By Debi Quirk, MSN, RNC
This week is National Patient Safety Week. Patient advocate Debi Quirk writes that although there has been some progress in reducing medical errors, mistakes are still far too common.
In 1999, the Institute of Medicine in its now-famous report, “To Err is Human,” found that as many as 98,000 Americans die in U.S. hospitals every year due to medical errors. Some experts argue the number is considerably higher.
The IOM report made patient safety a national concern and sparked efforts across the country to reduce medical errors.
Progress, however, has been slow and, now, more than ten years later, it is likely the situation is no better and probably worse.
A 2010 report, for example, found that 13.5 percent of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays that resulted in prolonged hospitalization, required life-sustaining intervention, caused permanent disability, or resulted in death.
The report, issued by the Office of the Inspector General at the U.S. Department of Health and Human Services, also found that an additional 13.5 percent experienced temporary harm events that required treatment.
The OIG investigators concluded that 44 percent of occurrences were preventable.
Some progress has been made. Many hospitals have adopted the practice of having “safety pauses” before a surgical procedure to make sure safety protocols that reduce errors are followed. And the adoption of checklist-driven protocols has been shown to drastically reduce central-line infections
But, at the same time, acceptance of such simple, commonsense practices as hand washing has been slow. The adoption of strict hand-washing guidelines and the installation of hand sanitizers in every room, for instance, prompt only about 60 percent of care providers to wash their hands prior to touching a patient or a patient’s surroundings.
And doctors have been known to be the least compliant in several studies.
- First, research the facility that you plan to use. Information can be found at hospitalcompare.hhs.gov about a facilities infection rates. Here, you can read surveys of patient experiences and look at what patient safety measures they have put into place.
- Take along a family member, friend, or a private advocate. When you are trying to heal, you’ll need someone else to write down the fine details of your procedure and recovery as well as ask the questions that will get you the answers you deserve. Find a reputable patient advocate through professional patient advocate associations such as www.advoconnection.com, and www.nahac.com.
- If you are having surgery, review the instructions completely with the nursing and medical staff; do not hesitate to call your advocate with any questions prior, during, and after.
- Learn about hospital-acquired infections and how to avoid them. Do not hesitate to ask your caretakers to wash their hands if you did not observe this.
- Read “A hospital survival guide” published by Consumers Report and available online for free.
- Know how to avoid prescription drug errors. Read “What You Can Do to Avoid Medication Errors” on AARP’s My Medical Manager page.
- Learn more from the National Patient Safety Foundation.
Despite the lip service given to making patient safety a priority, hospital staff does not report 86 percent of errors, according to report released in January by U.S. Department of Health and Human Service’s Office of the Inspector General,
Some of the most serious problems, including those that caused patient deaths, were not reported, the researchers found.
And even when employees report harm to patients, the investigators found that “hospitals made few changes to policies or practices.” In many cases, hospital executives told federal investigators that the events did not reveal any “systemic quality problems.”
Pressure on hospitals to get serious about protecting patients from harm is growing. To date, 27 states have passed laws requiring them to report their hospital-acquired infections rates. These and other statistics on quality of care are now being posted online at such national websites as HospitalCompare and LeapFrogGroup.org and, locally, on the Puget Sound Health Alliance’s Community Checkup website.
And next year a provision of the new health-care reform law goes into effect that will punish hospitals that fail to meet quality standards. The provision establishes a new “value-based purchasing” program that will cut Medicare reimbursement to hospitals that don’t measure up to a set of performance standards that will include patient-safety measures.
Hospitals delivering low-quality care stand to lose up to 2 percent of their reimbursement—a substantial amount of money to most hospitals, which depend on Medicare to survive.
Many health-care providers are making a serious effort to improve patient safety, but clearly we have a long way to go. In the meantime, you can protect yourself by taking some simple precautions (see panel) and by insisting your providers deliver the level of care they promise.
Debi Quirk has a Masters of Science in Nursing and is a nationally certified Registered Nurse who has worked for 34 years in hospital and home health care and has also taught future nurses at the university level. She currently is a private patient advocate in Seattle, Washington. She started RN Patient Advocates of Puget Sound because her passion is to empower patients to get the best health care possible.