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Patient Safety Innovation Simplified

patient safety data

Source: WHO

Hospitals are a place where patients go to heal, to seek treatment and to find a cure. They are not expected to be the source of harm or infection due to medical error, but all too often, this is the case. In fact, studies show that 1 in 3 Americans have experienced a medical error in their own or a family member’s care at some point in their life.

Patient safety was not a widely discussed topic until 1999, when the Institute of Medicine (IOM) released the landmark report To Err Is Human.This report revealed that between 44,000 and 98,000 people died each year in United States hospitals due to medical errors. At the time, that was more than the number of people who died in a given year from motor vehicle accidents, breast cancer or AIDS.

According to the Organization for Economic Co-operation and Development (OCED) the U.S. already spends more per capita on healthcare than any other country. In 2010, the U.S. spent an average of $8,233 per person, more than 2.5 times the OECD average.

Lapses in patient safety make up a large part of these costs. Medication errors can cause adverse side effects that need to be treated, hospital acquired infections and pressure ulcers require long recoveries and hospital readmissions are costly. By improving patient safety, studies show that some countries could save between $6 and $29 billion a year. Public Health Spending By Country A decade after To Err Is Human was released, Cheryl Clark, Senior Editor of HealthLeaders Media, examined these cost and safety factors associated with medical error, and evaluated what improvements were (and were not) being made to improve the healthcare system.

Clark found that while hospitals were still in the news for wrong-site surgeries, lapses in infection control, and medication mix ups, huge strides in patient safety and cost containment were being made. Many states started requiring reporting of adverse events and attention was brought to physician’s diagnostic and treatment errors.

Most surprisingly, one of the most impactful innovations in patient safety is also one of the simplest: Checklists. Dr. Atul Gawande, a public health researcher and surgeon at Brigham and Women’s Hospital in Boston, created a surgical safety checklist in collaboration with the World Health Organization (WHO).

The initial results were astonishing. In the study, complication and death rates fell an average of 35 percent.

In addition to using tools like checklists, in recent years hospitals have been urged to adopt a “no blame” system to encourage providers to report their errors and near-misses, rather than punishing an individual deemed to be at fault. By making this data widely available, the hope is that other healthcare systems could prevent the same mistakes from happening in their facilities.

Dr. Gawande’s TED Talk and New York Times bestselling book, The Checklist Manifesto, discusses the idea that modern safety is less about ignorance and uncertainty, and more about complexity. And according to his checklist study, it turns out a supportive team, along with checks and balances, is enough to dramatically improve safety.

Healthcare practice needs to move away from the autonomous doctor, Dr. Gawande says, and towards a team that’s completely dependent on, and supportive of, each other.