Big Surprise! More Bad News about Patient Safety
Last week the Boston Globe reported more bad news about patient safety. In an article entitled “Mass Hospitals’ Mistake List Widens”, the Globe reported that, “Massachusetts acute-care hospitals reported 753 serious medical errors and other patient injuries last year, a 70 percent annual jump that health officials attributed mostly to expanded definitions of what constitutes medical harm.
“So-called serious reportable events in other types of hospitals, including those that provide psychiatric or rehabilitative care, rose 60 percent from 2012, to 206.
“Instances where patients underwent a procedure on the wrong body part, were burned by an operating room fire or a too-hot heating pack, or were subject to contaminated drugs or improperly sterilized equipment saw some of the largest increases in reporting since 2012.
“Hospitals also reported more patient falls, serious bed sores, assaults, and suicides and suicide attempts.”
The article did not delve into the reasons for these disturbing statistics, except to suggest that perhaps increased reports were due to increased reporting. Is that supposed to be a plus? Asked whether this report was a sign that things are somehow getting better because hospitals are reporting more problems, Allan Frankel, (former head of patient safety at Partners Healthcare and now Chief Medical Officer at the wonderful Safe and Reliable Healthcare, along with my colleague Michael Leonard), responded candidly and emphatically,”No!”
Frankel is right. The questions that need to be asked when statistics like these are revealed are the following:
Are the hospitals in question doing team training in a systematic recurrent way?
What are their nurse to patient staffing ratios, the patient loads of their physicians, laboratory techs etc?
Who sleeps and when? Do nurses routinely work 12-plus hour shifts. Are resident physicians hour restrictions routinely violated? Are people afraid to speak up when they see a patient safety problem– like when they think a surgeon is about to operate on the wrong body part? Do hospitals use SBAR (see my last two blog posts) and other predictable patterns of communication? Do they use use surgical checklists, time outs, not just sometimes but all the time, not just sort of but really.
The list of questions could go on and on. The problem isn’t more reporting, the problem is less of the right kind of consistent systematic action on patient safety.
Thanks for publishing this alarming and serious problem. I think the points that you and Dr. FrankL are making are extremely important. This comes on the heels of a US Senate Subcommittee hearing in July where several experts offered testimony re: “Over 1000 preventable deaths per day in US hospitals”.
I would like to share my letter to the committee in response to the hearing in which I’m inviting a focus on the “Art of Safety” in addition to the “Science” of it. I believe it dovetails with your suggestions while offering another angle.
Open Letter to The Senate Subcommittee on Primary Health and Aging re: 7/14 Hearing on Patient Safety: “More than 1,000 Preventable Deaths a Day is Too Many”! http://bitly.com/1r7hN3W
Take care and thanks for your newsletter.