On July 17, 2014, the U.S. Senate’s Committee on Health, Education, Labor & Pensions Subcommittee on Primary Health and Aging held a hearing on the subject entitled, “More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.”
The Subcommittee Chairman opened the hearing by stating that preventable medical errors in hospitals is the third leading cause of death in the United States. He also referred to a recent study that estimates that as many as 440,000 people die from preventable medical errors in hospitals every year in the United States, and additional tens of thousands die from preventable medical errors outside of hospitals, from errors such as misdiagnoses and injuries from medications. And as many as 180,000 Medicare patients die from adverse medical events in hospitals each year in the United States.
The Subcommittee Chairman further noted that one in twenty-five patients acquire an infection while in the hospital, which led to 700,000 people getting sick and 75,000 people dying in 2011. Medical errors cost the U.S. health care system more than $17 billion in 2008. If you include indirect costs, medical errors may cost in excess of $1 trillion per year in the United States.
The Subcommittee Chairman stated, “Medical harm in this country is a major cause of suffering, disability and death as well as a huge financial cost to our nation. This is a problem that has not received anywhere near the attention that it deserves.”
Six individuals testified before the Subcommittee on July 17, 2014. Some of their testimony is quoted below.
John James, PhD, Founder, Patient Safety America, Houston, Texas, whose study on the prevalence of preventable adverse events was published in 2013 in the Journal of Patient Safety, testified that his estimate that more than 400,000 lives are shortened by preventable adverse events each year led him to conclude that patient safety is not going to improve substantially until the ‘playing field’ between the ill patient and the healthcare industry is leveled by an enforced bill of rights that would include the rights to legally defined and enforced right to give genuinely-informed consent; to know the safety record of their physician, outpatient clinic, nursing home, and hospital; to know costs for tests and elective procedures before hand; to transparent accountability in the case of an adverse event; to evidence-based care; to know when drugs are prescribed off-label; to be warned about bad lifestyle choices; to have an advocate present while hospitalized; and, to care by teams of professionals that build individual and team excellence through 360-degree performance reviews, which are anonymous reviews by patients, subordinates, colleagues, and leaders.
Ashish Jha, MD, MPH, Professor of Health Policy and Management, Harvard School of Public Health, Boston, MA, testified, in part, that “medical errors are largely the result of bad systems of care delivery, not individual providers … The strategy for improvement has to focus on three main areas: metrics, accountability, and incentives. Getting the metrics right may be the most important … But metrics and reporting alone will not be enough. We also need to make safe care part of the business of providing healthcare. And this requires incentives. In the current system, hospitals with high rates of medical injuries receive nearly the same compensation from Medicare as hospitals that cause fewer injuries. There is little to no incentive for hospitals to spearhead patient safety efforts … As the largest hospital payer in the country, Medicare can do a lot … with smarter metrics, greater transparency, more accountability and the right set of incentives, we can make big progress.”
Tejal Gandhi, MD, MPH, President, National Patient Safety Foundation; Associate Professor of Medicine, Harvard Medical School, Boston, MA, testified, in part, “Studies have shown that medication errors are common in primary care, and that adverse drug events, or injuries due to drugs, occur in up to 25% of patients within 30 days of being prescribed a drug … a key medication safety issue in ambulatory care, that is not an issue in hospitals, is non‐adherence. Patients do not fill one out of 4 prescriptions ‐‐ and these include prescriptions for important, highly prevalent chronic conditions such as high blood pressure and diabetes … Missed and delayed diagnosis is a key issue as well‐‐ this is the most common type of outpatient malpractice claim (usually missed and delayed diagnosis of cancer in primary care). Missed and delayed diagnosis is complex ‐‐ in one study, a single malpractice case had on average 3 steps in the diagnostic process that broke down and led to the missed diagnosis … Some of the most common breakdowns include failing to order an appropriate test, as well as failure to follow up on test results. The answer is not simply to tell clinicians to try harder or think better. Better systems are needed to help minimize cognitive errors ‐‐ failing to think to order a test ‐‐ such as computerized algorithms (also known as decision support). Better systems are also needed to manage test results ‐‐ ensuring that every test that gets ordered is completed and the provider receives the result, acts on it, notifies the patient, and engages them in their plan of care … we know that patients are vulnerable during transitions in care. These transitions occur all the time in health care ‐‐ hospital to home, nursing home to emergency department, rehabilitation center to visiting nurse. Transitions are high‐risk times, when key pieces of information (such as medication changes, pending test results, additional workups that need to happen) can be lost. For example, one study found that after hospital discharge, within 3 to 5 days, one‐third of patients were taking their medications differently than how they were prescribed at discharge. Another study showed that 40% of patients are discharged with test results that are pending (the final result has not come back) and these results are often not seen by the patients’ primary care providers … Clinicians need to be better engaged with patients to ensure that patients understand and agree with their care plan ‐‐ understand why the medication or test that is ordered is important for their care and understand what the plan is after leaving the hospital. This needs to be a partnership in order to really ensure that the goals of the patient are being met, and clinicians need to be trained to be better partners with patients … health information technology (HIT) is becoming ubiquitous in inpatient and ambulatory settings. We need to design better HIT systems to maximize patient safety benefits while minimizing new risks that can be introduced from these technologies.”
