Engaging consumers is critical to improving patient safety in U.S.

Medical errors are a continuing problem, according to a May 27, 2010 Richmond Times article about the annual Virginia for the tenth annual Virginians Improving Patient Care and Safety conference. Sorrel King, the keynote speaker, challenged and inspired the audience. She said that we’ve been talking about improving patient safety for ten years and it is time we started making it happen.

The patient safety movement was launched a decade ago with release of the Institute of Medicine report—To Err is Human—that documented nearly 100,000 patients die each year from preventable medical mistakes. Today, 100,000 patients continue die each year from preventable medical mistakes and another 100,000 die from preventable healthcare associated infections. Excess healthcare costs for these infections alone totals between $28 and $45 billion.

The Leapfrog Group is a national organization that was founded by leaders of Fortune 500 companies in response to their concerns about findings in the To Err is Human report. Each year, Leapfrog surveys U.S. hospitals and public reports their progress toward safe care. In 2009, the survey was voluntarily completed by 1,244 hospitals. This represents half of the targeted hospitals, according to Leah Binder, CEO of the organization and one of the conference speakers.

Research has shown that a patient’s risk of dying is reduced by two to four times, if care is obtained in a hospital that completes the survey and meets Leapfrog standards. If non-rural U.S. hospitals used the first three patient safety practices espoused by Leapfrog, 57,000 lives and $12 billion could be saved each year.

Binder used the fact that, as of 2009, only 59% of Leapfrog reporting hospitals even have hand hygiene policies to prevent the spread of healthcare-associated infections in place to convey urgency about improving patient safety to the conference attendees. She said that 100% of hospitals should have hand hygiene policies to reduce the spread of infection.

Proper hand hygiene is universally accepted as the single most effective method for preventing the spread of dangerous healthcare infections that harm and kill hundreds of thousands of patients every year. Yet, doctors and nurses in leading hospitals wash their hands less than 50 percent of the times required with rates varying from 30 to 70 percent.

A 2010 study published in Infection Control and Hospital Epidemiology used published data and transmission rates for MRSA (a healthcare-associated infection) from a Duke hospital to calculate the cost of hand hygiene non-compliance. Accordingly, a 200‐bed hospital incurs $1,779,283 in annual MRSA infection–related expenses attributable to hand hygiene noncompliance. Every 1% increase in compliance saves an average 200-bed hospital almost $39,650 in annual savings.

Last year, leaders of national safety, quality, and purchasing organizations published a consensus stating that zero healthcare-associated infections is the only appropriate goal for U.S. hospitals. The reason for their “chasing zero” consensus is that these infections are preventable.

As much as anyone, Sorrel King knows that engaging consumers is critical to improving patient safety. Her 19-month-old daughter, Josie, died due to a preventable medical mistake. Worse still, Josie’s mother reported her concerns about changes in Josie’s behavior to the staff. If the staff had been more accustomed to viewing patients and their family members as part of the healthcare team or if King had been better equipped to speak up for safety, Josie would be alive today.

King told the audience that was emotionally unprepared to accept money in exchange for her daughter’s life. Instead, she used the settlement money to create the Josie King Foundation. Through the foundation (www.josieking.org), King has developed safety education tools for patients. She told the audience that one of their tools will be available in a few weeks as an iPhone application.

Martin Hatlie, J.D., President of Patients for Patient Safety and co-founder of Consumers Advancing Patient Safety encouraged professionals attending the conference to partner with healthcare consumers to develop effective patient safety strategies. In reality, a patient or their lay caregiver will often be the only person around to remind a busy doctors and nurses to wash their hands or perform other basic safety practices.

Just giving patients hand outs telling them to speak up for safety is not enough. We need to recognize that patient safety is a major public health issue. It will require us to use all the methods public health has available to tackle our epidemic of preventable medical mistakes and healthcare-associated infections.

With potentially lethal healthcare-associated infections beginning to spread into outpatient clinics and community settings, there may be no other patient safety topic that requires more urgent attention than proper hand washing. However, “chasing zero” is a realistic goal only if healthcare learns to engage consumers in the process.

The first order of business is increasing public awareness about the patient safety crisis. This requires more than preaching to state choirs of dedicated health professionals. Consumers in every community must come to understand the nature of the crisis and their role in improving safe care.

Gretchen B. LeFever, Ph.D., is a psychologist and senior partner with Safety and Learning Solutions, www.yoursls.com.