Cultural transformation culture of safety patient safety

The Human and Financial Cost of Preventable Medical Errors

One of my passions is patient safety. I’ve written posts about it on many occasions and my team and I have developed patient safety initiatives for hospitals and health systems for more than a decade. Here’s a link to one of my more recent posts. One of the proud moments in my career was being published in the Joint Commission’s Journal on Quality and Safety: “A Multifaceted Approach to Education, Observation, and Feedback in a Successful Hand Hygiene Campaign,” Joint Commission Journal on Quality and Patient Safety,  January 2011, Volume 37, Issue 1.  I was one of many co-authors, primarily clinicians, from Tufts Medical Center. Additionally, our work on patient safety has been featured in Infection Control Today and USA Today.

Yesterday, I had the pleasure of attending a press conference at the Betsy Lehman Center for Patient Safety, a state agency in Massachusetts that uses communications, research, and data to catalyze the efforts of providers, policymakers, and consumers working toward safer health care in Massachusetts. The team at the Betsy Lehman Center was announcing the findings from two studies they recently undertook to assess the human and financial cost of preventable medical errors within the state. They are doing important work and I was honored to be in the audience while they summarized their findings.

Here’s an excerpt from the materials provided at the press conference:

‘There has been considerable progress on improving the safety of health care for patients over the past two decades, particularly in hospitals in Massachusetts and across the country. 

Yet preventable deaths and injuries associated with medical error persist. As more complex care is delivered outside of hospitals, risks to patient safety are an emerging concern anywhere patients receive care. Systems for keeping patients safe have not always kept up with the increasing complexity of health care delivery.

The challenges are great, but so are the opportunities for improvement—particularly in Massachusetts. Our report, The Financial and Human Cost of Medical Error… and how Massachusetts can lead the way on patient safety, details two sets of research findings and also proposes a coordinated response through which the Commonwealth’s providers, policymakers, and public can accelerate safety and quality improvement and lead the nation on this urgent health care challenge.

Our research uncovered almost 62,000 medical errors, which were responsible for over $617 million in excess health care insurance claims in a single year—just exceeding one percent of the state’s Total Health Care Expenditures for 2017. Because some of the most common types of errors (for example, medication and diagnostic errors) cannot be reliably identified using health insurance claims data, these numbers underestimate both total incidence and cost. From our surveys, we learned that many of the people who report recent experience with medical error are suffering long-lasting behavioral, physical, emotional, and financial harms. Individuals report that they have lost trust in the health system and some avoid not only the clinicians and facilities responsible for their injuries, but health care entirely. Moreover, most respondents expressed dissatisfaction with how their health care providers communicated with them after the errors.”

(Source: The Financial and Human Cost of Medical Error
and how Massachusetts can lead the way on patient safety. The Betsy Lehman Center, June 2019.)

I am grateful for the work done by the Betsy Lehman Center. They have been able to generate buzz around the serious need for more progress in the patient safety arena. Here are links to some of the significant press coverage the Center was able to generate:

To access a copy of their report, go to https://www.betsylehmancenterma.gov/assets/uploads/Cost-of-Medical-Error-Report-2019.pdf.

My Rant: During the press conference, there was little attention given to the astonishing number of deaths caused by medical errors. Instead, they tended to focus on the emotional toll on people harmed in these incidents and the loss of trust in their healthcare providers/organizations.  This focus is understandable. The Center is drawing attention to the vast number of people impacted by these medical errors. The report does a great job of detailing the physician, emotional, and financial impact of medical errors. At the press conference, they also spoke a great deal about the need to train providers in the art of apologizing to patients and families impacted by medical errors. They shared data that demonstrate that when there is open communication about the error from the provider, patients report lower levels of emotional harm.

“Despite a Massachusetts law that requires providers to disclose medical errors that cause significant harm and encourages apology, fewer than one in five (19%) say that they received an apology after the medical error. Only one quarter (25%) were offered one or more types of emotional, functional or financial support services; the most common additional help offered was spiritual support.”

(Source: The Financial and Human Cost of Medical Error and how Massachusetts can lead the way on patient safety. The Betsy Lehman Center, June 2019.)

It was also stunning (although not surprising) to learn that people who experience medical errors avoid future medical care. This is a serious, long-term cost associated with medical errors. I’m not even sure how you measure the impact of this reaction?

“Two-thirds of respondents expressed reduced levels of trust in health care no matter how long ago the error occurred. Well over half of people whose error happened 3-6 years ago said that they sometimes or always continue to avoid the individual doctors (57%) or the health care facility (57%) involved in the error. Of great concern is that more than one-third of all respondents report that they continue to sometimes or always avoid all medical care.”

(Source: The Financial and Human Cost of Medical Error and how Massachusetts can lead the way on patient safety. The Betsy Lehman Center, June 2019.)

Because I am an ardent patient safety evangelist, I’d like to see a lot more energy put into eliminating medical errors on the front end and communication generated that supports that mission. We need to create cultures of safety within healthcare organizations where everyone in the organization views patient safety as job #1. I’d also like us to call it like it is: from my experience, this is not an area where you can soft-pedal the messaging – medical errors kill people, hundreds of thousands of people each year. We’ve been talking about patient safety for 20 years and haven’t made the progress one would expect. I feel that the consequences of us failing to successfully address patient safety was somewhat underplayed in the messaging at the press conference. When there are too many messages, you run the risk of the most important messages being lost. Are we working to prevent medical errors and improve patient safety, or are we trying to mitigate the damage caused by these events? Right now, I think we are too accepting of a healthcare landscape where hundreds of thousands of patients lose their lives unnecessarily each year. Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical errors in the U.S. Today, it is estimated that 10% of all U.S. deaths are due to medical errors – the third leading cause of death.

I live-streamed video of the press conference on Twitter using Periscope. Below is a 23-minute clip of the press conference followed by a 10-minute clip of the panel discussion that followed the press conference.

Press Conference (23 minutes)

 

Excerpt from Panel Discussion featuring Kim Hollon, CEO of Signature Healthcare

(Note: Signature Healthcare is a long-time client of my firm and a leader in patient safety.)

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