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MEDICAL ERRORS may cause 400,000 deaths annually in US

Fifteen years ago, the famous To Err Is Human report issued by the Institute of Medicine estimated that the number of patients who die from medical errors is about 98,000 each year.  A more recent estimate puts that number at over 400,000 annually.  This is not meant to suggest that the problem has grown worse, rather that the earlier estimate was too low.  This brief report in JAMA is a recap of a Senate subcommittee hearing held in July (there is a link below to the video of the hearing if you’d like to watch the whole thing).

Dr. Peter Pronovost, who has been a champion in decreasing the rate of central line-associated bloodstream infections (CLABSI), testified that it would be beneficial to have a national system for collection of patient safety-related data.  Such a system might logically build on the existing database that tracks health care-associated infections that is maintained by the Centers for Disease Control.

It is also suggested that a national patient safety monitoring board should be created.

Sources: Kuehn, B.M.  Patient safety still lagging: advocates call for national patient safety monitoring board.  JAMA.  Aug. 20, 2014.  Click here for full text: http://jama.jamanetwork.com/data/Journals/JAMA/0/jmn140070.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

This article refers to a Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging hearing.  Click here for access: http://www.help.senate.gov/hearings/hearing/?id=478e8a35-5056-a032-52f8-a65f8bd0e5ef

The article refers to the report To Err Is Human, which can be accessed here: http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx

The article refers to the Centers for Disease Control and Prevention’s HAI Prevalence Survey, which can be explored here: http://www.cdc.gov/HAI/surveillance/index.html 


Best practices in avoiding retained surgical sponges

Despite established practices for counting, cotton sponges are the most common item to be left behind in a patient after intraabdominal surgery.  Several years ago, the Mayo Clinic (Rochester, MN) implemented a data-matrix-coded (fka bar coded) sponge counting system.  In 18 months of continuous use, there have been just under 2 million sponges used in the Mayo Clinic Rochester operating rooms and zero retained-sponge events.  There is a short learning curve to learn to use the new system (about 4 cases), and no increase in overall operative time was found.  There was an average cost increase of just under$12 per case to implement this new system.

Source: Cima, R.R., and others.  Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 monthsThe Joint Commission Journal on Quality and Patient Safety;37(2):51-58, Feb. 2011.  Posted by the AHA Resource Center, (312) 422-2050, rc@aha.org

Quality improvement: what is the best of current thinking?

The editors of the policy journal Health Affairs take on important themes and provide a forum that attracts top-notch contributors.  The April 2011 issue is devoted to the theme, “Still Crossing the Quality Chasm,” and provides 27 meaty, scholarly, data-rich articles, including several case study-like reports.  Here are some of the highlights:  (Classen, et al.) suggest that the number of adverse events is seriously underreported in U.S. hospitals just by the nature of the reporting mechanisms.  (Goodman, Villarreal, and Jones) calculated that adverse medical events resulted in a social cost of $393-$958 billion in 2006.  (Van Den Bos, et al.) calculated that measurable medical errors resulted in an annual cost of $17.1 billion nationally in 2008.  (Pryor, et al.) describes the success achieved by the large system Ascension Health in reducing the rate of avoidable deaths by at least 1,500 annually.  (Gabow and Mehler) review the approach taken at Denver Health to improve quality which included establishment of a department of patient safety and care quality.  (Joyce, et al.) describe how Legacy Health has been able to cut infection rates through its Big Aims initiative.  (Pronovost, Marsteller, and Goeschel) report on the progress nationally in cutting central line-associated bloodstream infections (CLABSI). 

Sources:  The following are all from Health Affairs;30(4), April 2011.

Classen, D.C., and others.  ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured, pp 581-589.

Goodman, J.C., Villarreal, P., and Jones, B.  The social cost of adverse medical events, and what we can do about it, pp 590-595.

Van Den Bos, J., and others.  The $17.1 billion problem: the annual cost of measurable medical errors, pp 596-603.

Pryor, D., and others.  The quality journey at Ascension health: how we’ve prevented at least 1,500 avoidable deaths a year, and aim to do even better, pp 604-611.

