One of the most referenced and influential reports on raising awareness of the patient safety crisis in the United States marked its 20th anniversary this fall. The Institute of Medicine released the groundbreaking 1999 report “To Err Is Human: Building a Safer Health System,” 20 years ago as rapid changes were occurring in the healthcare sector as patient safety and healthcare quality began to take the lead.

As a society, we accept that all humans make mistakes. It’s inevitable that humans are not perfect and will continue to make mistakes. Now, if you factor in that the healthcare industry deals with complex processes and relatively higher amounts of stress than other industries, the phrase “To Err Is Human” rings true. Long work hours, limited staff, and high turnover rates with sudden vacancies allow for medical mistakes to happen, more often than they should.

The 1999 report defines medical errors as the “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” [1] Beyond the cost of human life, according to the report, patients can face significant financial loss from the expense of additional care necessitated by the error and often the loss of household income or disability. Errors can also be extremely costly for healthcare organizations creating diminished patient satisfaction, broken trust, and tarnished reputations.

Since the movement towards higher healthcare quality, patient safety improvements, and medical error prevention, there have been some major wins in the industry. The focus became attaining zero harm and maximizing patient engagement. Even though the efforts were heading in the right direction with momentum from the US Congress to reduce the percentage of patient harm occurring, medical errors are still as prevalent today as in 1999.

A 2016 report from John Hopkins, with patient safety experts analyzing medical death rates over an eight-year period, calculated that more than 250,000 deaths are attributed to medical errors in the US which continues its rein as the third leading cause of death. [2] Medical errors now lead respiratory disease which kills close to 150,000 people each year.

A recent Time Magazine article, “The Health Care Industry Needs to Be More Honest About Medical Errors,” quotes from a September 2019 report on patient safety from the World Health Organization. Among WHO’s findings: “Globally, hospital-acquired infections afflict about 10% of hospitalized patients. Medical errors harm some 40% of patients in primary and outpatient care. Diagnostic and medication errors hurt millions, and cost billions of dollars every year.” [3]

The industry has a long way to go according to most patient safety experts today. The Joint Commission in their November blog point out that time, effort and resources directed at solving problems has seen some progress but a “one-size-fits-all” best practice simply can’t address each problem.

 

3 areas were called out as a way to shift the improvement paradigm in the future of patient safety:

  • Commit to zero harm

The goal of attaining zero harm is widely recognized in the aviation and nuclear power industries as they have adopted high reliability and a safety culture which accepts no less than zero   harm.

 

  • Overhaul organizational culture. 

Healthcare Leaders must stop the blame game and offer transparency and open communication across departments. Only when a safety culture encourages event reporting can adverse events be avoided and uncovered.

 

  • Adopt the most highly effective process improvement methods

Leverage technology, best practice, and industry expertise to drive high reliability. Using a Governance, Risk, and Compliance for Healthcare (GRCH) framework, Verge Health’s Strategic Advisory Services combine investigative workflow and process optimization with ongoing collaboration.

 

Verge Health is your partner on the pathway to zero harm and high reliability. Allow us to show you how Verge’s Converge Platform and patient safety application can remove barriers as your organization works toward high reliability in 2020. Learn more about our products here.

 

Resources:

[1] http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

[2] https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us

[3] https://time.com/5717545/medical-errors/

[4] https://www.jointcommission.org/high_reliability_healthcare/to_err_is_human_the_next_20_years_/

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