“Patient safety” is “freedom from accidental injury due to medical care, or medical errors.”

“Medical error” is  “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim…

[including] problems in practice, products, procedures, and systems.”   Institute of Medicine

This is the second of two articles about the role that patient safety plays in the current health care crisis.  Part 1, published in the June 2005 issue of richmondWOMAN, provided information on the scope of the patient safety issue and summarized the current state of efforts to reduce medical errors including actions taken in Virginia.  This article explores what should be done to make health care safer, save lives and reduce health care costs.

Some significant and positive changes have taken place since 1999 when the Institute of Medicine reported in To Err is Human: Building a Safer Health System that as many as 98,000 people die annually as a result of medical errors.  The most important change is that no one now tries to deny that the health care system in America has a safety problem.  At the same time, however, it is clear that this change in attitude and initial efforts to address the underlying problems have not yet resulted in any significant increase in patient safety or reduction in patient deaths. 

As Lucian Leape, MD and Donald Berwick, MD, reported in the May 18, 2005 issue of the Journal of the American Medical Association, “[b]uilding a culture of safety is proving an immense task and the barriers are formidable.”  JAMA, May 18, 2005, Vol. 293, No. 19, page 2385 .  Yet, some hospitals are proving that the goal of reducing patient deaths and injuries is not only realistic, it is achievable.

The 100,000 Lives Campaign, launched by the Institute for Healthcare Improvement, is showing that hospitals that focus on patient safety can prevent medical errors and hospital transmitted diseases, such as pneumonia and blood infections.   The campaign has adopted as its goals those suggested by the Institute of Medicine:  90% reduction in infections; 50% reduction in medication errors; 90% reduction in errors associated with high-harm medications; and 100% elimination of the National Quality Forum’s “never” list.  Reporting on the 100,000 Lives Campaign, the Associated Press recently reported that hospitals in Michigan and New Jersey have “virtually eliminated ventilator-associated pneumonia and blood infections from neck and groin catheters,” (“Hospitals Push to Curb Medical Mistakes,” Associated Press, June 2, 2005).

Achieving these results not only saves lives, but it saves money and reduces health care costs for everyone.  According to Dr. Thomas Rainey of the 100,000 Lives Campaign, each case of pneumonia is life threatening and increases health care costs by at least $40,000.  Infections from catheters kill 42% of the patients infected on average.  One hospital system in New Jersey reported that it saved $2 million in direct costs for medicines and supplies in one year by reducing patient complications well below the state average.

What can we do to encourage more emphasis on patient safety within Virginia hospitals and health care institutions?  In addition to encouraging a “culture of safety,” I believe that we must take three key steps if we are to improve patient safety in Virginia.  First, we need to collect and publish data that will allow patients and policy makers to make informed decisions about patient safety at Virginia health care institutions.  Without data, it is impossible to understand the problem or to design a solution.

Next, we need to use that data and implement a payment system that rewards institutions and providers with strong safety records. 

Finally, we need to consider additional changes to our system for compensating victims of preventable medical accidents and diseases that occur in institutional settings.

Getting the Facts

Virginia does not have a mandatory system for reporting all significant medical errors.  As the staff of the Joint Commission on Health Care pointed out in 2000, Virginia’s patient level data reporting system is inadequate to develop a comprehensive picture of medical errors occurring in Virginia institutions.  While mandatory-reporting systems cannot cure our patient safety problem, it is impossible to monitor patient safety and improvements in patient safety without reliable data. 

There is great concern among doctors and hospital administrators about mandatory reporting. A study reported in the March 16, 2005 Journal of the American Medical Association reported that “[m]ore than two-thirds of the doctors responding thought that a state-mandated public reporting system would discourage error reporting and would not improve patient safety. In contrast, the hospital executives thought that confidential reporting would foster the desire to focus on identified problems rather than lay blame and would lead to safer, higher quality care. “

The Centers for Disease Control have recommended establishing public reporting systems for one or more of the following medical errors related to hospital acquired infections: central-line insertion practices, prophylactic antibiotics for surgery, flu vaccination, bloodstream infections associated with a central-line, and surgical site infections following specific surgical procedures.  The CDC released guidelines in February 2005 to help guide states considering mandatory reporting of hospital-acquired infections.

It is time for Virginia to require health care institutions to report patient safety data.  Such data should be collected confidentially but information on the experience at individual hospitals should be aggregated and made public.   Once we know the actual dimensions of the problem in Virginia, we adopt goals and measure our progress in solving it.

Paying for Results

The National Quality Forum has developed a list of 30 evidence-based safe practices ready for implementation. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began requiring hospitals to implement eleven of these practices in 2003.

It is time to start paying for performance, and rewarding health care institutions that save lives and money.  According to Leape and Berwick, “[t]he current reimbursement structure works against improving safety and actually rewards less safe care in many instances.”  … In most industries, defects cost money and generate warranty claims.  In health care, perversely, under most forms of payment, health care professionals receive a premium for a defective product; physicians and hospitals can bill for the additional services that are needed when patients are injured by their mistakes.”  JAMA, May 18, 2005, page 2388.

In a report to Congress on March 1 of this year, the Medicare Payment Advisory Commission concluded, “it is time for the Medicare program to differentiate among providers when making payments.”  The Commission called for Congress to instruct the Medicare program to design a pay-for-performance system that rewards improvement, as well as attaining or exceeding certain benchmarks.

It is time for us to call on the Virginia legislature to implement a Medicaid reimbursement system that is structured to reward institutions that implement these safe practices.  Private insurers should follow suit.

Compensating the Injured

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) suggests that the current medical liability system fails patients because it does not effectively deter negligence, offer corrective justice, or provide fair compensation to those injured through the care process. The JCAHO has made 19 specific recommendations and identified three strategies for improving patient safety and reducing medical liability: (1) actively pursue patient safety initiatives that prevent medical injury; (2) promote open communication between patients and practitioners; and (3) create a patient-centered injury compensation system.

The Virginia General Assembly passed legislation in 2005 designed to facilitate open communication.  It allows doctors and hospitals to talk candidly with patients about mistakes without fear that their words will be used against them in a lawsuit.

The Virginia legislature should look carefully at the JCAHO’s recommendation that a no-fault system like the workers’ compensation system be developed to compensate patients for injuries and diseases incurred in a hospital setting.  Such a system could reduce the human and financial cost of medical errors while ensuring that patients receive timely compensation for preventable injury or death.

Of course, we will never get achieve the goal of a “culture of patient safety” without leadership.  Leape and Berwick report that, to date, “few of the chief executive officers and boards of hospitals and health-plans have made safety a true priority in their institutions or committed substantial resources toward safety.”  JAMA, May 18, 2005, page 2388.  It may well be that the only sure way to move safety up the priority list is to link it directly to the bottom line or profit statement of these institutions.