What the Work of the Inspector General Tells Us about Patient Safety…

March 2nd through the 8th were National Patient Safety Awareness Week – I don’t really know what that means either.  We seem to have a lot of these kinds of days and weeks – my daughters pointed out that March 4 was National Pancake Day – with resultant implications for our family meals.

But back to patient safety and National Patient Safety Awareness Week. In recognition, I thought it would be useful to talk about one organization that is doing so much to raise our awareness of the issues of patient safety.  Which organization is this?  Who seems to be leading the charge, reminding us of the urgent, unfinished agenda around patient safety?

It’s an unlikely one:  The Office of the Inspector General of the Department of Health and Human Services.  Yes, the OIG.  This oversight agency strikes fear into the hearts of bureaucrats: OIG usually goes after improper behavior of federal employees, investigates fraud, and makes sure your tax dollars are being used for the purposes Congress intended.

In 2006, Congress asked the OIG to examine how often “never events” occur and whether the Centers for Medicare and Medicaid Services (CMS) adequately denies payments for them.  The OIG took this Congressional request to heart and has, at least in my mind, used it for far greater good:  to begin to look at issues of patient safety far more broadly.

Taken from one lens, the OIG’s approach makes sense:  the federal government spends hundreds of billions of dollars on healthcare for older and disabled Americans and Congress obviously never intended those dollars pay for harmful care.  So, the OIG thinks patient safety is part of its role in oversight, and thank goodness it does.

Because in a world where patient safety gets a lot of discussion but much less action, the OIG keeps the issue on the front burner, reminding us of the human toll of inaction.

While the OIG has had multiple important reports in this area, the watershed one was their eye-opening November 2010 report. If you haven’t read at least the executive summary, you should.   The OIG looked at care for a national sample of Medicare beneficiaries and what it found was unexpected:  13.5% of Medicare beneficiaries suffered an injury in the hospital that prolonged their hospital stay, caused permanent harm, or even death.

An additional 13.5% of Medicare patients suffered “temporary” harm – such as an allergic reaction or hypoglycemia – things that are reversible and treatable, but quite problematic nonetheless.  Taken together, these data suggest that 27% of older Americans suffer some sort of injury during their hospitalization – much higher than previous numbers.

There are three more statistics from the OIG report that should give us all pause:  First, they estimate that unsafe care contributes to 180,000 deaths of Medicare beneficiaries each year.  This is a stunningly high number.  Second, Medicare pays at least an additional $4.4 billion to cover the costs of caring for these injuries.  And finally, about half of these events are preventable based on today’s technology and know-how.

I suspect that if we actually make safety a priority, many more events would become preventable over time.   And yet, although hospitals are supposed to identify, study, and track adverse events, the OIG says it mostly isn’t happening.  At least not in any systematic way.

This is all old news, of course, so on to new news:  the OIG just released another excellent report, this time on harm in skilled nursing facilities (SNFs).  While we have paid a lot of attention to acute hospitals, we have generally paid far less attention to what happens when patients leave.  And, about 20% of Medicare patients, after discharge, go to a SNF.

So, the OIG went looking at SNF care, and what they found is both unsurprising and quite disappointing:  during their SNF stay, 22% of Medicare beneficiaries suffered a harm that prolonged stay, caused permanent harm, or even death.  And, an additional 11% suffered temporary harm that could be reversed with a medical intervention.

Physician reviewers considered 59% of these events to be preventable and these physician reviewers “attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care.”  And these adverse events add an additional $2.8 Billion to Medicare spending.  And remember, none of these financial calculations include the financial harm patients suffer because of lost work, family members having to take time off to provide additional care, etc.

It’s been 15 years since To Err is Human and patient safety has gone from a niche topic to something far more mainstream.  We now recognize that safety is a huge problem.  However, over the past few years, we have seen consistently disappointing data that we aren’t making much progress.  It has caused many people to stop trying.

Of course, we can’t publicly admit that we are giving up when the human toll is so high.  So, instead, we are encouraging “voluntary reporting” that ignores most errors, using metrics to assess performance that don’t really reflect the safety of underlying care, and putting tiny incentives in place that aren’t meaningful enough to really change behavior.  In 5 years, when we talk about the 20th anniversary of the To Err is Human report, will we wonder again why we have made so little progress?