Gabow, P.A., and Mehler, P.S.  A broad and structured approach to improving patient safety and quality: lessons from Denver Health, pp 612-618.

Joyce, J.S., and others.  Legacy Health’s ‘Big Aims” initiative to improve patient safety reduced rates of infection and mortality among patients, pp 619-627.

Pronovost, P.J., Marsteller, J.A., and Goeschel, C.A.  Preventing bloodstream infections: a measurable success story in quality improvement, pp 628-634.

Speak up for safety! New report indicates that Silence Still Kills.

Over the past several years, powerful tools and protocols, such as universal precautions and crew checklists, have been developed to combat medical, surgical, nursing, and medication errors.  A recent study conducted jointly by the American Organization of periOperative Nurses, the American Association of Critical-Care Nurses, and VitalSmarts shows that even the best protocols in the world can’t be effective unless someone speaks up when they see something happening that contradicts these best practices. While more clinicians are using safety tools today then they were five years ago when the first Silence Kills study was released, there still remain three areas of grave concern: dangerous shortcuts; incompetent practitioners; pervasive disrepect.  The study shows how courage, conviction, and confidence are key to speaking up, being heard, and creating an environment that is truly safe – for everyone.  

Source:  Maxfield, David, interviewed by Bob Kehoe.  More clinicians speak up about flawed care, but silence kills.  Hospitals & Health Networks.  85(4):14-15, April 2011.  Full text at http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/04APR2011/0411HHN_Inbox_OtherVoices&domain=HHNMAG

Podcast of interview at http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=69000315

The full report, Silence Still Kills, is available for download at http://www.silenttreatmentstudy.com/ (free registration required).  The original 2005 report, Silence Kills, can also be accessed from this site.

Annual Cost of Medical Errors Estimated at $17.1 Billion

Analysts with the actuarial firm Milliman estimate that measurable medical errors cost the nation $17.1 billion in 2008. Pressure ulcers, postoperative infections, and post-laminectomy syndrome were the most frequently occurring errors identified in their examination of medical claims data. Ten types of errors were the most costly, accounting for two-thirds of annual medical error costs. Postoperative infections, pressure  ulcers, and mechanical complication of a noncardiac device, implant, or graft topped the most costly list of errors. Data is provided on the incidence,  expense per error,  and the national aggregate cost for each of the most frequent and most costly error types.

Source: Van Den Bos J and others. The $17.1 billion problem: the annual cost of measurable medical errors. Health Affairs, vol. 30, no.4, Apr. 2011, pp. 596-603. http://content.healthaffairs.org/content/30/4/596.abstract

Wrong site surgery: 1 case/year in typical 300 bed hospital

What is the incidence of wrong site surgery?

[The following is a selection from the health care literature on this topic.  A comprehensive search would yield more citations.]

(Stahel, et al., 2010) reviewed over 27,000 cases of adverse occurrences self-reported by physicians from 2002 to mid-2008 and found 25 instances of wrong-patient and 107 instances of wrong-site procedures.  Causes of the wrong patient errors were communication problems and errors in diagnosis.  Causes of the wrong-site errors were primarily errors in judgment and lack of a surgical time out. 

(Malloy and Hughes, 2008) summarized the literature in a concise chapter about wrong site surgery.  They discuss incidence, as well as techniques for avoiding this type of medical error.

(Clarke, et al., 2007) studied the incidence of wrong site surgery based on over 430,000 surgical operations performed in Pennsylvania from mid-2004 until the end of 2006.  Based on these extensive data from both hospitals and ambulatory surgery centers, the authors estimate that the typical 300-bed hospital is likely to have one wrong-site surgery event per year.  Wrong side surgery was the most commonly occurring type of wrong site surgery.  The majority (56%) of the reported events were near misses, caught before any care was rendered.  A table included in this article itemizes suggested process improvement actions to help prevent this type of medical error.

