Tuesday, May 26, 2009

Progress a decade after "To Err is Human" declared an immense public policy failure

The patient safety movement has backfired

The Safe Patient Project has just released a document claiming an appalling lack of progress in addressing patient safety since publication of the Institute of Medicine (IOM) report 10 years ago.

One expert commented in a Medscape report (italics mine):

The new report is "right on," says Lucian Leape, MD, adjunct professor of health policy at Harvard School of Public Health and longtime patient safety advocate. The lack of progress in implementing the IOM recommendations, he says, ''is an immense public policy failure."

The report makes two claims. The first, that we’ve implemented virtually none of the IOM’s recommendations, appears to be true. It’s easy enough to verify, and the reasons for this non-implementation deserve scrutiny. The second claim, that around 100,000 patients “still” die as a result of medical “errors”, is little more than the revival of an old canard.

First some background. The Medscape report notes:

In 1999, the Institute of Medicine (IOM) issued an alarming report titled "To Err is Human," detailing the toll of preventable medical errors in the U.S; it estimated that up to 98,000 Americans die annually from them.

The idea of “98,000 Americans killed in hospitals annually” became dogma as a result of obfuscation by the IOM and its media accomplices. First the Institute of Medicine distorted the original research in its report To Err is Human. In a NEJM Sounding Board piece the author of that research criticized the IOM report and said the claim of 98,000 deaths due to medical error was distorted and unwarranted by the research findings. The claim later became entrenched in American medical folklore by the media frenzy which followed.

The new Safe Patient Project report restates the popular myth of 98,000 lethal medical mistakes annually, then claims that the number is at least as high today with no good data to back up the claim. Although the media will trumpet their “findings” of at least 100,000 fatal medical errors yearly the writers of the report themselves admit they don’t have good data (italics mine):

Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year a million lives over the past decade.

So how far have we really come during the decade since “To Err is Human?” First we must be honest about the fact that we really don’t know how many patients die as a result of medical error. For what it’s worth, though, we can agree that virtually none of the IOM’s recommendations have been implemented. Let’s consider why. The entire IOM safety program was premised on there being a culture of transparency. The move toward transparency, though, never had a chance. From the moment the patient safety conversation was framed in terms of errors all good intentions of transparency were sabotaged by a rapidly developing culture of blame. You will never have transparency in a culture of blame. The authors of the Safe Patient Project report, who should be experts on patient safety, don’t even get it. Astonishingly, they want a stronger culture of blame and think tort reform is responsible for the lack of progress:

With a civil justice system weakened by limited compensation to harmed patients and inadequate oversight of health care, public reporting of preventable medical harm is today perhaps the only effective accountability measure we have.

The media frenzy following the IOM report resulted in increasingly careless use of the term “medical error,” such that many unavoidable events came to be characterized as errors. Worse, Medicare’s never event policy resulted in some unavoidable outcomes being administratively defined as error. Now, as a result, we are faced with a developing new legal standard in which such events are considered prima facie evidence of someone’s negligence. Thus the culture of blame is not only entrenched in medical culture but is becoming codified in our tort system. This will not only undo much of what has been accomplished by tort reform but also set the cause of transparency back, perhaps for decades.

I agree with the authors of the Safe Patient Project report that, after a decade, the patient safety movement is a failure, though not for the reasons they state. Although advances in medicine have improved patient outcomes over time the patient safety movement, in its attempt to effect beneficial system changes, has been worse than a failure. It has backfired.


Daniela Nunez said...

In 2007, the CDC estimated the number of deaths associated with HAIs in
U.S. hospitals was 98,987. See http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/infections_deaths.pdf

In our report, we combined the number of deaths associated with hospital acquired infections with deaths due to medical errors. This means that our estimate of over 100,000 deaths due to medical errors is conservative considering the limited evidence we've seen.

Daniela Nunez

Anonymous said...

The doctor should take a dose of his own medicine and undergo invasive medical procedures as an anonymous layperson in a foreign state. I think that one surgery would be plenty to disillusion him of his rose-colored outlook. It was political lobbying that undid the patient safety movement, and if anything the official estimates of adverse events are under-reported. I personally have had nearly a dozen 'excellent' doctors in a row progressively ruin my life and nearly kill me, all preventable injuries, and most of them not even true errors but rather willful, arrogant injuries and neglect inflicted simply because they did not like me and thought my complaints were all imaginary without bothering to do adequate testing or take preventive measures such as taking a comprehensive pre-surgical medical history and actually paying attention to patient pre-operative concerns rather than ignoring them, raising the bed rails, providing backup care, waiting for the patient to leave the hospital before the doctor leaves the hospital, adding some safety margin between removal of packing, hospital discharge, and doctor's vacation plan, in-home nursing care, bacterial cultures to identify resistant strains, taking images when pain/bleeding started, giving a realistic recovery plan once everything had failed, avoiding re-use of toilet-soiled dressings, not pushing the patient care off on neighbors rather than keeping patient hospitalized while depleted, lacerated, mutilated, and infected, and giving realistic, pre-emptive pain management to avoid chronic neuropathic sensitization instead of just tossing a handful of vicodin into the mix.

But as I have already mentioned on this site before, I expect my comments to be either censored or belittled, since the author of the site seems to have a degree of bias that could skew a prairie.