The path forward, although difficult, is pretty clear.  I’ve previously described a set of proposed solutions but in a nutshell, I think we should do three things:  Measure and monitor adverse events in a systematic and robust way.  This is increasingly possible with EHRs and we have described how before.  Second, make safety data public.  It will catalyze professional ethos, create real competition for safety, and force hospitals to get better.  Third, put big incentives on the table so that there is a clear business case for safety.

There are lots of ways to do it and are well described.  And if we actually want to do this, we will have to reform our malpractice system so that these data can’t be turned into information for litigation. Finally, we need to move beyond hospital safety (despite having made so little progress in this arena) and start including safety in in a much broader context.  As the OIG points out, there are lots of safety problems in post-acute care as well.  That’s my wish list for what we need to do.

I’m not sure it’s right, and others surely have better ideas.  But we can’t be satisfied with our current efforts.  And, thanks to the OIG, we are fully aware of the size and scope of the problem.

So, during Patient Safety Awareness Week, we should all take a moment to thank the Office of the Inspector General at HHS for reminding us that patient safety remains a pressing concern.  Fixing it, of course, will require tough solutions and a lot of unhappy “stakeholders” who like the status quo.  But, as the OIG reminds us, the human and financial costs of waiting is very high.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence where this post originally appeared. He is also the Senior Editor-in-Chief for Healthcare: The Journal of Delivery Science and Innovation.

12 replies »

  1. I am happy to hear that there is at least one organization in charge of a patient’s safety, even though the US Congress dislikes the amount of money invested into such activities. Hopefully they will manage to fight any possible obstacle.

  2. For the first time, Japan is trying to hold down the number of bedbound elderly people kept alive, sometimes for years, by feeding tubes.

    Cash reimbursed to hospitals from the national health insurance program for surgically inserting a tube to the stomach will be cut 40 percent to 60,700 yen as of April, while 25,000 yen will be added if a swallowing evaluation is done before the insertion, the health ministry said.

    Rehab per session will be doubled to 3,700 yen for hospitals “with an outcome of 35 percent recovery or higher.” The price paid back to stop the feeding and stitch up the incision will rise 17 percent to 140,400 yen. Hospitals performing 50 surgeries a year or more will face a further 20 percent cut in payouts for each new feeding-tube case ’’if they don’t evaluate all cases and the recovery is lower than 35 percent’’ from April next year.

    Recuperation hospitals will be encouraged to speed up rehabs to help discharge patients from hospitals quicker, said Yukihiko Ikebata, vice chairman of Japan Association of Medical and Care Facilities, which represents recuperation hospitals.

    The new rules recommend a guideline used for stroke patients to assess swallowing ability with feeding tubes cases. That includes practices such as checking throat muscles by having a patient swallow food coated with an imaging agent and see how it travels using X-rays or endoscopes.


  3. A review of the “Patient Safety” initiatives and movements of the past 20 years reveals that the problem is the same or worse than ever in 2014 in spite of the billions of tax dollars donated to the problem, and in spite of bad laws that have been passed by The Congress and State governments and/or implemented by the Executive. — as influenced by for-profit safety consultant entities in the private sector who are paid millions of dollars, as well, to consult about this “unsolved” problem. . .,

    The for-profit entities directly involved, i.e. the hospitals and the insurance companies, don’t want any solutions that will in any manner negatively impact their profits.

    The victims of this MESS, the public and those on Medicare/Medicaid, have no idea that their Medicare and private GAP and Advantage Insurers DO NOT REIMBURSE the hospitals for mistakes, errors, exceeding the DRG Caps, and non beneficial over treatment and ALL of the complications thereof.

    Covert/Overt DNR Code Status is epidemic in US Hospitals today but this is a final “adverse” event that is ignored by The Congress, The Executive, and the so called “free press” of the United States.

    Why hasn’t the national Organization of Health Care Journalists who seems to informally monitor hospital safety inspection reports, etc.. ever written about the problematic DNR Code Status that has been identified and written about for at least 40 years, according to experts like physician Muriel Gillick of the Hastings Center? .

  4. What is really disgusting is that these errors, i.e. “adverse events” are NOT reimbursed by CMS or GAP and Advantage Insurers. Medicare/Medicaid patients (most prone to suffer from adverse events) who pay Medicare and Social Security taxes their whole working lives have NO IDEA that they are the victims of errors and “charity” patients for the hospitals —and that they may be hastened unto death for fiscal expediency and to hide the errors. .

