Healthcare Hygiene magazine January 2020 | Page 35

patient safety & quality
By Kathy Warye
20 Years After the Patient Safety Revolution
N
ovember of 2019 marked the 20th anniversary of To
Err is Human, the groundbreaking report from the
prestigious Institute of Medicine on the state of patient safety
in U.S. hospitals. Developed by a panel of highly credible
leaders from across the spectrum of care, the report found
that approximately 44,000 to 98,000 people died each year
from preventable healthcare harm. It was nothing short
of a clarion call for transparency and improvement. At the
institutional level, the code of silence around preventable
error had been broken.
Prior to the report, “the general belief was that medical
errors came about because of impaired physicians,” said
William C. Richardson, PhD, MBA, president-emeritus of
Johns Hopkins University. But, in contrast to that belief,
To Err Is Human shed light on the systems of care, finding
that medical errors occur because of problematic healthcare
systems or “non-systems” as the report stated, marked
by a combination of factors including decentralization,
fragmentation, faulty processes and conditions that caused
healthcare workers to make mistakes.
Notable is the fact that the report gave scant attention to
healthcare-associated infections (HAIs). Several years after
publication of the report, estimates of HAIs alone eclipsed the
estimate of total number of medical errors. While progress
has been made, HAIs still present a formidable challenge to
safety. Due in part to the application of systems thinking,
reduction of central line bloodstream infections (CLABSI)
represents an improvement bright spot. In 2018, CDC
reported a 45 percent reduction in CLABSIs nationwide.
According to the Agency for Healthcare Research and Quality
(AHRQ) National Scorecard, healthcare-associated conditions
(HACs) decreased overall by 21 percent between 2010 and
2015. This represented a total of 3.1 million fewer HACs
contracted by hospitalized patients over five years, saving
an estimated 125,000 lives and $28 billion. Together, these
findings represent substantial progress.
However, the data around SSIs and other forms of harm
paints a very different picture. AHRQ reported no reduction
in the set of SSIs reported to the National Healthcare Safety
Network between 2015 and 2018. And new challenges
have emerged such as those related to ambulatory care.
Almost two decades after the research was conducted
that formed the basis of the report, a study in the Journal
of Patient Safety estimated the true number of premature
deaths associated with preventable harm at more than
400,000 per year. 1 And serious harm was estimated to be
10- to 20-fold more common than harm resulting in death.
In 2015, a panel of top health leaders gathered at the
National Academy of Sciences to review the progress since
To Err Is Human was released, and to discuss challenges
and opportunities in patient safety. The group issued nine
specific recommendations.
www.healthcarehygienemagazine.com • january 2020
➊ Establish a federal agency for safety in medical care
similar to the Federal Aviation Agency (FAA)
➋ Include patients and families in efforts to improve
patient safety. CMS now involves patients and families in all
its quality measurement and development work
➌ Ensure that medical facility CEOs and boards of
directors make patient safety and quality care top priorities
➍ Develop agreement on how much and what needs to
be reported in order to standardize quality-of-care metrics
and transparency
➎ Extend efforts to improve quality and safety beyond
hospitals to ambulatory and long-term care settings
➏ Ensure non-punitive, supportive cultures that foster
patient safety, including incorporating nurses in the planning
and implementation of patient safety efforts
➐ Establish more coordination of care to prevent medical
errors, including interoperability of electronic medical records
➑ Use a systems-engineering approach to health
care delivery, which aims to prevent errors through
safety-oriented design
➒ Take advantage of healthcare workers’ intrinsic
motivation to improve patient safety and quality of care.
To the list above, I would add one more recommendation.
By shining a spotlight on our healthcare institutions, the
media played a critical role in driving new standards of
transparency and accountability. For a decade after the
release of To Err is Human, there was considerable media
attention to the problem of healthcare-associated infections
and medical harm in general. In the intervening decade,
however, our national attention has turned primarily to
the issue of insurance, the uninsured, underinsured, the
fate of the Accountable Care Act and finding a sustainable
solution to access and cost. Other than occasional, mostly
negative headline worthy incidents, preventable harm and
HAIs are no longer in the news. While there is perhaps no
more important challenge in healthcare today than access
to affordable care, as patient safety advocates, we need to
keep the issue of preventable harm in the forefront of our
national healthcare dialog. With the emergence and growth
of resistant organisms, few issues are of greater consequence;
and while much progress has been made since 1999, there
is still much to be done.
Kathy Warye is the founder and CEO of Infection
Prevention Partners where she provides strategic guidance
on the commercialization of solutions that detect, prevent
or manage infection.
Reference:
1. James JT. A New, Evidence-based Estimate of Patient Harms Associated
with Hospital Care. J Patient Saf. Vol. 9, No. 3. September 2013.
35