The #1 Hospital Error

Medication mix-ups and surgical instruments left in a patient's body may get most of the media's attention, but it's a little-known error called "failure to rescue" that costs more in terms of fatalities than any other US hospital mistake. When nurses or other caregivers don't respond to

“A hospital is no place to be sick.”—Samuel Goldwyn

Medication mix-ups and surgical instruments left in a patient’s body may get most of the media’s attention, but it’s a little-known error called “failure to rescue” that costs more in terms of fatalities than any other US hospital mistake.

When nurses or other caregivers don’t respond to symptoms that indicate that a patient is in danger of dying from preventable complications, the result is a death that could have been avoided. According to a report from HealthGrades, a healthcare rating organization, failure to rescue claimed the lives of more than 188,000 hospital patients between 2004 and 2006, a rate of 128 deaths per 1,000 at-risk patients. According to the Patient Safety in American Hospitals Study, it was the top patient care risk for the fifth constructive year.

“Failure to rescue is not whether you get the wrong IV in the first place,” explains Sean Clarke, PhD, the associate director for the Center for Health Outcomes and Policy Research. “It’s how fast do people pick up that you’re going south and turn it around? It’s the basics. It’s about breathing, it’s about circulation, it’s about bleeding. Breathing issues are a huge, huge, huge deal.”

Although many patient advocates call for more and better trained nurses to solve the problem, Michael DeVita, MD, professor of critical care medicine at the University of Pittsburgh School of Medicine believes the most effective solution is to use rapid response medical teams that can respond quickly when monitors detect that a patient’s symptoms show that he/she is in crisis.

The concept of rapid response has cut the number of unexpected deaths at Dr. DeVita’s hospital from 6.5 per 1,000 admissions to half that number, a success story that has not gone unnoticed by the Joint Commission, the national hospital accreditation agency. The Joint Commission now requires hospitals to have a system in place that identifies patients who are in danger and provides an immediate response.

238,337Number of potentially preventable hospital deaths from 2004 to 2006.(HealthGrades, 2008)