More than a decade after the landmark IOM report on health care quality and patient safety, preventable adverse events are still a major problem.
One in seven hospitalized patients suffer iatrogenic harm; almost half of unexpected adverse events (UAEs) are deemed "clearly or likely preventable." Preventable events fall into three broad categories: 1) insufficient patient monitoring, 2) medical or surgical errors, and 3) substandard care. Examples of these include, but are not limited to, problematic combinations or poor timing of medications, dosing errors, bleeding, intravenous mistakes, infection, and unanticipated problems with or after surgery.
Although serious mistakes such as operating on the wrong extremity or organ are “never should happen" events, they actually represent less than 1% of all adverse events according to the Office of the Inspector General for the Department of Health and Human Services. However, the New York Times article “Mistakes Chronicled on Medicare Patients” reports that the HHS says all UAEs collectively contribute to 180,000 deaths a year and contribute about $4.5 billion to health care costs borne by the government. The Institute of Medicine estimates that 44,000-98,000 Americans die in hospitals from preventable medical errors in the United States annually.
In "Medical Errors Take 15,000 Seniors' Lives a Month: Inspector General,” we re-learn the unfortunate reality -- patients cannot find comparative or normative statistics upon which to base their decisions about hospital care; they cannot even find out how well a hospital identifies and addresses medical or surgical errors.
For a definitive treatise on the subject of quality improvement, read "Corrective Action Plans in "Medical Errors and Patient Safety,” by Joseph L. Halbacj, MD, MPH, and Laurie Sullivan, PhD, CSW.
Next week's post “Quality Suffers; 10 Steps to Improvement,” will explore the opportunity and the fundamental importance of aligning payment and quality to motivate improvement.