The Sorry State of Patient Safety

Since the Institute of Medicine’s by now famous report To Err Is Human was published in 1999, there has been enormous public attention and huge public and private resources devoted to patient safety.  All kinds of things have been promoted as silver bullets that will supposedly prevent thousands of patients from dying or suffering from preventable complications.  Billions have been spent on health care information technology (HIT) as well as initiatives to get health care staff to wash their hands, pay attention to which leg they are amputating, and make sure they are giving the right patient the right drug.  In spite of all this effort, time and money, things are not improving for patients.  In Mid April, of 2010, the Agency for Healthcare Research and Quality, released a report that compared rates of bloodstream infections between 2009 and 2010. The 2010 rate of bloodstream infections, the agency reported, increased by 8 percent in one year, while, in the same time period, catheter associated urinary tract infections had likewise increased (by 4 percent). There was good news, e.g., pneumonias were down.

In June, 2010, only two months later, two professors from Case Western Reserve published an article in The Berkeley Technology Law Journal with even more distressing news. Doctors, the authors, warned should be wary of the promise of electronic medical records. Software bugs, lack of adequate training in complex technology, incessant warnings of drug interactions with no real threats, and errors that generate the wrong output, all can create significant patient safety hazards for which physicians may be held liable. In the late summer, Rhode Island hospital was again cited for performing a wrong site surgery — one of several in a short span of time. And just last week, the New England Journal of Medicine published a sobering report by Christopher Landrigan and his colleagues. Landrigan who is a pioneer in the study of the impact of physician lack of sleep on both doctors and their patients, was the principle investigator on a study that looked at the progress of protecting patients from harm.  To assess this progress, the investigators looked at hospitals in North Carolina — a state that has demonstrated, as the authors put it, a “high level of engagement in efforts to improve patient safety.”

Did those efforts pay off?

Sadly not much.

Do the investigators think patient safety efforts around the country are working?

Not really.

The investigators conducted a six year study of ten hospitals in the state and sifted through 2300 randomly selected medical records of patients admitted to the hospital.  Too many patients suffered from harm.  Out of the 2300, 588 instances of harm were found, including, 14 deaths, 50 life threatening incidents and 17 instances of permanent problems.  Over the six year period, there was no significant reduction in harm to patients — this in spite of myriad patient safety initiatives.  Although the study focused only on North Carolina, the authors believe they can be applied to the rest of the country.

The conclusions of the study are worth everyone’s attention.  The investigators write that there has been so little progress because of lack of “penetration of best practices” into the health care context, as well as failure to implement even basic electronic medical record keeping .  A critical contributor to patient harm to which the authors point is the fact that “Physicians in training and nurses alike routinely work hours in excess of those proven to be safe.  Compliance with even simple interventions such as hand-washing is poor in many centers.”

I would add to this list that nurses and doctors all shoulder too high patient loads.  I know of nurses in North Carolina and other states who routinely care for 6,8 or even more patients and at night the workload skyrockets.  Doctors too are seeing too many patients for too short a time.  And, many patient safety initiatives are poorly designed because they fail to include front line workers in the design, planning, implementation, evaluation and refinement phases.

These issues and more are the subject of a book that I am editing with medical sociologist Ross Koppel.  Koppel and I  asked a number of patient safety experts  — Christopher Landrigan among them – to contribute essays on the “Inconvenient Issues in Patient Safety.”  The book will be out in the spring of 2012.

But don’t wait till 2012.  Read the Landrigan article and think about your own work if you are a health care worker or professional.  What is going on in your institution?  Do you get enough sleep?  Is your patient load too high?  Do you have time to think?  Do you have time to recover from an emergency?  Or an upset?  Or a patient death?  Do you have time for teamwork?  Are you fried when you leave the workplace?  We need to hear from you about all this and more.  If health care workers don’t talk about what is going on in the workplace more patients will be hurt.  Sadly, but inevitably, more will die.

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