    Disgracefully, our Congress, HHS, CMS and Big Insurance, when they developed the policy to NOT reimburse hospitals/physicians for adverse events, made no law that protects the patients and that requires hospitals, physicians, or Medicare to notify patients that they are the victims of errors and “charity” patients for the hospital. Often, these elderly/disabled Medicare/Medicaid patients are hastened unto death with covert/overt(default DNR Code Status. for the fiscal expedience of Big Insurance and the hospitals.

    This is what happens when you have “profit-centered” health care and not patient-centered healthcare. The epidemic of unilateral covert/overt(default DNR Code Status that is extrapolated into the hospital charts of elderly/disabled Medicare/Medicaid patients to limit/withhold life-saving and life-extending treatments that won’t be reimbursed is a national disgrace.

    The OIG has to know this is a MESS that is ignored by HHS and the Congress and that is “stepped over” and not cleaned up because it is a MESS that is not understood by the Medicare/Medicaid population who CAN be hastened unto death without their knowledge and/or informed consent.

  5. Dr. Harrison:

    I’m not a betting man except for sure things. So call this two-part gentlemen’s wager. Part 1: I’ll bet that your hospital has far, far more preventable deaths and injuries from infections and other causes unrelated to EHRs than it does from the EHR. Part 2: In a random sample of physicians, more will be concerned about the unsafe potential of any medical device you pick (EHR or other) than of the behaviors of the clinical team.

    The OIG is focusing on where most of the deaths and injuries occur in the hope that a steady stream of data will cause the profession to do what it should have already accomplished, given that the IOM report came out 15 years ago.

    That doesn’t forgive the problems in EHRs. However, for those of us who have been in the patient safety world for many, many years, to talk about EHRs without first acknowledging their relative importance grates a bit, even though you certainly did not mean it that way.


  6. No, sadly it isn’t.

    But, may be it pushes the conversation towards great action — and makes the person in the surgical waiting room a couple of years from now a little safer.

  7. This is not reassuring reading for anyone in a hospital surgery waiting room…

  8. Michael,

    I always love your comments on my blog — pithy, insightful. Tejal Gandhi is a smart, committed person. I would love to see them be effective.

    But, OIG isn’t enough. I would like to see CMS and others come back with a response that is proportionate to the size and severity of the problem.

    Some have dismissed prior reports on patient harm as exaggerations. The OIG doesn’t strike me as a squishy organization prone to simplistic exaggerations.

    Thanks for weighing in.

  9. The National Patient Safety Foundation began Patient Safety Awareness Week in 2002. It has proven to be just as effective in improving patient safety as has the National Patient Safety Foundation, a spin-off of the American Medical Association that depends heavily on corporate support. NPSF recently got new leadership — let’s hope it’s more effective than in the past.

    Ashish, to use a technical term about your terrific suggestions: “From your mouth to God’s ears.”


  10. “a lot of unhappy “stakeholders” who like the status quo.”

    And a LOT if that status quo goes to the chronic continuing prevalence of toxic psychosocial healthcare workplaces — e.g., the “Bully Culture,” also a topic long recognized as an identifiable component of patient safety, yet also an area short on systematic analytic study pointing to effective remedies.

    People working on the front lines in healthcare are under increasing “productivity treadmill” time constraints, amid an increasingly complex technological and cognitive burden work environment. And, the “shame and blame culture” continues to hold material sway, notwithstanding all the tired Smiley Face Happy Talk regarding “fix the problem, not the blame.” The error rate / patient safety upshot of FUD environments should come as no surprise.

    None of this is exactly news. We KNOW that error rates are significantly correlated with workplace stress. People under duress make more mistakes, all other factors being equal. Until we pay systematic and prolonged attention to improving the psychosocial “health” of healthcare operations, all we’re likely to get — in addition to ineffective coercive “workplace wellness” programs — are more slick data reports pointing fingers in every direction.

    Calls for “critical thinking” among workers fashionably abound. But, you simply cannot have a “critical thinking” CQI operation within a culture where one speaks truth to power at one’s peril. Dr. Toussaint of The ThedaCare Center added an 8th waste to the Lean model — the waste he calls “unused talent.” Part of that cannot but be the waste of the talents of people who might well be able to help improve things like patient safety but who are too often cowed by FUD. The first-rate talent moves on at the first opportunity. The ostensible “lesser lights” quickly learn that surviving in your job means keeping your head down and not making waves in the face of executive and managerial arrogance and the error-escalating subterranean hostility it invariably breeds.