The Latin phrase “Primum non nocere” is familiar to all physicians: First, do no harm. Care providers do their best to avoid hurting people in the process of treating disease, but despite their best efforts, patients are sometimes harmed while undergoing medical care. Some harm is considered unavoidable, such as post-operative bleeding despite perfect surgical technique. Preventing other harm — harm due to mistakes — is a cornerstone in the movement to improve patient care and safety. This issue is serious. Up to1,000 patient deaths per day can be attributed to preventable medical errors. This means preventable harm is the third leading cause of death among Americans, behind only heart disease and cancer.
What Is Preventable Harm?
Lack of a clear, agreed-upon definition obfu¬scates a full understanding of the nature of preventable harm. Most working definitions include the idea that the harm is “identifiable” in that it can be attributed to medical care and “modifiable” in that it is possible to avoid. For the purpose of this article, we will be using The Institute for Healthcare Improvement definition of preventable medical harm as “Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.” Defining preventable harm is important because some studies suggest that up to half of the harm patients experience in hospitals is not preventable or not the result of an identifiable error. In addition, there is conflicting evidence regarding the prevalence of preventable harm.
Eliminating preventable harm is certainly a desirable goal, but, in practice, it may not actually be possible. The sad fact is, while harm may be “preventable,” a certain level of harm is considered inevitable because health professionals, like everyone, make mistakes. Hospital-acquired infections, misdiagnosis, wrong surgeries, medication errors, in-hospital falls and burns, some cases of deep vein thrombosis, surgical site infections and bedsores are common examples.
Most in-hospital injuries are the result of falls.
Rates of falls in U.S. hospitals range from 3.3 to 11.5 falls per 1,000 patient days.
There are three types of medical misdiagnosis: False positive:misdiagnosis of a disease that is not actually present. False negative: failure to diagnose a disease that is present Equivocal results:inconclusive interpretation without a definite diagnosis.
No reliable data is available on misdiagnosis. Available studies vary widely in their conclusions.
Deep Vein Thrombosis (DVT)
DVT is a blood clot that forms deep in the body, often in the lower leg or thigh. When a blood clot breaks off, it can travel through the blood stream and block blood flow in the lungs, heart or brain, resulting in an embolism. Risk for DVT is greater when in the hospital because major surgery and immobility can both cause DVT.
A Centers for Disease Control and Prevention study found the estimated annual hospitalization rate for DVT at 547,596 from 2007 to 2009. It is unknown how many of those cases were preventable.
What Are the Costs?
The human toll of preventable harm is staggering. The most cited statistics come from a famous 1999 report by the Institute of Medicine (IOM) “To Err is Human.” This report, one of the first of its kind to bring hard science to the study of preventable harm, shocked readers by reporting 98,000 people die every year due to preventable adverse events. While many still quote this figure today, newer, similarly rigorous studies estimate the actual prevalence of preventable harm to be much higher — between 210,000 and 440,000 instances per year.
Besides the toll preventable harm takes on human life, ample evidence suggests medical errors cost health consumers billions of dollars each year. A 2012 study broke down these costs into additional medical bills ($17 billion), increased mortality rates ($1.4 billion) and lost productivity ($1.1 billion). If we include the indirect costs of preventable harm, the economic impact could easily reach $1 trillion annually. It should be noted that these cost analyses are based on the incident numbers provided by the IOM’s “To Err Is Human” study — if these calculations were redone using the higher numbers reported by more recent studies, the resulting costs would be up to 10 times higher.
Preventable harm also levies an emotional toll on everyone involved. Treating instances of preventable harm means doctors have patients under their care for a longer period of time, nurses have more patients, and resources get stretched — creating an environment that could produce more instances of harm and a loss of morale. Family, friends and caretakers are affected as they put extra time and effort into helping loved ones recover. Finally, patients take more time off from work, school and other activities they enjoy in order to fully regain health.
What Can Be Done to Prevent This from Happening?
