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How safe are patients in America’s hospitals? For healthcare reporters, tackling this critical question has always represented a significant challenge. A staggering number of people in this country are killed each year by medical errors–more than car crashes or breast cancer or drug overdoses. Sixteen years ago, the Institute of Medicine (the health arm of the National Academy of Sciences) sounded the alarm when it published a landmark report estimating that “at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.” In December, the Obama administration touted some notable improvements in patient safety, including that incidents of hospital-induced harm fell by an estimated 17 percent from 2010 to 2013 and saved the lives of some 50,000 patients.
How should reporters assess ongoing efforts by federal and state agencies to reduce medical errors? Where are the areas of real safety improvement (and not)? How might reporters improve their coverage of this topic? I recently interviewed Dr. Ashish Jha, professor of health policy at the Harvard School of Public Health, one of the country’s leading experts on patient safety and a go-to source for the media. What follows is a lightly edited transcript of our conversation about patient safety and the press.
It’s been 16 years since the IOM issued its landmark report, “To Err Is Human.” Are patients any safer?
The answer to the big question is an honest, “we don’t know.” While we have clearly made some progress in a few areas, I think there has been little progress in other important areas of patient safety.
What areas?
We’ve made clear progress with healthcare-associated infections. We have clear evidence that rates of certain types of infections have gone down, particularly for surgical site infections and for central line infections, which are down 40 to 50 percent nationally. Eight years ago Peter Provonost discovered that four simple steps to reduce these infections, including washing hands, using a certain type of anti-disinfectant, using sterile gloves, and avoiding the groin for insertion could make a big difference. The medical community discovered a cheap simple intervention that saves lives and money. Nearly a decade later, how is it that this approach is not used universally? Yet, there is evidence that as many as half the hospitals are not reliably employing this simple checklist.
The field of patient safety is full of stories about amazing interventions that can save patients’ lives but do not end up getting widely adopted.
What are other areas where we haven’t made much progress?
Blood clots are one. We do know that lots of people have them, and we generally know how to prevent them. When people are in the hospital, being immobile can be deadly. Immobility sets people up for developing blood clots especially after major surgery. Falls are very common, especially in nursing homes and other healthcare settings. Pressure sores are also a huge issue with little evidence that we have made progress.
Has the press had an impact in making the public more aware of patient safety, particularly in hospitals?
Yes. I would say in general the press has done a pretty good job of keeping the issue in the public eye. But given the size and scope of the problem, you could ask, have they done enough? Maybe not, but it’s a criticism at the margin. I have some specific concerns about what gets covered and how it is covered. The thrust of most stories is still about bad people doing bad things–finger-pointing but too little attention on the underlying system that fails. There’s still a lot of stories where there’s a big focus on finger-pointing and how you are going to hold people accountable.
Can you give an example here?
I understand that journalists have to begin with a story. Mrs. Jones was the victim of an error, and her doctor messed up. Then the story goes in one of two directions–the hospital blames the doctor or tries to deny and cover it up. Either way you’ve missed the point. The larger story is how the error was allowed to happen in the first place. For example, what systems were in place and why wasn’t the error caught, intercepted, or mitigated? Unless you are talking about deliberately bad behavior, blaming the doctor isn’t the point. The lack of a system to mitigate the event is.
How can journalists reframe their stories to make them better?
You can lead with the story, but it has to circle back to the systems that failed. Here, I think, most bad events should hold the organizational leadership to account–the CEO, the chief quality officer, or the chief medical officer. What did they do to prevent the error in the first place? Don’t get me wrong, it’s fun to read stories about outrageous behavior of a doctor or nurse like the surgeon who left an operation in the middle to go to the bank. Even in that case, as odd as it was, it raised a series of systems questions. What process did the hospital have in place to deal with unusual emergencies like that? What was the culture of the hospital that didn’t make it safe for the OR nurse to stop the surgeon from leaving or immediately calling in another surgeon to ensure the patient was safe? These are the real issues.
Use specific cases to ask about system fixes. We’ve known about the problem for 16 years. Are we making progress? Why or why not? And if we’re not, what can be done and who is responsible? Good journalists are inherently skeptical. They should be asking: show me the evidence.
