Hospital and Health Care Patient Safety

My work in health care-related issues has evolved over the past year to advocacy for broad-based employer health programs to much more targeted initiatives in four areas:

• Prevention and wellness, especially programs that have rapid and significant return on investment, such as immunizations;
• Wellness programs;
• Providing information to patients that improves their engagement in managing their health more effectively; and
• Hospital patient safety.

This last subject, patient safety in hospitals, is of broad interest to the federal government because the number of deaths occurring in hospitals because of deficient patient safety practices exceeds 200,000 people a year. If these deaths occurred in spectacular airplane crashes, it would be equivalent to 10 fully loaded 747’s crashing every week and having every passenger die. Unnecessary deaths in hospitals are the third-leading cause of death in America, larger than every cause than cancer or heart disease. More people die in one month in American hospitals than have died in the entire history of the Iraq and Afghanistan conflicts combined.

This is a particular area of focus for Dr. Don Berwick, the new head of CMS, the federal government agency responsible for both Medicare and Medicaid programs. I am going to do my best in 2011 to make sure it is of equal importance to hospitals, health plan administrators, and those who pay for hospital care, namely, businesses and individuals.

The New York Times highlighted this issue in the November 25, 2010, issue with a front-page story reported by Denise Grady, entitled “Hospitals Make No Headway in Curbing Errors.” In the article, Ms. Grady reports on a five-year study conducted in 10 North Carolina hospitals, which found that harm to patients was common and that the number of incidents did not decrease over time. According to my good friend and colleague at the Harvard Advanced Leadership Institute program, Dr. Chuck Denham, the founder and head of TMIT, a non-profit devoted to transforming health care, there are three root causes to patient safety issues:

• Hospital acquired infections;
• Adverse drug events; and
• Deficiencies in care transitions or hand-offs (between emergency rooms and the remainder of the hospital, between shifts, between caregivers, between acute care and care after people leave hospitals, and from one hospital to another).

The Society of Actuaries, in a 2008 study, just focusing on the documentable costs at hospitals, found that hospital patient safety errors cost almost $20 billion a year, and it is highly probably that this estimate significantly understates the total cost. There are many cost-saving opportunities in the health care system that will be resisted, because they involve cutting payments to health care providers, reducing health care capacity, reducing health insurance coverage, or requiring people to pay more for health care. However, no one can defend spending money on health care that kills or injures people, or results in serious, hospital-acquired infectious diseases. Saving money by reducing the frequency of bad hospital care practices is a no-brainer.

Dr. Denham pointed out that, while the airline industry has never had this intolerable unsafe record, it was far more dangerous to fly 40 years ago than it is today. He referred me to a book by John Nance entitled Why Hospitals Should Fly. Nance points out that many of the solutions to the patient safety are relatively easy, low-tech solutions, such as the consistent use of checklists, a practice that airline pilots and air traffic controllers have used for decades. Many hospital errors occur simply because humans forget to check or recheck something they need to do.

Safety across all activity sectors also requires the elimination of excessive error-prone steps in processes in which errors create risks. The simple substitution of putting bar codes on drug containers that eliminate human key entry errors reduces the frequency of people administering the wrong medicines.

This past summer, my daughter worked in a research lab and made an error frequently made in hospitals. She picked up the wrong glass vial to commence an experiment. When she described what happened, I pointed out to her that she made an error for the same reason errors are often made in hospitals: the vial was not color-coded to help remind her of its contents. Hospitals make this same mistake with much deadlier consequences, by having health care workers confuse medications with saline solutions or water, because the containers are not clearly marked.

The incidence of hospital-acquired infections is often a result of health care workers not attending to a process of washing their hands frequently enough. While it is easy to blame them, the opportunity to make hand washing easier is easy to create. At Pitney Bowes, we put hand-sanitizers everywhere, and we reduced the frequency of seasonal influenza, as well as upper respiratory infections.

Hospital workers and doctors sometimes believe that taking the time to wash hands reduces their productivity in terms of the number of patients they can see during the day, but increasing staffing to give everyone time to wash their hands is an investment that easily pays itself back.

The other big issue, which the recent health care reform legislation makes an effort to address, is the problem with preventable readmissions. Many people end up back in the hospital for the simple reason that they fail to comply with the instructions hospitals provide them when they are discharged. Early this year, I visited a major academic medical center that had a world-class electronic health information system, thanks, in part, to the work the brother of a close friend of ours had done.

However, despite the world-class information system that existed within the hospital, the discharge instructions provided to the patient upon discharge were in paper form. There was no easy-to-use and standardized system for getting these instructions to the primary care physician for the patient or to whoever could most closely help the patient manage the post-hospital health care process.

The health care reform legislation will provide incentives to those hospitals,which do the best job in reducing preventable readmissions. This is a welcome change in the law, but we have to go much further if we are going to reduce and eventually eliminate this problem. Dr. Denham has done a wonderful and hard-hitting documentary entitled Waiting for Zero, which eloquently portrays the problem, with the help of actor Dennis Quaid, who, despite his wealth and influence, and his ability to secure what he believed to be the best available for his twin daughters, almost lost both of his twins because of hospital errors several years ago.

The hospital safety problem is the largest piece of a broader systemic problem of sloppy, error-prone health care in our country. The solution is not a single-payer, or single-provider, system, or consumer-directed health care, but a relentless focus on error-free care delivery in every part of the health care system.

I should note that health care errors do not just happen in acute care settings. In 1989, we lost a son at birth because of a poorly-administered lab test that prevented physicians from from diagnosing a condition that would have led to a early, planned, and, most likely successful cesarean birth. Medical errors can happen anywhere and have devastating results.

Regardless of what else I do in 2011, I would expect that focusing on patient safety will be a high priority.