Why Are Medical Errors Still a Leading Cause of Death?
“We’ve historically looked at errors and harm through a punitive lens in healthcare,” points out Patricia McGaffigan, RN, MS, CPPS, chief operating officer and senior vice president of program strategy and management at the National Patient Safety Foundation. “But the vast majority of times where error and harm occurs, it is not at all related to an egregious attempt of somebody to do something wrong. It’s a reflection of system factors that create the conditions and, unfortunately, sometimes allow the holes in the model to align and cause an error to get to the patient.”
So what is being done to close these “holes”?
A more proactive approach to error prevention
The BMJ article, along with the many responses it incited, has helped draw attention to the need to address medical errors from a much broader, more proactive perspective.
A perspective article in the March 2017 Journal of Patient Safety (JPS), “Estimating Hospital-Related Deaths Due to Medical Error: A Perspective From Patient Advocates” (Kavanagh, Saman, Bartel, & Westerman, 2017), urges the U.S. healthcare system to implement effective strategies to reduce adverse events and deaths.
“Our utmost concern is that—despite having the knowledge to prevent adverse events—many health systems do not adequately invest in patient safety to put well-known safety improvement strategies in place,” comments Kevin T. Kavanagh, MD, MS, FACS, of Health Watch USA in Somerset, Kentucky, and one of the JPS article’s authors. “I am a firm believer of what is measured is managed. The data in the studies we have tends to not capture all of the problems and tends to underestimate the events.”
Kavanagh is calling for a greater investment in safety protocols and research from hospital C-suites.
“Patient advocates are asking for the implementation of known strategies and for a commitment to invest in patient safety,” he says. “The setting of firm well-defined standards for proper staffing and implementation of prevention strategies, such as those for infection control, will be necessary.” Kavanagh also encourages healthcare organizations to support policies that prevent patients from being discharged too early.
The biggest commitment, however, must come in the form of a culturewide commitment to safety.
“[We need] a commitment of the hospital’s administration and hospital board to invest in the culture of safety and proper staffing,” Kavanagh says. “Just last week, I met with a group of infection preventionists, and they were distraught (and some angry) over the lack of support and proper staffing which prevented them from effectively doing their job.
It’s a demand being heard at every level of most institutions. “There is no doubt that incident reporting is necessary to find the gaps in patient safety, but all too often maximum patient safety is not achieved because the needed financial resources are not committed,” Kavanagh says.