Since To Err Is Human was published, a great deal has been done to improve patient safety. Hospitals have started to model themselves after other high-risk industries that manage to maintain stellar safety records. Companies that experience less than one in a million disasters, in spite of their high-risk operations, are referred to as high reliability organizations, or HROs. Even though most American hospitals now follow the same steps HROs use to build cultures of safety in their facilities, this has not been enough. Through improved monitoring of patient safety events, it has become evident that nearly half a million (or more) hospital patients in the United States die each year as a result of preventable errors—more than twice the rate of harm originally estimated by To Err Is Human.
Preventable medical mistakes are now one of the leading causes of death in our country, far ahead of deaths due to auto accidents or almost all diseases that modern medicine seeks to treat. Any other industry that inflicted so much harm on its customers would be declared catastrophically unsafe, and it would be shut down or boycotted altogether. Perhaps it’s no wonder that disillusionment or project fatigue have begun to set in among healthcare professionals and that there has been recent Internet chatter about the patient safety movement flickering out. But giving up on patient safety is not an option.
Besides its human toll, this crisis is financially untenable. On an annual basis, patient safety events result in billions of dollars of direct healthcare charges, and about one-quarter of these involve out-of-pocket expenses. Taking into account indirect costs for lost workdays and short-term disability claims, the total outlay for healthcare-induced harm is estimated to be over one trillion dollars annually.
In any given year, all of us are likely to have someone we love be hospitalized, or be hospitalized ourselves—perhaps to deliver a baby, recover from an illness or injury, replace a joint, treat cancer, or repair a cardiac condition. Thus we all have a stake in making hospitals and other healthcare facilities safer. We, the public at large, represent the industry’s customer base, and yet the patient safety movement has treated our involvement largely as an afterthought. Getting a handle on any organization’s safety always requires employee engagement, which hospitals have sought to address with varying degrees of success. But when it comes to healthcare, consumer engagement is also of paramount importance because the industry’s customers become a dynamic part of the system the moment any of us walk or are wheeled through the hospital doors.
To be fair, healthcare has become increasingly sensitive to the need for and benefits of greater patient engagement. Experts now admonish us to speak up for safety. But this amounts to too little too late, especially when our safety instructions are first delivered during the anxiety-ridden hospital experience. It is about as effective telling a child how to behave once he is in the throes of a temper tantrum. Rather than receiving eleventh-hour and generic guidance about our role in safety, we need to be prepared to take specific actions to protect our loved ones and ourselves long before we are confronted with a hospital visit.
Ironically, at this juncture, much of the work that needs to be done to make hospitals safer must take place outside of them, in the communities where we live and work. You might wonder how the public could possibly help make the complex and complicated process of delivering hospital care safer, but we can. In fact, directing public efforts toward preventing just three types of patient safety events could reduce unnecessary hospital deaths considerably—perhaps by as much as 50 percent over a five-year period, which is a national goal that was set in 2000 and that healthcare has never come close to achieving.
Three issues that make sense to immediately tackle through public engagement are hospital-acquired infections, off-the-mark procedures (also called wrong-site surgeries), and medication administration errors. Together, these three categories of harm represent the most prevalent, predictable, and preventable medical mistakes—a trifecta of sorts.
If it seems hard to believe that tackling just these three problems alone could dramatically downshift the magnitude of the crisis, consider the fact that each year one hundred thousand people die from infections that they pick up as a result of their hospital care. That is a sizable portion of all preventable instances of hospital-induced deaths. Medication errors are another leading cause of preventable death in hospitals, with a third of all such errors occurring during the bedside administration of drugs. As a category, off-the-mark procedures don’t occur nearly as often as medication errors or hospital-acquired infections; however, every off-the-mark procedure signals, like a bellwether, that something might be seriously wrong with the healthcare delivery system.
Here, though, is what is special about the identified trifecta of safety issues. In addition to being prevalent, predictable, and preventable, these events can be avoided with simple, quick, and essentially cost-free behaviors that are performed during almost every patient encounter and in eyeshot of patients. They are essential and visible routines; however, for a myriad of reasons, providers don’t employ them or don’t do so consistently. If the public were to realize the use of these habits could mean the difference between life and death, who wouldn’t make sure they were employed?
Mastering key safety habits is something every healthcare provider must do, something every patient wants them to do, and something the public can help them do. I learned early in my career as a clinical and pediatric psychologist that changing the behavior of a troubled child is highly dependent upon changing the behavior of the adults around the child. So it goes with patient safety. In order to change the behavior of healthcare providers, we must influence the behavior of the patients around them. But we must also prepare providers to react approvingly when we do catch them having a momentary slip or lapse or the impulse to take a shortcut. In other words, education for the public must be tightly coupled with interventions that target healthcare professionals.
