Patient Safety: Rejecting the Status Quo

Abstract

little over five years ago, the National Academy of Science’s Institute of Medicine (IOM) released its groundbreaking report on medical errors To Err Is Human. 1 The report, a product of more than a year’s work by the Committee on the Quality of Health Care in America—on which I had the privilege to serve— was a startling indictment of the unsafe state of hospital care prevalent in the United States. As this report was released there was an enormous media response, especially to the body count of patients that the IOM attributed to safety lapses (44,000 to 98,000 deaths in America’s hospitals each year). The range of estimated fatalities meant that medical error was the fourth or eighth leading cause of death in the United States, and even more alarmingly, many of these deaths were said to be preventable. Reaction to the IOM’s To Err Is Human To Err Is Human caused a firestorm of reaction, some of which was highly critical of specific conclusions or recommendations made by the committee. While few denied that there were safety problems, many took issue with either the IOM’s assessment of the dimension of the problem or to its specific recommendations—especially those that proposed mandated changes in the ways that hospitals and health professionals went about providing care and how they were held accountable for the safety of patients. There was, in general, an expression of gratitude for the IOM’s leadership in bringing the problem to the forefront of national consciousness, and while many went back to business as usual, many other providers, professionals, and policy makers rolled up their sleeves to try to do something about the safety problem. President Clinton pulled together an interagency task force to tackle safety within the federal healthcare system. Congress, heeding one of the IOM’s principal recommendations, budgeted an extra $50 million to the Agency for Health Care Research and Quality (AHRQ) to be used to improve patient safety throughout the healthcare system. That same year, a group of large employers formed the Leapfrog Group to discuss how they could work collectively to influence healthcare quality and affordability. The group promised (and threatened) to use their combined financial leverage to drive the system toward improved safety and better quality outcomes. Hospitals began to plan for computerized physician-order entry systems (CPOE), bar coding, and the use of clinical pharmacists on rounds to reduce medication errors. Operative sites were to be marked for identification (or, was it the “nonoperative” site that was to be marked?), and operating room “time-outs” were instituted to ensure that the right patient was getting the right operation for the right site. Three decades or more of plans for converting from paper to electronic medical records, digitizing films and test results, and other ways of sharing critical patient information in real time were dusted off. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quickly developed accreditation standards that focused on patient safety, and the American Medical Association (AMA) founded the National Patient Safety Foundation. Legislatures in more than a dozen states began considering legislation aimed at attacking the patient safety crisis. So, from early 2000, it appeared, at least to some observers, that patient safety was an issue whose time had come, and that perhaps the IOM’s challenge to healthcare providers and professionals—to work toward a 50% reduction in medical errors by the end of 2004—was a real possibility. Quagmire