Senate Hears Testimony About Woeful Record of Patient Safety

Medical experts told a Senate subcommittee earlier this month that the health-care community’s efforts to monitor and prevent patient harm are insufficient. They implored Congress to do more to prevent deaths and injuries in hospitals and other health-care settings.

“Our collective action in patient safety pales in comparison to the magnitude of the problem,” Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine said. “We need to say that harm is preventable and not tolerable.”

“We can’t continue to have unsafe medical care be a regular part of the way we do business in health care,” said Dr. Ashish Jha, from the Harvard School of Public Health.

As reported by ProPublica.org, Jha claimed that patients are no better protected now than they were 15 years ago. That’s when the Institute of Medicine issued a groundbreaking report estimating that 98,000 hospital patients a year die from medical errors.

ProPublica, an investigative public interest site, supports an ongoing, interactive series on patient safety.

The hearing was called “More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety,” in a nod to patient advocate John James. He also testified before the subcommittee, and recently referred to a study in his Patient Safety America newsletter that found that 440,000 patients die yearly from preventable medical errors. (see our blog, “Protecting Yourself from the Thousand-a-Day Toll of Medical Error.”)

Preventable harm, as noted by Sen. Bernie Sanders, the chairman of the subcommittee on Primary Health and Aging, is the third-leading cause of death in America. The experts said one reason why the situation isn’t improving is because medical providers and public health agencies don’t measure the harm accurately. If you don’t quantify the problem, it’s unlikely anyone will be moved to resolve it.

Pronovost and Jha want the Centers for Disease Control and Prevention (CDC), which collects data about hospital-acquired infections, to widen its perspective, and track other forms of patient harms as well. They include:

• medication mistakes;
• adverse reactions to and injuries from drugs; and
• missed or delayed diagnoses.

Dr. Tejal Gandhi, president of the National Patient Safety Foundation, said medication errors and adverse events affect as many as 1 in 4 patients within 30 days of being prescribed a drug. She said outside measures are necessary to clean up this dismal reality. “We cannot just tell clinicians to try harder and think better,” she said.

The National Transportation Safety Board investigates aviation accidents, and James suggested the creation of a National Patient Safety Board as a similar type agency to investigate patient harm. He also proposed a national patients’ bill of rights defining protections like those defined for workers and minority groups.

Lisa McGiffert, director of the Consumers Union Safe Patient Project, advocated for greater communication about harm when it occurs. Raising consciousness of medical errors is the first step in empowering medical consumers to make informed choices about their care. And the bright light of publicity, she suggested, can only motivate providers to improve in their record of first doing no harm, which they all promise as part of their Hippocratic Oath.

We’re gratified that Congress seems to be interested in helping medicine to do far less harm than it does, and we hope the hearing is not the end but the beginning of meaningful action.