Patient Safety Issues Continue to Plague American Hospitals

Abstract

here has been a significant focus on patient safety issues over the past two decades. This began with the release of To Err is Human in late 1999, 1 but has included numerous other reports indicating the substantial number of deaths and injuries due to medical errors. Despite the focus on this topic by hospital associations, medical groups, and various professional organizations, such as the ECRI Institute, a recent report indicates serious challenges remain. 2 Johns Hopkins researchers recently published a study based on the latest available statistics estimating that 161,000 avoidable deaths occur each year. 2 While the good news is that this number is down from the 206,000 preventable deaths estimated in the original study from 2016, 160,000 or more avoidable deaths remains a large number of people who are dying from preventable errors in the delivery of health care and it is clear that serious safety challenges persist. It is also likely that this latest estimate may only be the proverbial "tip of the iceberg" because the number is likely to be an underestimate-there are no ICD codes for human and system errors-and because the estimate ignores other medical mishaps and morbidities that do not result in deaths.Medicare is trying to reinforce the importance of patient safety in its payment policies by reducing payments to hospitals that have demonstrated reasons for there to be concerns about the safety of patients. Between October 2018 and September 2019, 800 hospitals will have had their reimbursements reduced for patients discharged because of such concerns, with the penalties applied when hospitals submit their claims. Under the program, a hospital is given a total score based on performance according to six quality measures: Hospitals that fall in the worst-performing quartile will lose 1% of their Medicare payments for Medicare beneficiaries who were discharged in the year in which the safety concerns occurred.

Courageous leadership for a culture of emotional safety

“…For example, we repeatedly ask patients to state their name and birth date, take time out to verify procedures, and obsessively clean equipment. Yet, despite these precautions, estimates of preventable hospital deaths range from 22,000 to 160,000 per year 10,11…”

“…Yet, despite these precautions, estimates of preventable hospital deaths range from 22,000 to 160,000 per year. 10,11 Though more research is needed, it's possible that a number of these deaths resulted from caregivers struggling with the negative emotions cited in the Gallup study. In his seminal study on the psychology of military incompetence, Norman Dixon concluded that the primary distinction between competent and incompetent commanders was their ability, or inability, to manage anxiety.…”