Some years ago, a nurse paged me at 3 a.m. from the hospital because a patient of mine had spiked a high fever. Suspecting an infection, I called in antibiotics. A few hours later, the frantic nurse called to say my patient had turned red and was wheezing, likely from an allergic reaction.
I rushed to the hospital, and saw my own note in the patient’s chart stating that the patient was allergic to the antibiotic I had just ordered.
Overcome with shame and guilt, I realized I had made a preventable medical error. And so had the nurse who had missed seeing the patient’s allergy-warning wristband before administering the antibiotic through the IV, and so had the pharmacist who had neglected to check the patient’s drug allergy list before dispensing it.
Some months ago when I was on call during the weekend and seeing my sixth consult, I inadvertently ordered a penicillin-family drug for a patient with a penicillin allergy. This time the pharmacy’s software flagged the potential error and I changed the drug.
Despite the best of intentions on the part of physicians, nurses, pharmacists and all the others who care for patients in hospitals, errors that threaten a patient’s well-being remain common. Over the past decade as a hospital-based physician, however, I have noticed great efforts to improve patient safety. The software now in use at my hospital’s pharmacy is just one example of processes that have been changed successfully to better protect patients.
So I was astonished when a federal inspector general’s report on hospitalized Medicare patients released some months ago found that one in seven patients experienced an adverse event such as excessive bleeding, a hospital-acquired infection, aspiration pneumonia or an allergic reaction. When extrapolated to the general population, these events — some preventable and some not —
lead to an estimated 180,000 deaths in the United States each year.
Another study published in the New England Journal of Medicine, which examined 10 North Carolina hospitals, found that “harms (in hospitals) remain common, with little evidence of widespread improvement” from 2002 to 2007.
For me, these findings raise two critical questions: Why do adverse events happen in the first place? And why, after a decade of effort, have we not been more successful in lowering the number of adverse events in hospitals?
An analogy may help. Adverse events in the hospital, which can include medical errors like a drug overdose or side effects like a drug rash, are much like car accidents. The problem is complex, and the solutions require massive redesign of hospital systems and significant behavioral changes by individuals.
To reduce car accidents, system changes might include installing reflectors between lanes and redesigning dangerous intersections. Similarly, at hospitals, the use of checklists and electronic medical records are system changes designed to reduce adverse events.
On an individual level, motorists reduce road fatalities when they do not text or drink while driving. Similarly, in hospitals, doctors and nurses reduce adverse events when they dutifully perform hand hygiene and watch for drug interactions.
The major reason so many deaths occur on the roads and in hospitals, of course, is that both are inherently hazardous places. I am disturbed that 1.5 percent of the hospitalized Medicare beneficiaries who experience an adverse event die each year. But I also recognize that many elderly patients are so ill that despite our best error-free care they might well die anyway, and they would most certainly die without hospitalization. So to an extent, I see the adverse events at hospitals as collateral damage.
I asked a colleague who is the director of quality improvement at a local hospital why there are so many adverse events in hospitals.
In a thoughtful e-mail she replied. “There is no other situation where people from so many diverse backgrounds and skill levels come together every day to carry out a common mission with so much stress, so many high-tech processes, relying heavily on low-tech manual interventions, which are regularly influenced by the human factors that manifest mistakes. Unless, of course, you count war.”
Carolyn M. Clancy, the no-nonsense internist who has been director of the federal Agency for Healthcare Research and Quality since 2003, tells me that better tracking and expanded definition of adverse events have led to the reporting of larger numbers of them. That may well account for some of the large numbers of errors cited in the Medicare and New England Journal of Medicine studies. But I suspect another part of the story has to do with the gargantuan scope of the problem.
I asked other experts if they believe there is any hope of significantly reducing hospital errors in the near future. Most were optimistic. Although several large studies have not shown reductions in the overall rate of adverse events, they said, there has been significant success with specific measures involving focused effort. I agree.
Some of these successes have occurred at the state level. In addition to my clinical practice, I work with Qsource, a nonprofit quality improvement organization that works under a contract with Medicare to improve patient safety in Tennessee. Qsource has collaborated with 29 hospitals across the state to reduce MRSA infections and surgical complications.
MRSA is a staphylococcus bacteria that is highly resistant to antibiotics and spreads readily through hospitals and nursing homes. With education, hand washing, isolation measures and other types of teamwork, Qsource helped its partner hospitals reduce MRSA infections by 38 percent and the rate of MRSA transmission by 47 percent between 2009 and 2010.
At a national level, we are also seeing improvement on selected issues. The Centers for Disease Control and Prevention recently reported that since 2005 the rate of MRSA infections in hospitals has declined, on average, by 10 percent per year. And a national study conducted between October 2007 and September 2008 showed that the use of checklists led to a decline in surgical complications.
Experts tell me it’s practical tools, policy changes and, most important, leadership engagement that bring about marked, measurable improvement in hospital safety.
Recognizing that we can improve only what we can measure, and that we need a common method of measurement, the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality has developed “Common Formats,” which provide uniform reporting standards for hospitals that tally adverse events.
Also, state policies now require hospitals to publicly report certain adverse events, such as hospital-acquired infections. Dr. Marion Kainer, Tennessee state infectious disease physician, tells me that the rate of infections associated with central intravenous lines (those placed in a patient’s chest) plummeted in 2010, compared with 2008 — probably due in part to a legislative mandate that hospitals publicly report such infections.
Everyone agrees that the corporate administrators at hospitals must also be engaged in the effort to reduce adverse events. Now, financial disincentives are grabbing the attention of CEOs and CFOs. In September 2008, the Centers for Medicare and Medicaid Services (CMS) stopped paying hospitals for the cost of care resulting from “never” events — adverse events that should never occur with proper care, such as surgery on the wrong limb or infections from urinary-tract catheters. Preliminary data suggest these disincentives are beginning to have a positive effect.
So what more can we do? To focus national attention on this problem, CMS has initiated a Partnership with Patients campaign, whose goal is to decrease preventable hospital-associated infections by 40 percent. If successful, this would reduce the number of injuries related to infections and their complications by 36,000 and save 1,200 lives in Tennessee by the end of 2013.
All of this is good work that is leading those of us who work in hospitals to a new level of patient care. Previously, the quality of care and patients’ safety were the responsibility of the quality improvement director; now, they are becoming priorities for which every nurse, doctor, administrator, aide, housekeeper, dietary worker and hospital board member are responsible.
Drivers still make mistakes with dreadful consequences, but over the past decades we’ve created a culture on our roadways that is very well aware that traffic safety is imperative. Likewise, we health care professionals need to take charge in changing the culture — not just the strategy — of patient safety in hospitals.
Source : Commercial Appeal