200,000 Preventable Deaths: It’s Time for Fundamental Change
The Hearst Corporation news reports that an estimated 200,000 people will die from preventable medical mistakes this year is a sad and telling statement on the abundant waste and the thousands of errors in the current health care system.
It’s time for everyone in healthcare and for policy makers to admit that we need a fundamentally different way to deliver the safest and most effective care to every patient. These latest reports build on other credible national studies which have documented the thousands of people who are injured or die in healthcare settings every year as a result of preventable errors.
Most of the credible studies estimate that 30 to 50 percent of healthcare services do nothing to improve patient care. These are wasted resources.
Many healthcare leaders recognize the problem, and that’s why we are developing and implementing solutions to fix the problems. Lean healthcare eliminates the errors and mistakes that lead to death. It’s not just about preventing mistakes; it’s about preventing injuries and deaths.
Lean healthcare is a defined methodology that works. It’s all about system redesign coupled with a commitment to making daily improvements throughout the system.
For the past six years, ThedaCare, a community-owned healthcare system in Wisconsin, has used lean methods and tools to redesign the way patients are cared for in its hospital rooms and physician clinics. The results have been dramatic:
Heart surgery mortality rates decreased from 4 percent in 2001 to 1.4 percent in 2008 and zero percent in 2009
Medication reconciliations errors are at zero percent since February 2007, compared to one per patient stay prior to redesign
15 minute turnaround time on most common lab procedures in the clinic
Other healthcare systems across American have produced similar results using lean principles and tools. The staff at Allegheny General Hospital in Pittsburgh eliminated central line infections in a critical care unit in 2006 using lean improvement practices. In 2003, under the traditional approach, 49 patients got infections and 19 died. In 2006, under the lean system (called “Perfecting Patient Care”), only three patients got infections, and no patients died.
Many of us in the healthcare industry agree that now is the time for healthcare and payment reform. Group Health of Puget Sound, ThedaCare, Gunderson Lutheran and 12 other healthcare delivery organizations in the U.S. and Canada have come together to accelerate and spread our learning on delivering better patient value. The partnership between the Lean Enterprise Institute (LEI) and the ThedaCare Center for Healthcare Value brings together two of the world’s leaders in “lean thinking,” with a combined 20 years of experience in lean implementation and education.
The Healthcare Value Leaders Network members know we can reduce or eliminate billions of dollars of healthcare waste through the use of lean principles of quality improvement and focus on delivering greater value to each and every patient we treat.
The biggest internal barrier to change is the healthcare culture. At ThedaCare, we moved from a culture of blame to a culture of promptly finding out why mistakes happen and then designing best practices to make sure mistakes are not repeated.
Beyond culture change, the biggest barriers to reform are the backward incentives in the current payment systems, both in public and private insurance programs.
This is what healthcare reform should be all about. The current payment systems reward providers for delivering more and more expensive services, regardless of their quality and outcomes, while penalizing providers who increase quality and reduce costs.
Rather than delaying the inevitable, the President and Congress should include strong provisions in the reform plan to reward providers who improve quality, safety and access while reducing costs. Waiting around for ten years to learn the results of another Medicare CMS pilot study is like rearranging the deck chairs on the Titanic.
We have a proven methodology with the results documented by independent third-parties. It’s working in healthcare systems across America. It’s time to get on with the important work at hand. It’s time to make sure we can confidently tell our patients that when we take care of them, we will not harm them.
NEW YORK (August 9, 2009) - An estimated 200,000 Americans will die
needlessly from preventable medical mistakes and hospital infections this
year, according to "Dead By Mistake," a wide-ranging Hearst national
investigation, which began reporting the findings today
[www.deadbymistake.com]. Despite an authoritative federal report 10 years
ago that laid out the scope of the problem and urged the federal and state
governments and the medical community to take clear and tangible steps to
reduce the number of fatal medical errors, a staggering 98,000 Americans die
from preventable medical errors each year and just as many from
hospital-acquired infections.
"Dead By Mistake" is the result of an investigation conducted by Hearst
newspaper and television journalists.
Ten years ago, the highly-publicized federal report, "To Err Is Human,"
highlighted the alarming death toll from preventable medical injuries and
called on the medical community to cut it in half-in five years. Its
authors and patient safety advocates believed that its release would spur a
revolution in patient safety. But Hearst's "Dead By Mistake" reveals that
the federal government and most states have made little or no progress in
improving patient safety through accountability mechanisms or other
measures. According to the Hearst investigation, special interests worked
to ensure that the key recommendations in the report-most notably a
mandatory national reporting system for medical errors-were never
implemented.
