On July 17th the United States Senate Subcommittee on Primary Health and Aging met to discuss the leading causes of death in the US. The first two, heart disease, 597,000 and cancer, 574,000 came as no surprise. However, the third leading cause, preventable medical errors in hospitals, 440,000 a year or more than 1000 per day is unacceptable. Tens of thousands more died outside of hospitals from misdiagnosis and medication errors.

These errors cause human suffering and cost US healthcare more than $17 billion. When you include the indirect cost it is more than $1 trillion. This is not just a US problem, it is taking place all over the world. The panelists invited to discuss the issues: John James, Tejal Gandhi, Peter Pronovost, Ashish Jha, Joanne Disch, and Lisa McGiffert, recognized leaders in patient safety, and offered suggestions to improve the problem. Foremost is that medical harm has not received the attention it should have.

The American health care system cost about 50% more than the most inefficient systems in the world and the price is paid in hundreds of thousands of American lives. However, in terms of healthcare we rank somewhere in the middle of the pack in patient care.

Solutions offered by the panelists included:

  1. Senate should establish a standalone committee for patient safety.
  2. Expand CDC efforts in identifying, tracking and reporting preventable infections and develop validated metrics to identify and report issues.
  3. ID better measures for patient safety in ambulatory setting and redesign health care from a human factors perspective.
  4. Set up a follow-up method for patients being dismissed to ensure they understand how to take their medications and what they are suppose to do.
  5. Develop a reporting system to follow-up on non- filled prescriptions.
  6. Develop a better system to minimize primary care.
  7. Incentivize payers to have a more active role in reporting and identifying problems.
  8. Improve data collection and develop validated metrics.
  9. Misdiagnosis of outpatients is a primary area of concern but no way to identify. Investigate.
  10. System to identify failure to order and follow up on test results.
  11. System to share all information with patients.
  12. Create standards for the reporting of health care quality and cost measures by creating the equivalent of the Securities and Exchange Commission and Federal Accounting Standards Board for health care.
Pronovost stated that “Today there are no standards for publically reporting performance measures or using them in pay for performance programs. We need a system that identifies all preventable harm, not just those that fit into a narrow definition.”

One panelist stated the most frequently identified causes of sentinel events reviewed in 2013 were Human factors (635), Communication (563), Leadership (547), Assessment (505), Information management (155), Physical environment (138), Care planning (103), Continuum of care (97), Medication use (77) and Operative care (76). The first three factors relate to people:

  • Human factors - staffing levels, staffing skill mix, staff orientation, in‐service education, competency assessment, staff supervision, resident supervision, medical staff credentialing and privileging, rushing, fatigue, distraction, complacency, bias.
  • Communication - oral/written/electronic, among staff, with/among physicians, with administration, with patient or family.
  • Leadership - organizational planning and culture, community relations, service availability, priority setting, resource allocation, complaint resolution, collaboration, standardization and best practices, inadequate policies and procedures, non‐compliance with policies and procedures.
As for changing policy, there needs to be a clear chain of accountability; clear communication; an educated board, not just in finance but patient safety; have CEO pay tied to compensation and develop a program where senior team share success stories in their hospital and across their systems. These were a few of the outcome measures panelist felt needed to be addressed to achieve patient safety. They also felt that there should be a public reporting system for those hospitals with unacceptable error rates in infections, deaths and negative outcomes.

There are some success stories. For example, automated workforce solutions allowed Anderson Regional in Mississippi to make agile staffing decisions based on organizational needs and census resulting in safe and effective staffing, improved productivity and $2.5 million in reduced labor cost in eight months.

Policy issues of high reliability and reporting within the organization and transparency without penalty need to be established. Right now we are failing our healthcare professionals and their patients. Developing standards of education, practice and accounting need to be addressed.