Peter Pronovost, MD, PhD, Senior Vice President for Patient Safety and Quality and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, testified, in part, “Medicine today squanders a third of every dollar spent on therapies that do not get patients well, that result from treating preventable complications, and that result from administrative inefficiencies and fraud. This is about $9000 per U.S. household … Our main policy effort to improve safety and quality is to pay for quality … We need to declare right now that preventable harm is unacceptable and work to prevent all types of harm, including harm from care that patient’s feel is disrespectful care, not just one harm. We need to start viewing the delivery of health care as a science. We need to stop relying on the heroism of our clinicians to ensure safety and start relying on well‐designed systems, just as every other high risk industry has done … some policy recommendations: Charge the Centers for Disease Control with developing, monitoring, and transparently reporting the incidence rates of the top causes of preventable harm … Invest more in career development awards for patient safety improvement … Support AHRQ to coordinate collaborative implementation science efforts to reduce harm … Create standards for the reporting of health care quality and cost measures by creating the equivalent of the Securities and Exchange Commission and Federal Accounting Standards Board for health care … Invest in systems engineering learning labs to improve productivity and safety in health care and ensure patient data belongs to the patient not the health information technology (HIT) companies … Once again do that great thing: Invest in patient safety; Ensure we can measure safety and develop other measures; Invest in training researchers to bring Engineering to Medicine; Invest in the science of health care delivery, including supporting learning labs to make the Boeing or Lockheed Martin of health care.”
Joanne Disch, PhD, RN, Professor ad Honorem, University of Minnesota School of Nursing, Minneapolis, MN, testified, in part, “My points are three: (1) the impact of preventable events – death and serious preventable complications ‐ is even more extensive than the gripping title of this hearing suggests … ; (2) it is possibly the most bi‐partisan issue that exists today – since many, if not most, of us here have likely had the experience of being a patient or family member who experienced one of these events, or will in the future; and (3) it is one of the few issues that money alone can not solve … I will highlight some of the key factors influencing patient safety, and make three recommendations which I know, from my 46 years as a nurse, make a difference: (1) assuring an adequate and appropriately educated supply of registered nurses at the bedside; (2) actively engaging patients and families as partners in their care; and (3) moving hospitals and other health care settings to embrace a safety culture and become high reliability organizations … Nurses are the cornerstone of the American health care system. Registered nurses form the largest element (2.6 million), with more than half (58%) working in medical and surgical hospitals … For nurses to make their optimal contribution to improving the safety of health care, there have to be enough nurses and they have to be equipped with the right educational preparation.”
Lisa McGiffert, Director, Safe Patient Project, Consumers Union, Austin, TX, testified, in part, “Transparency at the patient level is absolutely critical to ending medical errors. When patients are harmed, they often are subjected to additional harm when caregivers fail to disclose or explain what happened. Medical records are withheld or altered or never documented accurately. Many families have to file lawsuits just to get information about how their loved ones’ died. This is the underbelly of medical errors – the cover-ups and the insults to injury. We must create a more just and fair system that encourages discussions without requiring patients’ rights in exchange, that compensates patients for their losses and that treats them with dignity and respect … Consumers Union and many of the advocates with whom we work are supporting the creation of a National Patient Safety Board, modeled after the National Transportation Safety Board. We would welcome the opportunity to work with members of Congress to develop a plan for creating this oversight agency … Some additional recommendations are briefly listed below. More information about them can be provided upon request[:] Support the infrastructures needed for public reporting and tracking of infections and errors. For example, the CDC’s National Healthcare Safety Network (NHSN) collects information from more than ten thousand providers. We need to sustain this system and ensure that it can grow in capacity into the future. This should include funding to the states to validate data being reported; Expand hospital infection reporting so that infections are being documented throughout the hospital and consumers have a clear picture of a hospital’s overall infection rate; Mandates are needed for antibiotic stewardship; Require hospitals to report on antibiotic usage and resistant infections using CDC-NHSN’s new modules for this purpose; Require medical error reporting. Electronic billing records could be used as a resource for documenting these events by improving their accuracy. Create a rigorous validation process that includes fines for hospitals that fail to accurately document patient stays; Require death certificates to indicate when infections or errors are the cause of death and document the presence of these events preceding or at the time of death; Hospital infection outbreaks should be disclosed to the public, the patients in the hospital, and patients being admitted; Make the National Practitioner Data Bank public so patients can refer to it to check on physicians that have licenses in multiple states; Continue adding measures to Medicare pay for performance programs and consider standardizing how incentives and penalties are calculated. Keep the programs growing but simplify the calculations.”
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