5 Scary Things About Healthcare Quality

Cheryl Clark, for HealthLeaders Media , October 31, 2013

"It should be no surprise that preventable adverse events that harm patients are frighteningly common in this highly technical, rapidly changing, and poorly integrated industry," he wrote. "The picture is further complicated by a lack of transparency and limited accountability for errors that harm patients."

And many of these deadly errors may not even be considered errors by the people who make them.

James draws these conclusions based on studies that used IHI's Global Trigger Tool to flag suspicious findings in medical records, "such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient."

He also extrapolated data from two Office of Inspector General reports and a North Carolina study that quantified these events for limited periods of time or small numbers of hospitals.

James cites the particularly disturbing survey findings of Eric Campbell, Director of Research at the Mongan Institute for Health Policy at the Harvard/Massachusetts General Hospital, published in the Annals of Internal Medicine a few years ago.

Campbell found that physicians said they "often refuse to report a serious adverse event to anyone authority." Cardiologists in particular, who as a group exhibit "the highest nonreporting group of the specialties studied," said they had "recently refused to report at least one serious medical error, of which they had first-hand knowledge."

Obviously, James says, this is "clear evidence of such unreported medical errors [that] often did not find their way into the medical records" of harmed patients.

To me, this is macabre.

2. A Cascade of Errors

It's not only deaths due to medical errors that are regrettable. Patients who survive adverse events can be harmed in ways that will haunt them for the rest of their lives.

1 | 2 | 3 | 4 | 5

Comments are moderated. Please be patient.

3 comments on "5 Scary Things About Healthcare Quality"

Suresh Nirody (11/1/2013 at 2:53 PM)
He didn't actually "count" anything... He looked at four studies(covering 4,252 records reviewed, which were associated with a total of 38 deaths) and then extrapolated their rates to the total 34.4 million discharges in 2007 to get his lower boundary... Beyond the deaths he estimates a mind-boggling 2-4 million serious adverse events (not resulting in death) a year! What IS shocking is that the 1999 IOM report was based on data from studies in 1984, and this latest report is based on years old data as well. It is an indictment of the system that analysis of something so important has to rely on such old data! Also, given the magnitude of the numbers discussed, I've been completely amazed to NOT have seen any analysis of this report, either to support or to disagree with the methodology and his numbers and conclusions... Surely there are learned people who can, and should, do this!

Lisa Sams MSN, RNC (11/1/2013 at 1:27 PM)
Cheryl, thank you for highlighting the James article. The doctor consider "father" of patient safety is confident in the analysis. And you raise an important question about the level of interest in harm and death that occur during a hospital stay. Unless it happens to someone we know....or to ourselves....I believe we have learned to ignore the data because it is One Person at a time. Many attempt to tell their story and organizations like the Walking Gallery offer visual representation of lost or harmed loved ones. These are system issues, as mentioned in other comment. But calling it a system problem does not remove the provider, administrator and other staff from the analysis. As a long time advanced practice nurse, I see the value in system analysis and development of a plan that can be tracked until the culture change is truly integrated into care. If we can reach critical mass with patient communities and clinicians sharing information, collaborating and basically taking charge of the problem it will change. No clinician goes to work looking to cause harm and when it happens it is devastating. It is time to share basic information with patients and families in how to stay safe in the hospital, to push back, to question and when necessary engage the CEO through a Risk Management report...done on a scrap of paper is all it takes. Yes, these are complex system issues but if your spouse, your mom or your child is not receiving the care you think they should then push and push hard. We have a good history of patient community driving change in the 60's & 70's. It was women who changed our closed doors and drug induced hospital births to family centered care. They became educated and expected more.

stan davis (10/31/2013 at 7:15 PM)
very irresponsible to write "He says that at least 210,000 deaths a year in the U.S.[INVALID]and as many as 440,000[INVALID]can be blamed on provider mistakes". nowhere in the paper does it state this as "provider mistakes". the errors are part of a system, and requires a system approach to fix.




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