THCB

Reduction in Hospital Errors—Progress, But Still Not Enough

Steve Findlay

Fifteen years after the landmark IOM report To Err is Human, we still haven’t figured out how to count medical errors and iatrogenic harm—let alone sharply reduce them. The debate surrounding this persists, as it must. For example, see the dialogue on THCB between Anish Koka and John James on the often-used figure of 400,000 deaths per year from medical errors. See also this Health Affairs blog from 2012 by Michael Millenson.

A simple answer to why it’s so hard to count medical errors, harm and deaths is that—well, it’s just a damn hard thing to do. Think about it: how on earth would we document every mistake, even fatal ones. It seems nearly impossible. It’s not like counting auto accidents or plane crashes. The majority of medical errors occur at a nuanced level, but yet can have profound effects down the road, as the IOM’s report on diagnostic errors recently emphasized.

A more complex analysis of why medical errors are hard to count and prevent would start with the fact that reporting is still largely voluntary. For example, we know next to nothing about medical errors in doctor’s offices and outpatient surgery centers, and we don’t have a complete picture for hospitals.

Then there’s the whole issue of which medical mistakes are truly preventable and should be counted as such—that’s part of the debate between Koka and James. The upshot: preventability remains very much in the eye of the beholder.  Patient safety activists argue that the debate over preventability is a diversion from pursuing a strategy of zero tolerance for errors. As support, they often point—justifiably—to success stories where concerted efforts have led to dramatic reductions in errors and hospital acquired infections. But doctors have long countered that medicine is a human enterprise that can never be perfect, that mistakes are inevitable, and that they have less control over medical outcomes than is often assumed.

Despite these ongoing debates, some errors and harms are being tracked much more carefully, and on Dec. 1 the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare and Medicaid Services (CMS) released their latest batch of numbers that put a positive spin on progress in at least one setting: hospitals.

They calculated that between 2010 and 2014 hospital patients experienced 2.1 million fewer “hospital-acquired conditions” (HACs), a 17 percent decline over what would have occurred had the HAC rate stayed at the 2010 level. They further calculated 87,000 fewer deaths due to HACs over that period and a savings of $20 billion in healthcare costs.

In raw numbers, HACs declined from 145 per 1,000 discharges in 2010 to 121 per 1,000 in 2014. (Notably and of concern, progress was flat from 2013 to 2014.)

About 40 percent of the overall reduction in HACs was attributable to fewer adverse drug events, followed by 28 percent due to a decline in pressure ulcers, and 16 percent due to a reduction in catheter-associated urinary tract infections (CAUTIs).  All together, about 25 types of HACs were measured.

The AHRQ/CMS report is refreshingly honest about three things: (1) the methodology is hardly full proof; (2) exactly why and which corrective efforts led to the decline is not well understood; and (3) progress to date is good but not at all sufficient.

On the methodology, see the report for the caveats. On why the decline, in their words: “The reasons for this progress are not fully understood. Likely contributing causes are financial incentives created by CMS and other payers’ payment policies, public reporting of hospital-level results, technical assistance offered by the QIO program to hospitals, and technical assistance and catalytic efforts of the HHS Partnership for Prevention initiative led by CMS.”

On the need for further progress, the report bluntly states that 10 percent of patients experiencing one or more HACs remains a serious problem.

All would agree. The challenge now is to accelerate progress by redoubling patient safety initiatives, in hospitals and other settings. That should include more mandatory reporting and more rigorous linking of payments under CMS’s value-based purchasing programs to medical error reduction. Many hospitals have clearly stepped up to the plate on this problem. But way, way, way too many people are still being harmed in hospitals even as best practices to reduce errors become well established.

Addendum: if the terminology surrounding medical errors and patient safety confuses and/or annoys you, Consumer Reports is having a webinar on the subject on Dec 11. Learn more here.

Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology.

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