Patient Safety Experts, Physicians Advocate for Prevention of Medical Errors


In a Senate subcommittee hearing last month, a panel of patient safety experts and physicians raised concerns about the problem of preventable medical errors, which they say can be linked to more than 1,000 patient deaths per day.

For their part, SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, FHM, says hospitalists should demand that their hospitals report better data on patient outcomes.

"When you talk about a patient death, you're talking about the efforts of an entire hospital going into the death or survival of that patient," says Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York. "If you ask, 'Where did something go wrong?' just looking at the mortality rate doesn't help. What service are you inquiring about? How can you get clean data that’s also useful to the clinician?"

In his testimony before the Subcommittee on Primary Health and Aging, hospitalist Ashish Jha, MD, MPH, referenced a landmark 1999 report from the Institute of Medicine (IOM), "To Err Is Human: Building a Safer Health System," [PDF] which estimated that between 44,000 and 98,000 deaths in the U.S. each year can be attributed to preventable medical errors.

Since the IOM report was published, little has been done to change the systems of care delivery that can lead providers to make errors, said Dr. Jha, an internist at the VA Boston Healthcare System and professor of health policy and management at the Harvard School of Public Health in Boston.

"When a physician orders the wrong medication because two drugs might sound alike, or when a patient develops a central-line infection because a rushed surgeon didn't use proper sterile technique, we now understand that we need to focus on the system that produced the errors," Dr. Jha told Senate subcommittee members.

Both Dr. Jha and panelist Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, said the Centers for Disease Control and Prevention should expand its National Nosocomial Infections Surveillance Program to collect and report data on medical errors.

Several other speakers said hospitals should be mandated to publicly report medical errors.

"Public disclosure is a critical element to preventing these events from happening," said panelist Lisa McGiffert, director of the Consumers Union Safe Patient Project in Austin, Texas. "It informs people about healthcare outcomes and motivates healthcare providers to do more to prevent errors." TH

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