Patient Safety is Alive but Consumers Pose Challenges: Response to “Who Killed Patient Safety?”

Abstract

July 18, 2022 In the title of their recently published commentary, Hemmelgarn and colleagues posed a provocative question, “Who killed patient safety?” In the body of their essay they restated the query in a slightly softer manner, “What happened to patient safety?” The authorship team is almost entirely composed of individuals who had family members injured or killed by medical errors, and they are all accomplished experts and activists in the field of patient safety. I too lost a family member to medical errors. As a result, I have also pursued advocacy along with consulting and research on this issue. However, I view the present state of patient safety differently, specifically that the glass is half full. Patient safety is alive and well but with more work to be done. Moreover, I have some different views of the challenges we face in patient safety, which include how Americans consumers are hurting the patient safety movement. When my family and I reconciled with the hospital system where my brother Jim died in 1998 from medical errors, the hospital’s CEO had a candid conversation with me. He stated that the 1990’s was the “age of justification” during which even the worst care could be justified or ignored by healthcare professionals. I have heard similar confessions from other healthcare professionals, including risk managers, defense attorneys, and the like. Yet, over the last two decades, as I have traveled the country and worked with countless hospitals and nursing homes, I have seen with my own eyes healthcare professionals who are now working overtime to diminish and eliminate errors. They are candid about the challenges they face and their desires for improvements, both within systems and individual clinicians. Yes, they are still not as transparent with patients and families as we would like, nor are they are sharing de-identified cases and stories between healthcare systems with the frequency we would prefer. However, we should not diminish the attention, care, and work that is being put into this issue. People are trying. If anything, healthcare professionals are attempting to fix this problem because of all the medical malpractice lawsuits and negative media (and social media) attention that has caused enormous damage to the bottom line of countless entities along with personal risk of lawsuits and complaints to state medical boards. As a family member, I take comfort in this reality. We should agree that the reporting systems around medical errors are not fully developed and haphazard, at best. Those attempting to estimate injuries and deaths from medical errors are truly making guesses on incomplete information. In Year 2000, the IOM pegged the death count from medical errors somewhere between 44,000 to 98,000 Americans annually, yet Makary in 2016 suggested that medical errors are the third leading cause of death in the United States by claiming in excess of 400,000 souls annually. More recently, it has been suggested that 25 percent of Medicare patient suffer adverse events in hospitals. How accurate are these numbers? Do the numbers indicate that patient safety has stalled or gone backwards – as Hemmelgarn et. al suggest? Evidence suggests alternative explanations. First, different methods were used in these three studies to estimate the number of deaths caused by medical errors. In the past two decades healthcare systems have become more aware of the problem of medical errors, and more accurate at counting them. A glass half-full interpretation is that healthcare has pulled its collective head out of the 1990s sands of denial and is finally being honest about the problem. The higher numbers may be a sign that healthcare professionals are now, finally, becoming serious about the medical errors. I wholeheartedly agree with the proposal proffered by Hemmelgarn et. al for a federal or national reporting body to share de-identified cases. Whether this entity be part of the federal government or a private, non-profit entity is a question that should be considered and debated. Too much learning is locked up in settled cases with scary gag clauses that unnecessarily -and disingenuously -intimidate patients and families into silence. Moreover, we should all agree that more resources should be provided to healthcare organizations working to adopt disclosure and apology programs. This might include passage of second-generation apology laws that encourage the development of such programs. On the other hand, I have to protest repetition of the tired trope of “why can’t medicine be like aviation?” sewn into their editorial. I view this as an oversimplified argument that is aggravating to healthcare professionals and counterproductive to the cause. It should be retired. My late father was a PhD engineer who worked in aviation and nuclear engineering. Following Jim’s death, dad and I had many conversations on this topic, and we even published an Commentary