Are patient safety organizations losing the war on error?

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The war on medical error was officially launched in 1999, when the Institute of Medicine (IOM) published its landmark report To Err is Human, alleging that up to 98,000 yearly deaths in US hospitals were due to human missteps.

Despite significant ambiguities in the definition of a medical error, numerous militias known as Patient Safety Organizations (PSO) sprung up almost overnight to help combat the terrible enemy.  Under the IOM’s strategic directive, and enforced by government regulators and private health insurers, PSO’s organized a counteroffensive that would aim to model health care institutions on the pattern set by the aviation industry.

The main weapons deployed in the war on error are ever-growing numbers of surgical checklists, procedural time outs,  distraction-free safe zones, root-cause analyses, and other protocols and disciplines which must be implemented by hospital personnel with the same diligence as might be seen at Cape Canaveral.

Under the ever-watchful eye of the electronic health record, progress in this campaign is assessed with “scorecards” documenting adherence to the paramilitary discipline.  Failure to comply can result in significant loss of income for hospitals and for medical practices, lest they harbor potential errorists.  Needless to say, every administrator, every nurse, every physician, every pharmacists, and every orderly has been placed on red alert, if not put on notice.

After 15 years of this severe regimen, one would think that the potent measures would demonstrate some tangible progress.  Instead, recent statements by the leader of one the most influential PSO’s in the country testify of a sobering reality.

Food for thought

With an apparent 10-fold increase in medical errors since the advent of the patient safety movement, one may wonder if the methods employed to reduce complications, modeled on the achievements of the airline industry, are not themselves part of the problem.

After all, airplanes are artifacts of the human mind with a known blueprint and a pre-specified destination agreed upon by all involved. Human beings, on the other hand, are natural products of biological evolution or of the divine mind, have unfathomably complex designs, and display surprisingly self-directed behaviors.

In confusing the patient with the jumbo jet, could it be that PSOs needlessly distract health care personnel from their most precious and unpredictable cargo?  Could it be that, enthralled by a grossly mistaken analogy, PSOs are in fact committing the biggest medical error of them all?

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5 thoughts on “Are patient safety organizations losing the war on error?

  1. What is the nature of the medical errors that are leading to death? Certainly it could be because of a misunderstanding or lack of understanding about a patient’s body, but it seems more likely that they are related to human constructs similar to an airplane. For instance man-made drug names that appear alike or inappropriate dosages of medicines.

    • There is no end to the kinds of behavior (on the part of doctors or anyone involved) that can lead to complications, including those you mention. The question is, what is the best way to minimize them? Forcing the medical community to focus entirely on those aspects of medical care that resemble industrial processes may lead to more problems than it solves.

  2. The means for measuring harm from error are too inaccurate at present to discern trends over time, so in my opinion the premise of this article is wrong (that errors have increased 10-fold). What is clear to most (but apparently not you) is that, even with large error bars, harm from error is unacceptably high and remains so. In my opinion, this is not because of PSOs, but because the efforts to reduce error have been inadequate. Some of the measures you cite (e.g., checklists and time-outs) have very strong evidence supporting their effectiveness, but the sources of error are numerous and the low-hanging fruit has been picked.

    Blaming PSOs for the various patient safety measures that have been taken since the 1999 IOM report stimulated pressure to reduce errors, however, is simply wrong. PSOs don’t do anything, they just analyze reported errors and make suggestions on how to prevent them in the future. To say that they ORGANIZED a “counteroffensive” is a gross overstatement of the role and effect of PSOs. It would be accurate, however, to say that Medicare, private health insurers, employers, and the public, all of whom bear the cost of medical error, organized a counteroffensive, without which zero progress would have been made.

    A factual correction: After the 1999 IOM report, PSOs did not spring up “overnight.” Their creation was recommended in the 1999 IOM report, but the enabling legislation was not enacted until 2005 (Patient Safety and Quality Improvement Act of 2005) and the implementing regulations were not issued until November 2008 (see http://www.hhs.gov/ocr/privacy/psa/regulation/index.html). The first PSOs were not certified and operating until after that, so it seems we cannot blame them for the counteroffensive until at least 2009.

    • Dear David,

      Thank you for your comments. It reminds me of the story of the 3 statisticians who walk into an error bar…

      Michel