By John Palmer
Despite considerable improvements in patient safety, an unacceptable number of medical errors still occur at the local and national level.
That’s the finding of the report released in June by the Betsy Lehman Center for Patient Safety, a Boston-based advocacy group started in 2004 by the state of Massachusetts in honor of the late Boston Globe reporter. While Betsy Lehman was in the hospital for breast cancer treatment, the healthcare team made a series of fatal mistakes, including administering her a fourfold overdose of chemotherapy drugs. After Lehman’s death at age 39, a national movement to improve patient safety was started, and her case was highlighted in the 1999 Institute of Medicine report, To Err Is Human.
The latest report from the Center, titled The Financial and Human Cost of Medical Error, sought to analyze the financial and human cost of medical errors—both in Massachusetts and nationwide—associated with services covered by health insurance.
Among other things, the report found that patients are largely dissatisfied with caregivers’ level and frequency of communication when medical mistakes occur, and that open communication when mistakes occur is linked to lower levels of adverse emotional impacts for patients.
“Our research shows that despite the investments and gains of recent years, medical error remains a persistent challenge in all health care settings, even in Massachusetts,” the report concluded. “Preventable harm from these errors imposes significant costs on the state’s health care system and lasting physical, emotional, and financial impacts on patients and families.”
The report was the result of two studies in Massachusetts, a state that consistently receives high marks on patient safety and satisfaction. Still, those two studies uncovered some 62,000 medical errors in the state, which were responsible for over $617 million in excess healthcare insurance claims in just one year—a number that exceeded 1% of the state’s total healthcare expenses in 2017.
The first study analyzed health insurance claims for one year in Massachusetts, using 100 diagnostic codes commonly attributed to preventable harm. The second took a random sample of 5,000 households in the state and found 1,000 people who had experienced a medical error in the previous five years.
“From our surveys, we learned that many of the people who report recent experience with medical error are suffering long-lasting behavioral, physical, emotional, and financial harms,” the report said. “Individuals report that they have lost trust in the health system and some avoid not only the clinicians and facilities responsible for their injuries, but health care entirely.”
Not shocking, but frustrating
According to some statistics, medical errors continue to cause hundreds of thousands of preventable deaths and injuries each year in the United States, to the tune of some 115 incidents out of every 1,000 hospitalizations. These needless incidents cost an average of about $8,000 per admission. The report added that the risks to patient safety have increased as more patient care is delivered outside of hospitals, including home-based care and services provided at physician practices and nursing homes. The largest number of medical errors by far is caused by mistakes administering medications, and it’s estimated that one in 20 U.S. adults will experience a diagnostic error every year, with half of them considered “potentially harmful.”
Turning to efforts at prevention, the report authors pointed to the Centers for Medicare & Medicaid Services, which introduced a pay-for-performance reimbursement program for hospitals that receive Medicare funds. As a result, hospital-acquired conditions declined by nearly 1 million instances from 2014 to 2017, saving about $7.7 billion.
So why isn’t withholding Medicare funds sufficient to prevent more medical errors? The problem, the report conceded, goes much deeper and conspires against the best intentions of healthcare organizations looking to make improvements.
Some of the problems include the complexities of modern medicine, such as usability issues with electronic medical records or unclear labeling of medications; taken together, these details create unintended safety risks.
Culture is also an issue. Employees in many organizations still fear retribution for pointing out errors and unsafe practices. Safety continues to take a back seat to competing priorities in many hospitals. In some organizations, there is an overriding sense that the hospital is already doing as good a job as it can.
Hospitals also struggle with reporting and data systems that don’t provide enough information to guide improvements. In addition, many providers are still paid not only for healthcare services that result in preventable harm, but for the additional services necessitated by the harm, resulting in very little financial incentive for the organization to reduce errors.
“Healthcare is a human-based complex technical system endeavor, and therefore it’s very difficult to completely eliminate errors, but I think we have to be driving toward zero errors and zero harms,” said Kim Hollon, president and CEO of Signature Healthcare, a member of the Massachusetts Healthcare Association (MHA)’s Board of Trustees and chair of MHA’s Clinical Issues Advisory Council, in a written statement. “Often, errors are related to the process, not the care itself. Patients appreciate when we explain to them what happened and how we can improve the process.”
Opportunities for improvement
Many of the report’s findings centered around the idea that healthcare providers and patients simply don’t communicate enough. As a result, patients who are on the receiving end of errors claim that those errors have long-lasting physical and emotional impacts. That leads to a general mistrust and even avoidance of healthcare, which can result in more problems that ultimately necessitate a hospital stay.
Communication after an error is often lacking, with about 60% of patients saying they were dissatisfied and 64% saying their care team either did not communicate with them at all, or did so in fewer than two ways. Only about a quarter said they were offered any kind of emotional, functional, or financial support following an error. (For what it’s worth, even though fewer than one in five survey respondents said they received an apology after a medical error, 82% of those who got one said it was sincere.)
“Another major theme expressed by respondents was that they were dismissed or not heard when trying to alert care team members that they had known reactions to a proposed medication, were at risk of falling, or their symptoms did not align with the doctor’s diagnosis,” the report authors wrote. “Unclear or incomplete discharge and follow-up instructions to patients were another frequent concern.”
The report also found that while patients and families are often astute observers of what happened and why things went wrong, many factors lead to their observations being dismissed or ignored. About 40% of survey respondents said the medical error had not been discussed with anyone other than the patient’s family members or friends, such as a healthcare professional, administrator, health insurer, government agency, or lawyer. Of this group, 71% said it would “do no good.”
“Our findings on the mitigating effects of open communication on emotional harm and health care avoidance strongly suggest that patients and providers alike would benefit from implementation of proven programs that facilitate difficult conversations following adverse events,” the report concluded.
“Preventing these events from happening in the first place will require long-term commitment and coordination to ensure that the principles of safety culture and high reliability are woven into the fabric of health care delivery in every setting—from hospitals to medical offices, nursing homes, urgent care centers, and more.”
Some Massachusetts healthcare organization groups said they welcome the report’s findings and plan to use them to improve patient care in the state’s hospitals.
“This new report from the Betsy Lehman Center both acknowledges the advances Massachusetts hospitals have made in terms of patient safety in recent years and helps illustrate how care provided in hospitals and other healthcare settings must improve,” said Steve Walsh, president and CEO of MHA. “Our hospitals are working hard every day to bolster their harm prevention efforts and enhance patient safety. This report will serve as an important component of the hospital community’s road map to continued advancement.”
As a result of the report’s findings, the Betsy Lehman Center is creating a Massachusetts Health Care Safety and Quality Consortium to create and manage a process to identify actionable, measurable steps and coordinate a series of initiatives under the four “pillars” of patient safety, which include transparency, culture, learning systems, and support for patients and providers.
By establishing the consortium, the Center hopes to improve Massachusetts patient safety through the following accomplishments:
- Establish a forum to amplify the efforts of the many organizations whose participation is needed to accelerate progress—and to support them in doing what they are best situated to do
- Provide the administrative backbone required to engage and support all essential public and private stakeholders
- Identify opportunities to reintegrate safety with ongoing quality improvement initiatives
- Identify opportunities to adapt safety management systems and culture of safety best practices from non-healthcare industries
- Facilitate state engagement in the National Patient Safety Steering Committee
- Keep safety and quality in the public eye
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.