One of the "ten simple rules" for building a smarter, higher quality health system mentioned in another thread was:
A NYT article today serves as a reminder that there's still a long way to go on that front. It's about a recent report from the HHS Office of the Inspector General that found "Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized." More importantly, errors are shrugged off as isolated incidents (i.e. lapses in individual responsibility of practitioners) with little attention given to addressing the systems that enable them.
Preventable medical errors remain a serious problem, though there is now a nationwide effort to address some of the systemic problems that allow many of these errors to occur: the Partnership for Patients.
Current: "Do no harm" is an individual responsibility. New: Safety is a system property. Patients should be safe from injury caused by the care system. Ensuring safety requires greater attention to systems that help to prevent and mitigate errors.
A NYT article today serves as a reminder that there's still a long way to go on that front. It's about a recent report from the HHS Office of the Inspector General that found "Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized." More importantly, errors are shrugged off as isolated incidents (i.e. lapses in individual responsibility of practitioners) with little attention given to addressing the systems that enable them.
Despite the existence of incident reporting systems, Mr. Levinson said, hospital staff did not report most events that harmed Medicare beneficiaries. Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.
Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.
The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.
Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said. [...]
More often, Mr. Levinson said, the problem is that hospital employees do not recognize what constitutes patient harm or do not realize that particular events harmed patients and should be reported.
In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or suspected that the events were isolated incidents unlikely to recur.
The inspector general found that hospitals made few changes to policies or practices after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any systemic quality problems.
Organizations that inspect and accredit hospitals generally do not scrutinize how hospitals keep track of medical errors and other adverse events, the study said.
The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said.
Preventable medical errors remain a serious problem, though there is now a nationwide effort to address some of the systemic problems that allow many of these errors to occur: the Partnership for Patients.