During the last two months disturbing reports have been issued regarding patient safety and errors. They point to the fact that hospital medical errors account for a third of U.S. hospital deaths. That means about 440,000 people die from preventable errors. If the information is accurate “we are burying a population the size of Miami every year from medical errors that can be prevented,” according to Leah Bender who is the CEO of The Leapfrog Group and responsible for one of the studies.
The Leapfrog Group used the information to update their hospital safety scores. Of the 2,539 general hospitals evaluated, less than 33% received an A rating. 661 hospitals scored a B. 893 scored a C, 150 obtained a D, and 22 received an F.
Unfortunately, the impact of medical errors isn’t new. We have known about it since the landmark 1999 report by The Institute of Medicine titled “To Err is Human; Building A Safer Health System”. What is new is that the 19990 estimate 98,000 annual deaths caused by medical errors may have been off by a factor of 4.
The Journal of Patient Safety’s most recent article on the subject indicated that hospitals are struggling with Preventable Adverse Event (PAE) issues for a number of reasons. Topping the list are challenges with continuing education, physician guidelines, and supporting systems for patient care as well as hand offs between inpatient and outpatient care. Their study found PAEs fall into one of the following error categories:
- Commission – either the wrong action is performed or the right action is performed improperly
- Omission – obvious necessary actions are not performed
- Communication – failures to exchange accurate information between providers or with patients
- Context – failure to take unique situations (e.g., patient’s ability to comply with treatment) into consideration
- Diagnostic – considers actions resulting in under/over/incorrect treatments
While I am certain the investigations and push for safety will continue, not enough is being done to take advantage of the tools and resources that are currently available. Advanced Communication Services are available now for the purpose of expediting information access and guiding clinical workflow processes down the proper pathways. Using closed loop multimedia services much can be done to reduce PEAs in every category. We understand how, where, and what to use for the purpose of accelerating information access and delivery. Simply put, hospitals are often not aware of the Advanced Communication Services that are available. We must do a better job educating them as to their capabilities and availability.
Congratulations If you belong to one of the organizations receiving an “A” patient safety rating! If not, please consider looking into how Advanced Communication Services can be used to reduce hospital medical errors.