What are some systemic problems journalists should be looking for?
One huge issue is around culture. Here I think we have made progress but in too many organizations, the culture around patient safety is still not where it needs to be. Good safety culture means that everyone thinks high quality care is their job. It means the nurse can speak up in the OR, and it means the junior physician can speak up to the senior physician when he or she thinks that care is suboptimal. And it means that physicians and nurses and really everyone else can push back on senior management when there is inadequate focus on safety and quality. This is what good culture would look like, and it is still not commonplace in US hospitals. Electronic systems are another issue. Are hospitals really using those systems to maximize safety? Do they build in redundancies for really important issues where mistakes have catastrophic consequences.
You’ve been critical of the way journalists portrayed the government’s December announcement that incidents of hospital-induced harm fell by 17 percent and saved the lives of about 50,000 people. What did journalists do wrong here?
I was surprised at the lack of critical examination of the HHS report. First, for two of the major types of infections [catheter-related urinary infections and central line-associated blood stream infections], the program used measures that are not validated and not widely used. This was surprising and unusual… If everyone in the industry agrees that there is one standard approach to measuring something, and when HHS puts out a press release that has undergone no external review and uses a totally different approach to measurement, it should at least raise some questions.
What other evidence did reporters not examine?
There were other areas that concerned me. The HHS report appeared to be constructed to give credit for improvements to the ACA. For instance, they reported a 49 percent reduction in central line infections between 2010 and 2013. But of course, we all know that those rates started falling in 2008 and have declined steadily through 2013. There’s no evidence that I’m aware of that the ACA had any kind of beneficial or harmful effect on this rate. Yet the HHS report picked 2010 as the baseline year and appeared to attribute all the gains to the ACA programs… [Coverage of the report] felt more like cheerleading than a careful, skeptical examination of the facts.
Sometimes journalists have supported mandatory reporting of hospital errors. Has this reporting been effective?
It has been something between unhelpful and useless. I am unclear if it has made any difference whatsoever. Very few hospitals actively look for bad outcomes, and most hospitals only report what is brought to their attention, if that.
What’s wrong with the measures of patient safety we are now using?
Right now we have a mix of some very good measures like the ones that the CDC uses to track hospital-acquired infections and some not so good measures like using billing codes to identify who developed blood clots. The problem is many complications and adverse events go unrecognized or are poorly documented. If you don’t have a robust measurement program, then hospitals that are particularly diligent at identifying problems and documenting them will end up looking much worse than hospitals that are not paying attention. Once you tie that to financial incentives, you’ve created a system where the good guys–those paying attention–end up getting penalties. This needs to be addressed.
Why haven’t we made more progress?
To be frank, it really isn’t anyone’s top priority–except maybe the patient. How many times have you heard stories about the hospital CEO getting fired because of the hospital’s infection rates? I haven’t. There’s no evidence that having a high infection rate or a high mortality rate has any effect on CEO salaries. There may be individual cases where this matters, but systematically when you look across the landscape of non-profit hospitals, all the evidence says that quality doesn’t much matter.
Has CMS (Centers for Medicare & Medicaid Services) done enough?
They would argue they have. I personally think they have not. I like the idea of tying more payments to patient safety, and in that CMS has been a leader.
What’s the single most important thing the government can do to make patients safer?
I would say there’s a really amazing agency, the CDC, which has done a terrific job in patient safety. They need small additional resources to take the model they have developed for hospital-aquired infections and build it out for other care settings and for other types of adverse events. It’s a trivial investment but could, if done well, lead to massive improvements in care. Given the CDC’s track record of doing this well, I would suggest that it’s worth a try.
Can patients make a difference?
Yes, of course. Patients need to be vigilant when they are in the healthcare system. Gently push back if you think something isn’t right. But all this points to the biggest failure of all. We are now at a point where I am asking patients who are sick and often in pain to be their own advocates for safety because the system hasn’t done its job. We don’t expect airline passengers to advocate for safety when they get on an airplane. Yet that’s what we have come to. Until the industry makes real gains in safety, we will need to continue to rely on patients to make their care better.
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Should Health Journos Use Hospital Safety Data?
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