Among the key findings of the Hearst investigation:
-- 20 states have no medical error reporting at all, five states have
voluntary reporting systems and five are developing reporting systems;
--Of the 20 states that require medical error reporting, hospitals report
only a tiny percentage of their mistakes, standards vary wildly and
enforcement is often nonexistent;
--In terms of public disclosure, 45 states currently do not release
hospital-specific information;
--Only 17 states have systematic adverse-event reporting systems that are
transparent enough to be useful to consumers;
--The national patient-safety center is underfunded and has fallen far short
of expectations;
--Congress approved legislation for "Patient Safety Organizations" as a
voluntary system for hospitals to report and learn from errors, but the new
organizations are devoid of meaningful oversight and further exclude the
public;
--Hearst journalists interviewed 20 of the 21 living authors of "To Err is
Human"-16 believe that the U.S. hasn't come close to reducing medical errors
by half, the primary stated goal of the report;
--New York's reporting system has run out of money and staff-its last public
report is four years old;
--The law mandating reporting in Texas expired in 2007, and funding ran
out-a new reporting law has been passed, but no funds have been allocated;
--Washington State requires reporting, but doesn't enforce that
requirement-and the legislature failed to provide funds to analyze the
results.
"Dead By Mistake" includes profiles of more than 30 people who died or were
injured while seeking medical care. Most lost their lives, some in lingering
pain. Others lived on, with paralysis, amputation, burns and emotional
distress. Families suffered in the aftermath. In some cases, paperwork was
lost, or mischaracterized the cause. "Ranging in age from newborn to 91,
these Americans are a small sample of a huge and poorly accounted for
population," said Hearst Newspapers Editor-at-Large Phil Bronstein, who
oversaw the project. "To the families, each case is a unique and compelling
argument as to why a system that allows such preventable mistakes is
intolerable."
In addition to investigative reporting and case profiles, DeadByMistake.com
features an interactive map that provides a state-by-state snapshot of
reporting systems and two interactive databases created as part of this
investigation. One database tracks hospitals' participation in three
prominent national safety programs. The second brings together the millions
of anonymous patient discharge records that Hearst reporters collected from
California, Texas, New York and Washington. Hearst worked with expert
statisticians at the Niagara Health Quality Coalition, a not-for-profit
think tank, to analyze this data to produce never-before published patient
safety ratings from medical details buried in hospital records. The results
appear on five searchable databases with interactive maps.
"More people die each month of preventable medical injuries than died in the
terrorist attacks of September 11, 2001," Bronstein added. "The annual
medical error death toll is higher than that for fatal car crashes."
Bronstein continued, "'Dead By Mistake' is the result of two things
converging: a critical and neglected health-care issue that dramatically
affects hundreds of thousands of Americans every year and the tireless work
of a team of skilled and dedicated journalists."
The investigation utilized the reporting resources of seven Hearst
newspapers-the San Francisco Chronicle, Albany Times Union, San Antonio
Express-News, Houston Chronicle, Greenwich Time, Stamford Advocate and the
Connecticut Post-as well as SeattlePI.com and Hearst Television. In
addition to contributing to the national television, print and Web stories,
these Hearst journalists also produced market-specific reports highlighting
the results of local investigations. Students, faculty and graduates of the
Stabile Center for Investigative Journalism at Columbia University Graduate
School of Journalism also contributed research, stories, photos, audio,
video and Web content to the report.
"This comprehensive investigation allowed us to draw on the unique
journalistic resources of our various Hearst properties and platforms, and
enabled us to broaden the breadth and depth of the reporting," Bronstein
said. "This investigation is a new, collaborative way of reporting, but,
more importantly, it is a public service focusing on the plague of fatal and
preventable hospital errors."
"Dead By Mistake" is the third Hearst investigative reporting initiative,
following January's series on Boy Scouts councils across the country logging
and selling prime woodlands to turn quick profits, sometimes on lands that
were bequeathed to the organization for preservation purposes. Before that,
Hearst Newspapers' I-team investigated disastrous military housing
privatization programs across the country, which earned a 2008 George Polk
Award for Military Reporting.
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