Patient safety advocates might have been excited, at first, by the February 9, 2010 front-page headline in The Virginian-Pilot that began, "To Err Is Human." To advocates, the headline might suggest the newspaper was ramping up for an editorial about preventable medical errors and the 10th year anniversary of the Institute of Medicine (IOM) patient safety report, "To Err Is Human," or about Rep. John Murtha’s (D-PA) recent death from an apparent medical error. Alas, the story was about how the newspaper published the Super Bowl scores in reverse—not once, but twice—due to “human error.” Readers probably appreciated the paper's public apology. Super Bowl scores are serious business, but so are preventable medical errors.
The 1999 IOM report estimated nearly 100,000 people die in U.S. hospitals annually due to preventable medical mistakes. That's equivalent to a jumbo jet liner crashing daily and killing all its passengers. After its first decade, the patient safety scoreboard is sobering. Today, the number people who die from preventable healthcare acquired infections, called HAIs, alone is equivalent to the daily crashing of a jumbo jet liner with an estimated excess $28-45 billion in direct healthcare costs. The healthcare industry seems insufficiently apologetic.
For over a century, healthcare workers have known how to prevent the spread of lethal HAIs. The solution is as simple. It's largely a matter of washing hands properly every time healthcare workers enter and exit patient rooms. There is perhaps no other single and simple act that can save millions of lives and billions of dollars. Yet, across the U.S. hospitals, doctors and nurses wash their hands only 30-70% of the times required.
Rep. Murtha died from a complication of an elective gall bladder surgery. Many such deaths—like the Super Bowl blunder—are the result of easily preventable human error. The survival rate for elective gall bladder surgeries is excellent. However, anybody who undergoes the knife is vulnerable to infection if simple procedures are not followed such as administration of antibiotics at the start of surgery and proper hand washing by healthcare workers who come into contact with surgical patients.
In the few states that mandate full disclosure of medical errors, malpractice claims have remained stable or decreased. Patients are less likely to sue when treated with honesty and humility. However, doctors in many states still vociferously resist full disclosure efforts. In addition to pressing for full disclosure policies, patient safety advocates encourage hospitals to voluntarily complete and publicly report their comparative progress in patient safety through The Leapfrog Group. They commend the growing number of Leapfrog-transparent hospitals because such reporting allows market forces to drive improvements in patient safety. Unfortunately, neither hospital involved with Murtha's care posted safety information to Leapfrog's website (www.leapfroggroup.org).
The 2009 Atlantic Monthly story, "How American Health Care Killed My Father," is an insightful account of an HAI-related death and the American patient safety crisis. It notes that the number of patients who die each year as a result of preventable medical errors is twice the number of vehicular deaths, five times the number of homicides, and 20 times the number of armed forces who have died in Iraq and Afghanistan. The lack of public outrage over our country's patient safety crisis and industry's resistance to disclosure is perplexing.
When a congressman, or any patient, dies as a result of simple human error, timely disclosure and apology are in order. As a start, in some states, hospitals are mandated to report certain HAIs. Because this information is not easily accessible, the Virginia Business Coalition on Health publishes this information for Virginia hospitals and provides a link to the recent Consumer Reports comparative rates among U.S. hospitals for central line infections (a specific HAI) at www.myvbch.org.
As important as Super Bowl scores are, they aren’t a matter of life and death. Hospital scores are.
Gretchen B. LeFever, Ph.D., is President of Safety & Learning Solutions, a consulting firm in Virginia, and an adjunct faculty member at Old Dominion University, Gretchen@yoursls.com.
