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TopWhat Do We Know About Patient Safety In Us Health Care?
Healthcare is not as safe as it should be. The problem of patient safety in the U.S. became a major priority following the publication of the Institute of Medicine’s “To Err Is Human Report” in 1999 (Institute of Medicine, 1999). That report relied heavily on the findings of the 1991 Harvard Medical Practice Study (HMPS), (Brennan, 2004; Brennan, 2004) which identified an adverse event rate of 3.7 events per admission in a random sample of patients from New York cared for in 1984.
“To Err Is Human” resulted in substantial funding, and major growth in publications in this area. However, several recent studies suggest that nearly one in four admissions includes some type of harm event. These included a report from the Office of the Inspector General (OIG) published in 2022 (Grimm, 2022) on 2018 data and done in Medicare patients, which found that about a quarter of these patients suffered harm during their admission, 43% of which were preventable. It also included the SafeCare study (Bates, 2020), done in a sample of 11 hospitals from Massachusetts, using methods like the original Harvard Medical Practice Study, which similarly found a harm rate of 23.6%, of which 38% were judged preventable (Bates, 2020).
So why are these rates still so high—and why are they nearly ten times as high as the original estimates from the Harvard Medical Practice Study? Differences in study methods and changes in health care make comparisons between the HPMS study and recent reports challenging. During the original study, paper records were the norm, and they were often hard to find and not always legible. Today, they are electronic, and adverse events are likely easier to detect. Second, the adverse event definition used in the more recent studies are broader than in the original study, which required death or disability at discharge, or prolongation of length of stay by two days. Third, the detection approaches today are better; triggers are used, and nurse reviewers are assessing cases with specific triggers in mind, such as unexpected transfer to the intensive care unit. Globally health care diagnostics and therapeutics have advanced, and the site of care has changed with more services being delivered in the ambulatory setting. In many ways, the health care we are evaluating in 2018 bears little resemblance to health care evaluated in 1984.
Nonetheless, harm rates measured before the pandemic have gone up, not down, even though we are 25 years out from “To Err Is Human.” Much has changed on the safety front. Nearly all hospitals have spontaneous reporting of error systems in place, and safety groups which review these reports. Many root cause analyses are performed, and mid-course corrections are made. The “blame and shame” approaches in dealing with those who made errors are much less frequent, and many institutions have “just culture” programs, which are focused on changing the way that errors and accidents are perceived. This kind of approach helped aviation become safer, and indeed the U.S. aviation industry has gone years between fatal crashes.