Welcome to Episode 3: The Unsettling Facts. Every day there are stories appearing online and in publications about the harms that individuals and families have experienced due to quality and safety problems. Like Emily, who celebrated her third birthday in a hospital getting a final round of chemotherapy that arguably was not necessary. Unfortunately, during the IV therapy she was given a dose of sodium chloride that was at least four times the ordered concentration and that resulted in her death. Or Lisa, an oncology nurse who had a breast biopsy that was mixed up with someone else's breast biopsy specimen. She was misdiagnosed as having an aggressive form of breast cancer, and subsequently had radical breast cancer surgery for what turned out to be a benign lesion. Or 74 year old Carolyn, who received a contrast dye that was contraindicated for her spinal surgery and she nearly died as a result. These are only a few examples of the many people who suffer each and every day from avoidable medical errors. While personal stories are not equivalent to data, it's striking that nearly all of us can relate an experience of healthcare error or instance of poor quality that happened to us or a close friend or relative. We've made some progress in the US since the Institute of Medicine's 1999 report, To Err is Human. However, the data from patient safety studies remains disconcerting. Findings from a 2013 study suggest that medical error is still a major issue and ranks the third leading cause of death in US hospitals. While hospitals have received the vast majority of attention, harm from medical error occurs in every setting. For example, in skilled nursing homes it has been estimated that 33% of Medicare beneficiaries experience harm, costing approximately $208 million in a single month, totaling a cost of 2.8 billion per year. Nearly 60% of those harms were preventable. Looking beyond the US, The Commonwealth Fund compares 11 developed countries including Australia, New Zealand, Canada, several European countries, and the US. In no case were the results comforting, but the study did show that there was wide variation in error rates. For example, experiencing a medication or a lab error is less common in Switzerland and the United Kingdom, and the highest in the US and New Zealand. Rates of leg amputation in patients with diabetes, an often preventable complication of that disease, are substantially lower in Australia and Sweden and highest in the US and Germany. Overall, the country with the highest preventable number of deaths per thousand inhabitants is the US, and the lowest are France and Australia. While the Commonwealth data provides only a relatively crude snapshot of health system performance, it clearly demonstrates that there is a worldwide need to focus on providing care that is safer and of higher quality, regardless of the geography. In looking at other industries, take transportation for example, including both aviation and automobile travel, and in many other areas of commerce, there have been remarkable improvements in quality and safety over the past few decades. So why has improvement in safety and quality of healthcare lagged behind that seen in other areas? Many reasons have been sighted including complexity, fragmentation of care, the central role of human interactions, the limited ability of consumers to judge quality of care, and even factors such as patients' strong belief that their own healthcare providers are infallible. Other reasons that some feel have been particularly important in the relatively poor performance of the United States in safety and quality is the way healthcare is reimbursed. Whether a patient received excellent or poor care, providers traditionally are reimbursed at the same payment rate. Even instances where care is needed as a result of medical error, providers are often fully paid for the that care. Moreover, those directly paying for much of healthcare in the US, such as state and federal government, private insurers, or employers, let alone individuals, have not until recently demanded any real level of accountability based on accurate measures of safety and quality of care. More recently some payers, such as the federal government and the Medicare program for the elderly and disabled, has instituted policies of nonpayment for services that are provided as consequence of errors or poor quality. For examples, hospitals are not reimbursed for patients who develop an infection post-surgery or experience a preventable fall with injury. Another somewhat counter-intuitive factor that is unique to the US is the widespread belief that malpractice litigation is an effective means of improving safety. The adversarial nature of malpractice proceedings, the secrecy surrounding the process, as well as the highly inconsistent link between the occurrence of an error and decision to file a malpractice case make it very difficult to correct errors. The long lag period between the incident and legal resolution makes it very difficult to correct problems in a timely way. And finally, the reluctance to report and act on errors or near-misses because of the fear of malpractice have all been noted to be barriers, or at least distractions, to creating a culture of safety and quality. In the US and throughout the world, poor quality and safety lapses not only cause suffering to patients, but there is strong evidence that these lapses result in extraordinarily large social and economic costs. A study by faculty at the Harvard School of Public Health estimated that least 43 million people worldwide experience medical harm, resulting in the loss of 23 million healthy days each year. While the statistics we've presented in this episode are a source of great interest, data alone do not result in any change. In our next episode, we'll take a look at some of the primary causes of quality and safety problems, the importance of identifying preventable errors, and how lessons learned from other industries provide models for positive change.