In order to prevent harm, administrations, governing bodies and professional organizations do their best to develop evidence-based guidelines and best practices to raise the standard of care. When things go wrong, it is typically multifactorial and involves a systematic or human error (and sometimes both). Systematic safeguards are typically in place to prevent human error. So systematic failures, such as dysfunctional teams, lack of resources, bad communication, poor health administration, disregard for safeguards and checklists, or malfunctioning technology often predicate and facilitate human errors such as lack of knowledge or skill, caretaker fatigue and technical mistakes. Continuous monitoring of adverse events, along with working to update policies and safeguards, is the best defense against repeated adverse medical events.
As we develop new treatments and safeguards, what seems inevitable today can be preventable tomorrow. How do standards of care get developed and put into practice? Lets look at a common example: An elderly patient falls getting out of her hospital bed to go to the bathroom. The patient requires further care to set her arm and prevent infection, and she does not leave the hospital until several days past her original discharge date. After getting back home, friends and family must monitor her and assist her with every day tasks.
Back at the hospital, a team of health care providers and administrators investigate if an intervention on their part would have prevented the patient’s fall. Was the nursing staff spread too thin to respond to her call promptly? Should she have been fitted with a catheter or bedpan? Was the floor wet? Was she given non-slip socks? There are three possible outcomes to such an investigation: (1) they could find that the current standards of care would not have prevented the fall and modify them as a result; (2) they could find there were reasonable safeguards in place but they were not followed; (3) they could find there was no way to prevent the incident in the first place.
The hospital’s analysis finds that while all current safeguards were adhered to, no one discussed the high risk of falls with the patient, and the patient did not consider herself at a high risk for a fall. To prevent this from happening in the future, an additional safeguard was put in place where the nurse on duty communicates with the patient about the danger of hospital falls and encourages her not to leave her bed without assistance.
There are many resources available to those looking to reduce the number of adverse medical events. Many nonprofits, health organizations and governmental organizations work to provide both the public and the medical community with the latest and greatest in health care innovations. In addition, it is important that we educate the next generation of doctors, nurses and health administrators to understand the gravity of preventable adverse medical events and encourage innovation in finding solutions.
A 501(c)(3) nonprofit, the National Patient Safety Foundation (NPSF) has been a central voice for patient safety since 1997. NPSF organizes Patient Safety Awareness Week and offers resources for patients, families and health care professionals.
Synesis is a Georgia-based consulting company that works with hospitals to help them pursue “zero preventable harm.” Their clients include the Mayo Clinic, Inova Health System and the United States Department of Veterans Affairs.
Founded by Joe Kiani, the Patient Safety Movement calls on hospitals, physicians and medical device companies to make pledges to reduce preventable harm. Massachusetts General Hospital, Baylor Scott and White Health Care System, and GE Healthcare are among the health care organizations that aspire to reach zero preventable harm deaths by 2020.
The National Quality Forum (NQF) is a “not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in health care.” In 2012, NQF endorsed the implementation of 26 patient safety measures related to medical errors.
Dr. John T. James, the former chief toxicologist for the National Aeronautics & Space Administration (NASA), created Patient Safety America. He started the organization after his son died in 2002 as a result of what he describes “as uninformed, careless and unethical care by cardiologists at a hospital in central Texas.” A National Hospitalized Patient Bill of Rights is among the organization’s policy goals.
Beth Israel Deaconess Medical Center is a model of hospital transparency. Its website provides up-to-date preventable harm statistics by injury type and detailed accounts of how it is working to address those issues.
Founded by the Leapfrog Group, Hospital Safety Score assigns safety scores to nearly 2,500 hospitals around the country. The scores allow patients and families to understand how reliably a particular hospital delivers safe care from the correct use of antibiotics to the frequency of employee hand washing.
Spearheaded by the Center for Medicare and Medicaid Services, the Partnerships for Patients is a collaborative effort between health providers and federal and state governments to make hospitals safer.
Through its Patient Care Program, the Gordon and Betty Moore Foundation spent $49 million in 2013 on projects that “eliminate preventable harms and unnecessary heath care costs.” Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, and the University of California, San Francisco, were among its grant recipients.