Can't fix it if you don't know how bad it is

We're Still Not Tracking Patient Harm

by Marshall Allen, ProPublica

WASHINGTON, D.C. — The health care community is not doing enough to track and prevent widespread harm to patients, and preventable deaths and injuries in hospitals and other settings will continue unless Congress takes action, medical experts said on Capitol Hill.

"Our collective action in patient safety pales in comparison to the magnitude of the problem," said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine. "We need to say that harm is preventable and not tolerable."


Dr. Ashish Jha, a professor at the Harvard School of Public Health, said patients are no better protected now than they were 15 years ago, when a landmark Institute of Medicine report set off alarms about deaths due to medical errors and prompted calls for reform.

"We can't continue to have unsafe medical care be a regular part of the way we do business in health care," Jha said.

One of the biggest problems, the experts told the Senate Subcommittee on Primary Health and Aging, is that providers and public health agencies still are not accurately measuring the harm.

Sen. Bernie Sanders, I-Vt., the panel's chairman, said afterward that most patients probably don't know that preventable patient harm is the third-leading cause of death in America. He said the problem hasn't received the attention it deserves in the public arena or from lawmakers.

Jha said it is crucial to develop better metrics to produce credible data about harm that is valid and credible. Without data, providers don't know how they're doing or if quality improvement efforts are working, he said.

Pronovost and Jha called for requiring the Centers for Disease Control and Prevention, which already collects data about hospital-acquired infections, to begin tracking other patient harms.

Dr. Tejal Gandhi, president of the National Patient Safety Foundation, said studies show that medication errors, adverse drug events and injuries due to drugs occur in up to 25 percent of patients within 30 days of being prescribed a drug.

Missed and delayed diagnosis is also a problem, and a primary cause of malpractice lawsuits in the outpatient setting, she said. Systems need to be put in place to monitor patient care instead of simply relying on doctors to get it right, Gandhi said.

"We cannot just tell clinicians to try harder and think better," Gandhi said.

The title of the hearing, "More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety," was inspired by a study by John James, a scientist and patient advocate whose son died because of a string of medical errors.

James' recently published study estimated that preventable harm in hospitals contributes to as many as 400,000 deaths a year.

James suggested that lawmakers establish a National Patient Safety Board — similar to the National Transportation Safety Board — to investigate patient harm. He also proposed a national patients' bill of rights that would contain protections similar to those for workers and minority groups.

Lisa McGiffert, director of the Consumers Union Safe Patient Project, urged the legislators to ensure there is more meaningful public reporting of the harm to patients, so consumers can make informed choices and providers will be motivated to improve.

Like this story? ProPublica's ongoing investigation into patient safety has highlighted many of the issues. Check out our Facebook group and online questionnaires for patients and providers.