Striking out Preventable Patient Harm

The health care system has historically operated in silos. This fragmented care has resulted in over three million patient deaths and many millions more harmed. In the U.S., annual patient death rates from preventable medical harm have been estimated to be over 250,000 with annual costs estimated to be between $9.3 billion and $958 billion.

However, creating safe care for everyone requires a concerted effort. Take for example the game of baseball – one of the most popular American pastimes – a player cannot score a home run without running every base. The same concept can be applied to the health care system. No shortcuts can be taken.

While in recent years, there have been improvements made to save lives across central line infections and ventilatory associated pneumonia bundles, pulse oximetry to detect and treat opioid respiratory depression and other single factors – nothing has covered all the bases.

While hitting singles has set the foundation, it’s time to swing for the fences and try clearing the bases. This means setting the sights on eliminating preventable medical harm. To achieve this goal, the Patient Safety Movement Foundation has called for a Patient Safety Moonshot™. Similar to other “moonshot” goals in the past – such as landing on the moon, eradicating polio and curing hepatitis C – this audacious goal requires a collaborative effort by all stakeholders.

But before we can hit the home run, here are the three bases we need to make sure are covered first. These three critical areas lay the foundation needed to drive safe, high quality health care for all.

FIRST BASE – IMPROVE SAFETY DATA TRANSPARENCY

There is a lack of transparency in health care, especially as it relates to patient safety data. As a result, the public does not have easy access to make informed decisions about where to seek care. To address this, we first need decision-makers to acknowledge this gap and understand why this has been the status quo.

In the past, fear of litigation, blame or loss of reputation have made organizations and clinicians fearful to be transparent with patients and families about medical errors that have occurred. This has resulted in a “deny and defend” culture. To improve transparency, organizations first have to shift the focus to system failures instead of individual blame. The Agency for Healthcare Research and Quality (AHRQ) introduced the CANDOR (Communication and Optimal Resolution) program to help organizations address these situations and when properly implemented it has been shown to increase transparency, improve patient outcomes, lower healthcare costs and foster continuous learning. By opening the conversation and improving transparency, healthcare systems can benefit from shared learning. To get safely to first base, decision-makers need to acknowledge the lack of transparency and commit to addressing the issue – which includes listening to potential solutions to expose patient safety data to the public.

SECOND BASE - ALIGN INCENTIVES

The current incentive model rewards unnecessary care or over-treatment, which increases both cost of care and risk of harm. However, to reach zero preventable harm in healthcare financial incentives need to be aligned with the goal of systemic prevention of all causes of harm in all care settings versus being paid according to the volume of hospitalizations, visits and procedures completed. We can’t make it to third base without first holding health systems to higher standards and shifting payments to quality and safety-related outcomes of care.

THIRD BASE - ESTABLISH REGION-APPROPRIATE OVERSIGHT AND SHARED LEARNING

Creating a national safety board is not a new concept. In fact, the aviation and transportation industries have one in place - the National Transportation Safety Board (NTSB) – an independent investigative agency responsible for investigating civil transportation accidents. Yet, the U.S. currently has no agency, authority or administration that independently reports, conducts reviews and shares learning on a national and regional level for the health care system. So, before we can hit a home run, it is critical that we create an NTSB to ensure that health care organizations share learnings that put evidence-based safety processes and training programs in place.

To truly hit preventable patient harm out of the park, we need a bases loaded “grand slam” home run that seriously addresses the preventable medical harm crisis in this country. Every base needs to be covered before we can truly achieve this goal. Reaching zero preventable patient deaths by 2030 is no doubt an audacious goal, but it is one that is necessary. So, let’s step up to the plate and hit this home run together. To learn more about the Patient Safety Moonshot or how to get involved, please visit: https://patientsafetymovement.org/advocacy/policy-makers/patient-safety-moonshot/

About the Author: Dr. David Mayer joined the Patient Safety Movement Foundation as the CEO in 2019 bringing decades of experience in both the public and private sector. In his concurrent role as executive director of the MedStar Institute for Quality and Safety (MIQS) he is responsible for leading specific quality and safety programs in support of discovery, learning and the application of innovative methods to operational clinical challenges.