Why Are Medical Errors Still a Leading Cause of Death?

The NQF report provides some guidance on how to reduce unnecessary variation in healthcare quality measures so that measurement can better improve care. For example, it recommends development of a database of measures both under development and in use to improve awareness of existing measures and pinpoint any potential overlaps.

Kavanagh agrees that improvements can be made through “setting well-defined safety standards and transparency of facility performance.” However, he also points out that enforcement of existing measures must be improved to truly impact patient safety improvements.

“The enforcement of regulations is often not uniform, or not at all. For example, according to a Centers for Medicare & Medicaid Services study using fiscal year 2014 data, the Joint Commission hospital surveys are out of compliance 42% of the time. By law, the disparity rate should not be higher than 20%. In addition, by law the surveys are shielded from the public unless the hospitals give permission for their release. We currently have patient advocacy issues with just the accreditation process and transparency—this needs to be fixed,” Kavanagh says.

Today’s bottom-up approach to safety 

At the care provider level, McGaffigan sees more attention being placed on taking a proactive approach to preventing medical errors.

“We see nurses thinking more broadly about the system that they’re working in,” she notes. “They’re path-leading and have a really critical role to play in accident and error ­investigations and also, more importantly, in knowing how and why errors occur. We’re starting to see nurses say, ‘We’ve got to really have strong plans in place to ensure that something doesn’t happen again.’ ”

McGaffigan sees a shift from low-level responses to actions that can generate more sustainable, long-term safety improvements.

“The old school of healthcare, not just nursing, would say, ‘If something bad happens, try harder,’ or, ‘We’ll do an in-service,’ or, ‘We’ll put reminders on the walls of the patient’s rooms or in the breakrooms,’ etc. Those are very low-level actions when you think about the action hierarchy of how to affect more sustainable change,” she says. “Telling someone to try harder and do better is not going to help us address these issues.”

More nurses are working to ensure errors don’t reoccur by looking at more solid and sustainable interventions, putting redundant systems in place, and fully committing to zero harm to patient and workforce by monitoring implemented measures, McGaffigan says.