Prevention of Medical Errors: The Mandate for Change

Introduction

What is the number one concern for hospital executives in the United States? The answer may be surprising given that we are firmly planted in the 21st century and healthcare has made great strides in the last several decades. However, one of healthcare's biggest concerns remains patient safety. According to a report by the Institute of Medicine (Kohn, Corrigan, & Donaldson, 2000), hospital care is only 97.1% perfect. Even if hospital care were rated 99%, the error rate would still equate to 2,000 unsafe airplane landings per week, 22,000 checks withdrawn from the wrong account per day, 2,000,000 tax documents lost per year by the Internal Revenue Service, or 5,000 surgical procedures gone wrong. At 97.1% perfect, nearly 300 preventable deaths occur in hospitals each day. That is the equivalent of a packed 747 falling out of the sky every single day.

There is at least a 2.9% chance of experiencing a totally preventable adverse event if hospitalized. For 100,000 people each year, this experience leads to death. This is more than AIDS, breast cancer, or motor vehicle accidents. Preventable adverse events resulting in death ought to be zero. In the U.S. healthcare system, the numbers speak for themselves. According to the Institute of Medicine report, patient safety means "Freedom from accidental injury" (p. 18, Kohn, Corrigan, & Donaldson, 2000). To paint an even more graphic and urgent picture, the IOM report suggests that the national cost of medical error is huge. The estimate of preventable medical errors ranges from $8.5 to $20 billion annually.

Historical Changes in Healthcare

To better understand patient safety in our current healthcare system, it is important to know the history of healthcare. For example, in our current healthcare system, a stroke patient stays 5-6 days in acute care versus a two-month stay 30 to 40 years ago. The treatment of new onset diabetes used to be three weeks in a hospital and two hours a day of diabetic education. Today, treatment consists of outpatient care, educational classes, reading materials, and possibly self-education by surfing the Internet. The continuum of care 30 years ago included hospitals, offices, homes for the aged, and one's own home. Today there is a panoply of offerings including hospitals, assisted living centers, home care, group homes, rehabilitation centers, telemedicine, etc. The complexity of healthcare has changed dramatically over the last 30 to 40 years.

The terminology has also changed over the years. Problems in the 1960s and 1970s were referred to as complications. In the 1990s, complications became known as adverse events. By the year 2000, the terms errors and patient safety were healthcare terms. Current terms regarding healthcare are medical errors and adverse events. These terms are not the same nor interchangeable when discussing patient safety. A medical error is the failure of a planned action to be completed as intended. An adverse event is an unexpected outcome caused by medical management rather than an expected outcome of the patient's underlying condition.

Although the terminology has changed over the years, the issues remain the same regarding complications, adverse events, and errors in patient safety. The 2000 IOM report (Kohn, Corrigan, & Donaldson, 2000), stated that over 100,000 deaths in hospitals were caused by reasons other than the initial cause for admittance. Two percent of all hospital admissions experience an adverse event (ADE) that usually results in an increase in the length of stay. This, in turn, increases the cost per event by an average of $4,700. In October of 2009, the Centers for Medicare and Medicaid stopped paying for acute care as a result of medical errors.

In 2001, The National Academy of Sciences repeated the IOM study and in 2003 published a landmark report titled Crossing the Quality Chasm: A New Health System for the 21st Century. Again, the report stated that an additional 100,000 deaths annually are due to medical error. The report revealed no difference over two years in the area of resolving medical errors.