Patient safety issues underscore the urgent need for incident reporting
Healthcare organizations are aware of the most common medical errors, but cultural change is a key in making progress in improving care.
In my commentary on patient safety in the last issue of HDM, I addressed the non-COVID cases that went untreated amid the pandemic. I noted that in the nearly two-year period through the end of 2021, nearly 100,000 more people died from non-COVID related diseases than would have died were it not for the pandemic.
Sadly, these deaths cannot be explained as consequences of the crisis; avoidable fatalities occurred with regularity before COVID struck. And now that the worst of COVID seems to be behind us, medical errors in hospitals continue to occur at an alarming rate.
Too many incidents
Before the start of the pandemic, one in 10 patients were harmed while receiving hospital care. Since then, there has been an increase in infection rates, no reduction in the number of overcrowded facilities, more staff burnout and shortages of providers. In some places, these continuing pressures may have generated an atmosphere of stress and depression, creating a mood that can easily affect the workplace – leading to less vigilance, more carelessness and far too many avoidable errors.
For example, it’s been recently revealed that an urban community hospital has been implicated in errors of neglect that allegedly contributed to the deaths of several patients. Nurses neglected to consistently monitor patients’ vital signs as they lay dying, doctors failed to give patients required medical assessments, the pharmacy took hours to fill potentially life-saving prescriptions, and the hospital failed to maintain equipment and follow infection prevention protocols.
This is an extreme example, but unfortunately, not an isolated one. A report issued in June 2022 by the Office of Inspector General in the U.S. Department of Health and Human Services, revealed that, in just one month, 25 percent of Medicare patients experienced what the OIG terms “adverse events and temporary harm events” during their hospital stays. The report says 43 percent of these events could have been prevented. Other data shows that avoidable medical errors are now the third leading cause of death in the United States.
This is shocking, and its significance mounts if we consider safety matters in other industries. In aviation, for example, an individual has a one in a million chance of being harmed while travelling on a plane, while the chance of a patient experiencing harm in healthcare is one in 300.
Categories of preventable medical errors
What kinds of errors are occurring in healthcare facilities? In a recent study compiled by RLDatix from several academic-level surveys, four factors were implicated in the nearly 800,000 medical errors that could have been averted in 2019.
Hospital-acquired infections. These include:
• Catheter-associated urinary tract infections
• Central Line-associated blood stream infections
• Infections following infusion, injection, and vaccination
Avoidable surgical complications. These include:
• Accidental puncture or laceration during a procedure
• Air embolisms during surgery
• Objects left in the body
Hospital medication errors. These include:
• Blood-type incompatibility
• Poisoning from drug interactions (wrong medication, wrong dosage)
Pressure ulcers. Specifically:
• Damaged skin caused by staying in one position for too long
These preventable medical errors could and do happen anywhere. But they are far more likely to occur in hospitals where standards have fallen, morale is poor and the administration of care has lost urgency.
Not all medical errors lead to fatalities, but preventable medical errors have that potential. And if we are to recover the urgency needed to treat this situation as the crisis it is, the healthcare community must acknowledge that errors were made; act to identify the source of the errors; determine who was responsible for the errors; and determine why they happened.
Above all, there is the enormously difficult task of gathering this kind of information. It is always difficult to admit a personal mistake. And it will always be difficult to blame colleagues if it appears to have been their fault. The percentage of individuals who say they would be willing to report mistakes they know about is about 13 percent.
The importance of perspective
In an influential study issued in 1999 by the Institute of Medicine Committee on Quality of Care in America, “To Err is Human: Building a Safer Health System,” several important insights were offered that remain relevant.
For example, the problem is not that there are bad people in healthcare -- it is that good people are working in bad systems that need to be made safer. The report does not – and we should not – point fingers at committed healthcare professionals who make honest mistakes. It challenges us to develop an agenda that can reduce medical errors and improve patient safety by designing a safer health system.
The title of the report points the way. Human beings, in all lines of work, make errors. Errors can be prevented by designing systems that make it difficult for people to do the wrong thing and easy for people to do the right thing. Cars are designed so that drivers cannot start them while in reverse because that prevents accidents. Work schedules for pilots are designed so they don't fly too many consecutive hours without rest; otherwise, their alertness and performance are liable to be compromised.
As healthcare and the system that delivers it become more complex, the opportunities for errors abound. Correcting them will require a concerted effort by healthcare organizations, purchasers, consumers, regulators and policymakers. Traditional clinical boundaries and a culture of blame must be broken down. But most importantly, we must systematically design safety into processes of care.
In a recent interview, Patricia McGaffigan, RN, vice president of safety programs for the Institute for Healthcare Improvement, offered useful observations that should help guide the quest for solutions. For example, she says healthcare organizations address patient safety via piecemeal initiatives when they should instead be developing broader, more systemic efforts. They apply standalone safety efforts to reduce a complication by a specific percentage. After the target is hit, they move onto other projects.
Or they may apply certain clinical and technical practices to reduce the high rate of catheter-associated urinary tract infections and then reduce the emphasis on them after the infection rate fails. These types of interventions unfortunately focus on patient-specific issues without considering that the organization needs to approach these matters much more broadly.
Still, there is an elephant in the room that can’t be ignored and may be the biggest impediment to improvement. Who will step up and report on the incidents? Who will have the courage to blow the whistle? The National Whistleblower Center says 31 percent of U.S. physicians say they are reluctant to report impaired colleagues, and 12 percent fear retribution for doing so.
This reluctance is understandable. To overcome it, healthcare organizations must replace the current culture that treats errors with retribution. Instead, they must encourage a workplace culture that eliminates shame, rewards those who come forward to share mistakes and provide desperately needed data about the mistakes that were made.