Why Are Medical Errors Still a Leading Cause of Death?

While today’s shifting healthcare environment is forcing virtually every department to do more with fewer resources, patient safety is itself the foremost mission. Given today’s focus on driving value over volume-based care, a commitment to safety falls in line with healthcare organizations’ philosophical mission, as well as their more practical aims.

“I find it really interesting that we ask healthcare executives to rate patient safety among their priorities,” McGaffigan says. “Really, that should be an integral part of the DNA of who we are and how we operate. Asking, ‘Where does safety rate?’ is a question that we shouldn’t have to ask.”

Addressing—and tracking—the fear of retribution

Many healthcare organizations are reluctant to embrace a culturewide commitment to safety due to fear of litigation and the expected high costs related to medical errors.

“We still have a healthcare delivery system where fear of punishment is a major detractor for all in healthcare to be comfortable anticipating and reporting errors. We’ve had systems where errors are reported, but there is no closed-loop feedback to take back to the individuals that were involved in either an error or near-miss,” McGaffigan says.

Kavanagh calls the need to create a safety culture where everyone is encouraged to report adverse or near-miss events “of utmost importance. This is not just for the frontline staff, but also for the hospital administration and hospital board,” he adds. “This is not a legal issue, but a moral imperative. How can people we trust our lives to justify covering up an event? Full disclosure, with an apology and prompt compensation, is needed and has been shown not only to improve safety but also to lower legal costs.”

In a 2015 commentary published in Patient Safety Journal, Dr. Steve Kraman of the University of Kentucky College of Medicine noted that Pennsylvania became the first state to require disclosure of serious events in 2002. The University of Pittsburgh Medical Center hospitals reported no significant increase or decrease in the number of lawsuits filed over the next nine years, although there was an increase in payments made as a result of disclosures.

Kraman acknowledges that disclosure of medical errors may have an impact on a hospital or healthcare organization’s financial health. However, just like tracking medical errors themselves, this is an area that is too little studied to be able to draw solid conclusions. He suggests that the disclosure approach may impact the consequences.

“When disclosure is all there is, and the patient feels that he/she has suffered a substantial loss and wants or needs redress, disclosing and walking away leaves the patient with no alternative but to look for a lawyer and attempt to sue,” Kraman writes.