Patient Safety Alert: Are Hospitals Missing the Mark on Preventing Harm?

Despite numerous calls for reform and increased patient safety measures, medical experts say that preventable deaths and injuries in hospitals and other healthcare settings will continue to be an issue unless Congress takes action. According to Dr. Ashish Jha, a professor at the Harvard School of Public Health, patients are no better protected now than they were 15 years ago, when the landmark Institute of Medicine report raised alarms about deaths due to medical errors, which led to demands for change.

“Our collective action in patient safety pales in comparison to the magnitude of the problem,” said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine. “We need to say that harm is preventable and not tolerable.”

A Failure to Track Patient Harm

One of the most significant problems, as medical experts told the Senate Subcommittee on Primary Health and Aging, is that providers and public health agencies still are lacking when it comes to accurately measuring harm. Sen. Bernie Sanders (I-Vt.) stated that most patients probably aren’t aware that preventable patient harm is the third-leading cause of death in the United States. He went on to explain that the issue hasn’t received the attention it deserves in the public eye or from lawmakers.

Both Dr. Pronovost and Dr. Jha advocate for the Centers for Disease Control and Prevention, which already collects data about hospital-acquired infections, to begin tracking other patient harms. Dr. Jha explained that it is crucial to develop better metrics to produce credible data about harm that is valid and accurate. Without data, providers are unaware of their performance or the impact of their quality improvement efforts.

Addressing the Most Common Types of Patient Harm

Dr. Tejal Gandhi, president of the National Patient Safety Foundation, highlighted studies that demonstrate medication errors, adverse drug events, and injuries due to drugs happen in up to 25% of patients within 30 days of being prescribed a drug. Systems must be put in place to monitor patient care instead of merely relying on healthcare professionals to make the right choices.

“We cannot just tell clinicians to try harder and think better,” Dr. Gandhi explained.

Missed and delayed diagnosis is another substantial issue and a primary cause of malpractice lawsuits in the outpatient environment. Such diagnoses could lead to complications or even fatalities if not addressed in a timely manner.

Potential Solutions to the Patient Safety Crisis

One proposed solution, inspired by a study on preventable harm in hospitals, involves the establishment of a National Patient Safety Board, similar to the National Transportation Safety Board, which would investigate patient harm. The study’s author, John James, who is also a scientist and patient advocate, suggested a national patients’ bill of rights that would provide protections similar to those for workers and minority groups.

Lisa McGiffert, director of the Consumers Union Safe Patient Project, recommended that legislators ensure more meaningful public reporting of patient harm. This would allow consumers to make informed choices and motivate healthcare providers to make the necessary improvements to patient safety. Without proper transparency, patients may not realize the risks they are unwitting subjects of, and healthcare providers may not have a strong enough incentive to invest in crucial safety improvements.

The Importance of Addressing Patient Safety

With preventable patient harm being the third-leading cause of death in America, it is clear that efforts have not been sufficient to address this unacceptable reality. Experts are urging Congress to take further action to protect patients and ensure that valid, accurate data about patient harm is captured, analyzed, and used to drive improvement. By creating a National Patient Safety Board, instituting a patients’ bill of rights, and increasing transparency in public reporting, healthcare providers may be more motivated to improve patient safety measures and avoid the tragedies that come with preventable harm.