(Kwaan, et al., 2006) analyzed 20 years of data from a malpractice insurer covering about 30 Massachusetts hospitals and developed an incidence rate.  The authors found 40 instances of wrong-site surgery during the study period, from which they estimated that the incidence for non-spine wrong-site surgery is 1 in 112,994 operations.  They mention that the incidence of retained foreign bodies is 10 times more likely to occur than wrong-site surgery. 

Surgical time outs

Lee (2010) studied the implications of instituting an extended surgical time out prior to anesthesia induction for pediatric patients at Kaiser Permanente Bellflower Medical Center.  The children did not seem to experience distress during the time out.  Although staff found the extended time outs to be helpful in improving communication, this approach did not eliminate wrong-site surgery.  Of greater efficacy were changes in the site marking process, which now may only be done by the surgeon.

(Altpeter, T., et al., 2007) describe the surgical time out practice adopted at The University of Louisville Hospital, which serves as a ‘reflective pause’ or ‘preop briefing.’  Besides focusing on confirming the patient identification and operative site, the hospital added an additional 5 components to the STO process.   

(Backster, et al., 2007) describe the effort at one hospital to expand the surgical time out into a ‘preparatory pause,’ which covers avoidance of perioperative risks.  The authors developed an estimate of the financial benefit of instituting an extended surgical time out of $900 per patient.


Altpeter, T., and others.  Expanded surgical time out: a key to real-time data collection and quality improvement.  Journal of the American College of Surgeons;204(4):527-532, Apr. 2007.  http://www.surgicalpatientsafety.facs.org/research/altpeter.pdf

Backster, A., and others.  Transforming the surgical ‘time out’ into a comprehensive ‘preparatory pause.‘  Journal of Cardiac Surgery;22(5):410-416, Sept./Oct. 2007. 

Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/pdf/20070900s00006p395.pdf

Kwaan, M.R., and others.  Incidence, patterns, and prevention of wrong-site surgeryArchives of Surgery;141(4):353-358, Apr. 2006.

Lee, S.L.  The extended surgical time-out: does it improve quality and prevent wrong-site surgery?  The Permanente Journal;14(1):19-23, Spring 2010.  http://www.thepermanentejournal.org/files/Spring2010/TheExtendedSurgicalTimeOutDoesItImproveQualityandPreventWrongSiteSurgery.pdf

Malloy, D.F., and Hughes, R.G.  Wrong site surgery: a preventable medical error, in: Hughes, R.G. (ed.) Patient Safety and Quality: An Evidence-Based Handbook for Nurses.  Rockville, MD: Agency for Healthcare Research and Quality, Apr. 2008, Chapt. 36.  http://www.ncbi.nlm.nih.gov/books/NBK2678/pdf/ch36.pdf

Seiden, S.C., and Barach, P.  Wrong-side/wrong-site, wrong procedure, and wrong-patient adverse events.  Archives of Surgery;114(9):931-393, Sept. 2006. 

Stahel, P.F., and others.  Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences.  Archives of Surgery;145(10):978-984, Oct. 2010.

‘Healing without harm’: HROs and islands of excellence

Commercial airlines, nuclear submarines, and nuclear power plants can be characterized as ‘high reliability organizations’ (HROs), in which the defect and error rate is low.  Health care organizations, by and large, have not achieved the same level of reliability.  Basic principles of HROs are described in the Delk et al. white paper.  Five provider organizations that are leaders in patient safety and quality, termed ‘islands of excellence,’ are described in detail, including: Sutter Health, Gundersen Lutheran Health System, SSM Health Care, Sanford Health, and WellStar Health System.  Another health system that has formally committed to the ‘healing without harm’ concept of a high reliability organization is Ascension Health.  A series of articles discussing the Ascension Health approach to eliminating preventable injuries and death is available in free full text here.

Sources: Delk, M.L., and others.  Healing Without Harm: 21st Century Healthcare Through High Reliability.  Center for Health Transformation, [no date, 2010?]  http://www.healthtransformation.net/galleries/wp-hospital/CHTHealingwithoutHarm_v3.pdf; and, Ascension Health.  Activity.