In mid-December, the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS) issued two reports on hospital adverse events and state reporting systems that endeavored to explore the critical factors involved. Just a week later, critical care specialist Peter Pronovost, MD, PhD, in an article in the Journal of the American Medical Association, emphasized that despite increased emphasis on patient safety, little progress has been made in making hospitals safer. Pronovost points to physician autonomy and a lack of standardization of safety protocols as the culprits.
“It’s been almost 10 years since the Institute of Medicine published ‘To Err Is Human,’ its treatise on the need for increased patient safety initiatives at hospitals,” says Pronovost, “yet we really haven’t made much progress.” According to Pronovost, “an average hospitalized adult will receive recommended therapy only 53 percent of the time. This accounts, in part, for the nearly 100,000 patients who die each year in the United States because of hospital error. Imagine, America has some of the best doctors and medicine in the world, yet we are only getting it right half of the time.”
Pronovost says improvements in patient safety must incorporate three principles: First, physicians must balance their autonomy with team-based standardized care protocols. Second, medical students and residents need to be trained in this new approach so they are fully socialized in their roles as patient agents rather than autonomous decision makers. Third, the process by which evidence-based standards and protocols are developed should itself be standardized and made clear. “Gone are the days when a doctor was on his own carrying all the tools of modern medicine in a black leather bag,” Pronovost says. “Today, much of care is team-based, and the wealth of techniques and wisdom is too much for one doctor to keep in his or her head. Standardization and a move away from physician autonomy will help guarantee that each patient receives the best treatment available.”
The OIG’s report, “Adverse Events in Hospitals: Overview of Key Issues,” includes seven issues that the OIG found to be critical to understanding adverse events:
1. Estimates of the incidence of adverse events in hospitals vary widely and measurement is difficult.
2. Nonpayment policies for adverse events are gaining in prominence and are viewed as a powerful incentive to reduce incidence but raise potential drawbacks.
3. Hospitals rely on staff and managers to report adverse events internally, but barriers can inhibit reporting.
4. Hospitals report adverse events to various oversight entities, although stakeholders suspect substantial underreporting.
5. Public disclosure of adverse events can benefit patients but also raises legal concerns for patients and providers.
6. Information to help prevent adverse events is widely available, but some hospitals and clinicians may be slow to adopt or routinely apply recommended practices.
7. Interviews and literature reveal strategies that may accelerate progress in reducing the incidence of adverse events in hospitals.
Infection prevention and control strategies can go a long way toward preventing adverse events — a point neither Pronovost nor the OIG report made explicitly — but we know them to be a pillar of patient safety.
Until next month, bust those bugs!
Kelly M. Pyrek
Editor in Chief