Why Are Medical Errors Still a Leading Cause of Death?
One of the ways nurses and others can drive some of this change is through the use of Surveys of Patient Safety Culture, provided by the Agency for Healthcare Research and Quality at www.ahrq.gov.
“These standardized surveys allow organizations to survey both their departments and units down to the local level to get a sense of how people feel about the safety culture and their environment. They’re available for hospitals, nursing homes, office-based settings,” McGaffigan says. The surveys are typically conducted every other year and present both a high-level overview for the organization and a look at how local units or departments perform. Many of the measures are associated with communication and teamwork, among other domains.
“I feel that organizations that choose to do these surveys show another level of commitment to patient survey especially—and perhaps only—if they do something with the results of their survey,” McGaffigan adds.
By and large, the surveys reinforce the need for top-down emphasis on safety. “It doesn’t matter what type of environment you’re working in—the lowest-rated areas are consistently tied to people’s comfort in reporting errors,” McGaffigan says. “They have a clear sense that there’s a risk of punitive response in their organization when errors occur.”
Without leadership support and commitment to these initiatives, effecting permanent change isn’t very likely.
The value of learning from our mistakes
Makary explained in the news release on his article that today’s medical coding system was designed to streamline billing services, not to collect national health statistics—yet the latter is how it is being used today. But as healthcare continues to evolve its focus on providing value to consumers, now is the perfect opportunity to put processes in place to gather data that will inform next-generation improvements in care.
Care coordination improvements and the wider use of safety nets are unlikely to be seen if no one is tracking these failures. It’s impossible to improve when there’s no baseline from which to grow.
Megan Headley is a contributing writer at Patient Safety & Quality Healthcare.
REFERENCES
Kavanagh, K. T., Saman, D. M., Bartel, R., & Westerman, K. (2017). Estimating hospital-related deaths due to medical error: A perspective from patient advocates. Journal of Patient Safety, 13(1).
Makary, M. A., & Daniel, M. (2016). Medical error – the third leading cause of death in the US. BMJ, 353, i2139.
National Quality Forum (2016). Variation in measure specifications – sources and mitigation strategies final report. Retrieved from http://www.qualityforum.org/Publications/2016/12/Variation_in_Measure_Specifications_-_Sources_and_Mitigation_Strategies_Final_Report.aspx