Developing a comprehensive strategy to unite patients and providers around the use of concrete safety habits represents the only realistic way to achieve consistent performance of safety routines that might seem too simple to matter. Community coalitions are a proven method for raising public awareness, motivating civic action, and promoting specific health-related behavioral change across large groups of people and organizations, but they are conspicuously absent from the patient safety movement. A key to their success is the ability to prioritize goals and objectives according to local interests and resources. Building a local patient safety coalition requires considerable and coordinated effort on the part of healthcare organizations, public health practitioners, and diverse community groups—but such work pays dividends. Successfully reducing the current safety trifecta (or any one of its component problems) will build momentum, confidence, and the capacity to tackle other pressing safety issues, including, for example, the American opiate epidemic and related heroin crisis. In the process, our trust that healthcare providers can reliably deliver safe care might be restored.
When things do go wrong, more than anything else, patients and families desire an apology, but the prevailing reaction of hospitals and providers is to deny their mistakes. For patients and families, such dishonesty adds insult to injury. Although medical mistakes are common, instances of reckless negligence are rare. Most medical mistakes involve honest human error, and this is as true for hospitals as it is for most nursing homes, freestanding surgical centers, and outpatient clinics. When a serious mistake happens, the event can be traumatizing for providers, especially if they are unable to be honest about what went wrong. The agony providers carry with them often leads to burnout that, in turn, undermines their ability to offer quality and safe care.
A few trailblazing hospitals and providers have shown us a better way. Their work proves that when hospitals and providers fully disclose adverse events—meaning that they admit their mistakes, learn from them, and apologize for them—everybody benefits. Patients and providers recover more quickly,
and the number of malpractice claims, settlement costs, and administrative fees are reduced. Support for this sort of honest and open communication is gaining momentum and legislative backing, but there is still a long way to go.
From personal experience, I know how healing a timely and genuine apology can be. It might have been the only thing that suppressed an otherwise litigious family member’s desire to sue the physicians and hospital that harmed my daughter. Fortunately she survived, but far too many families suffer more tragic hospital encounters.
My daughter lying in a coma after a medical mistake.
The sooner we accept the imperfect nature of healthcare and learn from our mistakes, the quicker patients and providers might forgive each other and themselves, and the better we can all recover from the physical, emotional, and financial wounds these errors inflict. By recognizing that we are all in this together, we can do a better job keeping patients and those who care for them safe from unnecessary harm.
I wrote this book because I am convinced public engagement through the creation of community coalitions can accelerate improvement in patient safety across the United States. Your Patient Safety Survival Guide presents a blueprint that can be adapted to meet the needs and interests of various hospitals and communities. Regardless of one’s interest in forming a coalition, this book offers information and action plans to help safeguard individual patients and healthcare providers. It draws on personal experiences, although names of real people and organizations have been disguised unless the incidents were previously publicized.
Chapter 1
Help Me, Heal Me, Don’t Harm Me
How Healthcare Frequently Injures Patients
There is no single medical intervention that will ever save as many lives as patient safety improvement. There is so much harm going on.1
—Donald Berwick, MD, Institute for Healthcare Improvement
The task is . . . not so much to see what no one has yet seen; but to think what nobody has yet thought, about that which everybody sees.2
—Erwin Schrödinger (1847–1961)
The Magnitude of the Patient Safety Crisis
If you aren’t concerned about being treated (or working) in a hospital, you should be. Keeping people safe during the delivery of healthcare is one of the greatest challenges facing modern medicine. In spite of the best intentions and Herculean efforts of millions of American doctors, nurses, pharmacists, allied health professionals, and patient safety advocates, at least 440,000 patients die needless deaths in US hospitals each year.3
For those who don’t relate well to dry statistics, this means that medical errors are now the third leading cause of death in the United States—far ahead of deaths due to auto accidents, diabetes, and everything else except cancer and heart disease.4 As one healthcare leader put it, these numbers mean “hospitals are killing off the equivalent of the entire population of Atlanta one year, Miami the next, then moving to Oakland, and on and on.”5 The equivalent of four Vietnam Memorials would need to be built each year to capture the names of US hospital patients who die as a result of hospital-induced harm.
We would consider any other industry that inflicted harm on so many of its customers to be catastrophically unsafe. The reality is any business with such a track record would be shut down or boycotted. But healthcare confers innumerable benefits, such that it is deemed essential to life. Thus, boycotting hospitals and locking their doors are not viable options, and we must bear the mistakes and associated costs until we make healthcare safer.
