Patient safety improving slightly, 10 years after IOM report on errors

A new report does find "unmistakable progress," despite setbacks. Critics say mandatory disclosure of medical errors is the key to breakthrough safety improvement.

By Kevin B. O’Reilly — Posted Dec. 28, 2009

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November marked a decade since the release of a seminal Institute of Medicine report that cited research estimating as many as 98,000 Americans die annually from preventable medical errors.

The report, "To Err is Human," attracted a flurry of media attention and political scrutiny -- as well as criticism from physicians who said the estimate was too high. It also helped catalyze the modern patient safety movement, but to what end?

A report issued in December in the policy journal Health Affairs, said patient safety efforts since 1999 deserve a B-minus grade, compared with a C-plus for 2004.

The report cited improvements in error reporting and quality initiatives led by the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality, the Joint Commission and others. But, the report said, safety gains from health information technology have largely failed to materialize due to slow take-up, unintended consequences and implementation problems.

The last 10 years have seen "unmistakable progress, even though hard evidence of improved outcomes remains elusive because of our rudimentary measurement capacity in safety," according to the report authored by Robert Wachter, MD, chief of the medical service and chief of the division of hospital medicine at the University of California, San Francisco, Medical Center.

The report represents Dr. Wachter's personal assessment of the country's progress in protecting patients from harm. He said the lack of reliable national safety metrics that can be tracked over time is an impediment to progress.

"It's a huge problem," said Dr. Wachter, editor of AHRQ WebM&M, a case-based online safety journal, and author of the 2004 book, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. "It leaves us in a difficult position of trying to figure out whether what we're doing is working, and how to prioritize our efforts and resources."

Still, Dr. Wachter cited progress related to milestones such as the IHI's 100,000 Lives Campaign, which in 2005 enrolled 3,000 hospitals to implement proven safety interventions to prevent ventilator-associated pneumonia and other health care-associated conditions, and a Michigan hospital initiative that drastically cut central-line infections.

But other assessments of patient safety have not been as kind.

A December article in Quality and Safety in Health Care, authored by many of the doctors and other experts who put together the 1999 IOM report, said progress in the last decade has been "frustratingly slow."

And, David B. Nash, MD, editor of the American Journal of Medical Quality, said Dr. Wachter "is an easy grader."

Dr. Nash, dean of the Jefferson School of Population Health at Thomas Jefferson University in Pennsylvania, said he would give "a C-plus grade overall, just a little bit above average. The evidence to support the C-plus is regrettably strong. We have continued wrong-site surgeries, continued drug misadventures and continued unexpected mortality."

He said to make real strides, it's necessary to mandate public reporting of errors. "Sunshine is the best disinfectant, and public reporting of errors without punitive consequences will reduce the error rate."

Is reporting the answer?

Lisa McGiffert, director of the Consumers Union's Safe Patient Project and Stop Hospital Infections campaigns, agreed with Dr. Nash's dour assessment. She said a B-minus is "not an appropriate grade for a system that harms millions of people every year."

In May, Consumers Union issued a report citing the Centers for Disease Control and Prevention's estimate that 99,000 people die each year of hospital-acquired infections as evidence that patient safety has not improved. That report gave "the country a failing grade on progress" in safety.

She said every U.S. hospital should publicly report its infection rates and other kinds of preventable harm.

The Patient Safety and Quality Improvement Act of 2005 allows for confidential, voluntary reporting of preventable patient harm, such as hospital infections and medical errors. Twenty-six states now require public reporting of hospital-acquired infection rates, and 27 require hospitals to report so-called never events, such as wrong-site surgery.

Dr. Wachter said limiting error-reporting to serious events, as opposed to every "near miss," has helped hospitals focus their safety efforts. Nonetheless, he said, hospital self-reporting is an unreliable indicator of quality.

"You could have a hospital culture of see no evil, hear no evil," Dr. Wachter said. "In that error-reporting system, it looks like a hospital with fewer error reports is much safer, but it may not be. It's a really important scientific problem to figure out a way of measuring [safety], and capturing this with good reliable data, and I don't think we're there yet."

He added that focusing on any one element to drive improvement -- regulation, reporting or payment, for example -- is likely to be ineffective.

"I wish there was one button you could push to make this all better, but it's not like that," Dr. Wachter said. "There has to be a tapestry of solutions."

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Grading safety

A new report says the health system merits a B-minus overall on patient safety, up from a C-plus five years ago. Here is how the report graded the different factors that contribute to keeping patients safe from harm when first released in 2004, and when updated in 2009.

Safety category 2004 grade 2009 grade
Health information technology B-minus C-plus
Malpractice system and accountability D-plus C-plus
National and international organization interventions N/A A-minus
Patient engagement and involvement N/A C-plus
Payment system interventions N/A C-plus
Provider organization leadership engagement N/A B
Regulation/accreditation A-minus B-plus
Reporting systems C B-plus
Research N/A B-minus
Work force and training issues B B-minus

Note: Areas marked as N/A were not graded in 2004.

Source: "Patient Safety At Ten: Unmistakable Progress, Troubling Gaps," Health Affairs, published online Dec. 1 (link)

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External links

"Transforming healthcare: a safety imperative," Quality and Safety in Health Care, December (link)

"Patient Safety At Ten: Unmistakable Progress, Troubling Gaps," Health Affairs, January 2010, abstract, published online Dec. 1 (link)

"The End Of The Beginning: Patient Safety Five Years After 'To Err is Human,' " Health Affairs, Nov. 30, 2004, abstract (link)

"To Err is Human: Building A Safer Health System," Institute of Medicine, Nov. 1, 1999 (link)

Consumers Union's Safe Patient Project (link)

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