Date: February 1st, 2005
Potentially deadly mistakes continue to plague U.S. hospitals, according to a new report. The study, which analyzed three years of Medicare patient records, estimates that medical errors cause an average of 195,000 in-hospital deaths per year.
HealthGrades, a health care quality monitoring company, conducted the research. Their figure is more than twice the previous estimate from a landmark study conducted in 1999 by the Institute of Medicine. Different methodologies account for much of the difference, but experts are quick to emphasize that both studies are cause for concern.
“One medical error is one too many,” said Denise Remus, Ph.D., R.N., senior research scientist, quality indicators, at the Agency for Healthcare Research and Quality.
AHRQ is the health services research arm of the U.S. Department of Health and Human Services (HHS). In 2002, the agency developed a set of 20 patient safety indicators as a way for researchers to get a handle on the difficult task of measuring patient safety. These indicators include such medical events as complications following surgery, failure to diagnose and treat a patient in time, and conditions - such as bed sores - that are caused by improper care.
Researchers at HealthGrades used 16 of AHRQ’s indicators to screen 37 million patient records, and found about 1.14 million patient safety incidents. One in every four of the patients who experienced a patient safety incident died.
Why do medical errors happen?
Health care experts and patient safety advocates agree that medical errors occur largely because the system relies on an outdated infrastructure that has not kept pace with a fast-moving industry.
“The issue is not an issue of bad providers giving bad care. It’s the fact that you have care being delivered in an incredibly complex system, on an organism that is incredibly complex,” said Diane C. Pinakiewicz, interim executive director and member of the board at the National Patient Safety Foundation. “The science of medicine has progressed geometrically over the years. What has not happened as rapidly is improvement in the processes.”
These processes underlie how practitioners learn about new research, how patient information is stored, and how clinicians interact with each other and their patients.
Health information technology a possible solution
In October, HHS announced $139 million in grants and contracts to promote the use of “health information technology.” The term refers to tools that streamline the system and reduce the room for error.
Proponents of health information technology envision a system where always-current electronic health records would follow patients throughout their lives - even when they move, change doctors or visit specialists. Computerized physician order entry would allow physicians to choose prescriptions from drop-down menus on computers, eliminating the risk that pharmacists might misread handwritten instructions.
A national health information system would also incorporate current medical research, so all health care providers are providing up-to-date care according to the best information available.
“Health research is developing more new learning than any individual is capable of taking in and learning. The goal is to bring the most recent learnings to the bedside to improve patient outcomes,” Pinakiewicz said.
Some of these technologies are already in place in some areas, Remus said, but the systems in use may not be able to talk to each other, and smaller hospitals often cannot afford a large technology investment.
“A key issue is packing it nationally,” she said. “Hopefully we can come to some standards.”
Providers can make improvements now
Incorporating a whole new way of doing business into hospitals nationwide will not be easy. New systems will be expensive and difficult to implement in an industry where professionals already feel they have too little time to do what their jobs require.
The HHS plan outlines ways in which the federal agency can help to plan and develop the new infrastructure and use grants and loans to help hospitals with the investment. Until a new infrastructure is in place, simple and inexpensive changes in hospital practice will help.
“Being diligent in what we have to do as health care providers - checking vital signs, washing hands - doesn’t require a multi-million dollar investment,” said Dr. Samantha Collier, vice president of medical affairs at HealthGrades. “The study shows that basic front line care we do day in and day out isn’t being done well. We can start that right now.”
Organizations such as the Joint Commission on Accreditation of Healthcare Organizations already provide standards for health care providers in hopes of improving patient safety. JCAHO also collects information from its accredited providers about their patient safety events, and provides resources they can use to prevent medical errors.
“Consumers can take heart in the fact that the health care industry is working very diligently. The industry is all about doing the right thing for patients,” Pinakiewicz said.