety or any other public report
and analysis of patient safety data that would permit the public to track
Virginia’s progress toward the IOM report goal of reducing medical errors by
It is clear that more can and should be done to enhance
patient safety and to reduce medical errors and preventable accidents and
injuries to patients in hospitals. Part
2 of this article will address some policy options under consideration in
Congress and in other states along with those recommended by the Joint
Commission on Accreditation of Health Care Organizations.