Patient Safety Missing from Health Reform Discussion

Janice Simmons, for HealthLeaders Media , May 26, 2009

Nearly 10 years ago, the Institute of Medicine released its report To Err Is Human: Building a Safer Health System, which put a spotlight on problems surrounding patient safety. Last week, a panel of providers and policymakers who initially experienced firsthand the impact of that report—which estimated that upward of 98,000 people died each year in hospitals due to medical errors—had a chance to reflect how the report exceeded or fell short of expectations during the intervening years at a meeting of the National Patient Safety Foundation Annual Congress outside of Washington.

Lucian Leape, MD, one of the authors of the report and an adjunct professor of health policy at the Harvard School of Public Health, said the early publicity over the report "really took us very much by surprise."

Overall, there were three messages to the report:

  1. This is a serious problem
  2. It's not bad people but bad systems
  3. This needs to be a national priority

"Unfortunately number three never happened, and that's the big disappointment," he said.

In the healthcare reform area, patient safety should be an important issue in the debate, but federal attention has not been there, said James Guest, who is president of Consumers Union. "I think it's critically important that in addition to access, in addition to cost savings, and in addition to other factors, patient safety really ought to be front and center in health reform."

Last week, Consumer's Union issued a report that said as many as 100,000 people still may be dying in hospitals because of medical errors. "There's really a dichotomy here," Guest said. At the macro level, many hospitals have "poured their heart and soul" into quality improvement efforts addressing patient safety. But at a macro level, the data and direction has not been there to address patient safety concerns.

Overall, more transparency and accountability are needed, Guest said. In places where hospitals are required to be more transparent with data reporting—such as in states requiring disclosure of hospital-inquired infections, they may face "some pressure and incentive to really do some things to make a difference," he said.

The IOM report also signaled the appearance of patient- and family-centered care in a new light, said James Conway, senior vice president with the Institute for Healthcare Improvement.

However, in his home state of Massachusetts, 10 patients died last year because of medication errors. "We have so much more work to do. And unfortunately, the news isn't shocking," Conway said.

One of the problems is that while great stories are told about individuals addressing patient safety concerns, "we don't have a collective urgency," to make changes now, Guest said.

For instance, more than 15% of the nation's CEOs in an American College of Healthcare Executives survey, said they don't go to sleep at night worrying about quality and safety as part of their first three priorities. "That's an enormous place where we need to go."

Carolyn Clancy, MD, the head of the Agency for Healthcare Research and Quality, said the IOM report "gave us a brilliant roadmap . . . but that roadmap needs to be updated periodically."

One area where she thinks the nation has "fallen down a bit" is establishing and updating "a national reporting system that right now would let us know across the nation how we're doing," she said. "There's still a lot of sensitivity about being transparent about all of this."

Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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