An initial estimate of the financial impact of the patient safety crisis indicated it totaled around $5 billion annually, about one-quarter of which involves out-of-pocket expenses.6 However, that figure is outdated and probably always represented a gross underestimate of the true cost of medical mistakes. A more recent analysis, which included a greater number of studies and more comprehensive data-capturing methods, indicated that the excess cost related to hospital-acquired infections alone—just one of many patient safety problems—would be between $28 billion and $45 billion annually in 2007 dollars.7 In today’s dollars, this would equate to between $32 and $52 billion annually. And when the indirect costs for lost workdays and short-term disability claims are accounted for, the total outlay for healthcare-associated infections may be as high as $1 trillion annually.8
As astounding as these figures are, they represent conservative estimates—not exaggerated claims—and they do not tell the whole story. Over the past five years or so, most US hospitals have implemented electronic health record systems. These systems have made it possible to more accurately determine how often healthcare causes harm to patients. Information extracted directly from patients’ hospital records indicates that the problem is ten times higher than previous estimates: one out of every three hospital patients is inappropriately harmed during the process of receiving care.9
Rates of harm are incomplete, whether they are generated from voluntary reports or from information extracted from electronic medical records. First, both methods tend to overlook errors of omission and diagnostic errors that only become evident in the days, weeks, and months after patients leave the hospital. Research indicates that one in five patients will experience an adverse event after being discharged from the hospital—and many of these will represent what should have been preventable return visits to an emergency department or hospital readmissions.10 Second, neither method tallies the harm that occurs as a result of mistakes made in freestanding surgical centers, nursing homes, or outpatient clinics. Finally, the majority of American physicians acknowledge that they sometimes choose not to report serious medical errors of which they have firsthand knowledge,11 and some alter records or leave them incomplete to obfuscate the evidence of harm.12
Healthcare providers may perpetuate harm; however, sometimes they also are secondary victims of patient tragedies. Among physicians who have been involved in a serious safety event, up to two-thirds report that the experience undermined their job confidence and satisfaction.13 Many providers experience lingering anxiety, guilt, and fear—emotional devastation that causes some to perform suboptimally or leave the field altogether. Although medical mishaps can shake providers to their core, we do a poor job of alleviating their trauma or the related problems of burnout and on-the-job physical injuries. Hospitals are one of the most hazardous places to work, with an employee injury rate that is nearly twice as high as all private industries combined. “It is more hazardous to work in a hospital than to work in construction or manufacturing.”14 None of this type of hospital-related suffering is considered when assessing the magnitude or cost of the patient safety crisis.
Whatever the ultimate magnitude of healthcare-induced harm, there is universal agreement that it is far too great.15 Before there can be any real hope of curtailing this epidemic, more providers and consumers of healthcare must take charge.
What a Patient Safety Event Looks Like
To be clear, we are not talking about people dying from the illnesses that caused them to seek treatment in the first place. We are also not talking about complications that result from procedures where known risks are perceived as worthwhile compared to the likely outcome if the procedure is not performed. Patient safety events refer to wrongful events of healthcare-induced harm and death. These events are not due to breakdowns in complex medical decision making or the lack of access to care. Most often, patient safety events involve basic human and system error. “None of us is ever very far from a terrible medical mistake.”16 So, what does a terrible medical mistake or a patient safety event look like?
It is the teenager whose skin and organs have been ravaged and permanently deformed by a superbug infection that he picked up in the hospital because people neglected to wash their hands.
It is the mother-to-be who had the wrong embryo transplanted into her womb because the in vitro clinic didn’t use the universally approved preoperative
checklist, leaving the mother to cope with a court order to share custody of the child with a complete stranger—the man whose sperm was used to create the embryo that grew to be her baby.
It is the newborn whose heart stops after receiving a medication dose that was calculated for an adult because an overworked pharmacist made a mistake and a nurse did not double-check the order before injecting the drug into the baby’s IV.
Every single day, these errors kill one thousand hospital patients and cause serious harm to another ten thousand to twenty thousand. Nobody is immune—not doctors, nurses, or hospital CEOs. It happens to newborn babies, pregnant mothers, and the elderly. It has happened to me, and it could happen to you.
The Underreported Disaster and Its Untapped Resource
In an average week—week, not year—more patients will die from the care they receive in US hospitals than the total number of people who died in natural disasters between 2005 and 2015, including Hurricane Katrina and the massive earthquakes in Nepal. Among the nine deadliest natural disasters since 1900, only the great China Flood of 1931 had a death toll that surpasses the weekly rate of preventable death in American hospitals. While hurricanes, tsunamis, earthquakes, and other natural disasters make national news and receive round-the-clock coverage, the patient safety death toll climbs week after week with scant media attention or public awareness.
Along with the press coverage of natural disasters comes thousands of people who freely give their time, talent, and resources to help stabilize the situation and heal the afflicted. If the American public understood the magnitude of the patient safety crisis and had a clear idea of how they could make hospitals safer, they would offer a helping hand. But here’s the rub: even if the public stepped up to help, healthcare workers aren’t prepared to accept their help. That is why I decided to write this book—to help prepare patients to act as genuine partners in safe care while also encouraging providers to embrace this help.
Your Patient Safety Survival Guide Page 2