Abstract
After 15 years of concerted efforts of American hospitals to improve patient safety, the rate of healthcare-induced harm has not been curtailed. Over 200,000 U.S. hospital patients die and countless more are harmed each year as a result of predictable and preventable human errors. The excess costs associated with these events are estimated to be well over $30 billion annually. Ironically, much of the work necessary to improve patient safety within hospitals must occur outside hospitals through public health initiatives designed to raise awareness, motivate civic action, and offer hospital patients manageable steps to ensure safer care for themselves and others. The best return on investment may be realized by first addressing three event types that, together, are most prevalent, predictable, and preventable. The case of healthcare-acquired infections is used to illustrate why mitigating the hospital safety crisis will require a paradigm shift that unifies efforts from healthcare systems, public health, and society overall.
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Notes
An off-the-mark procedure refers to the same category of event as a wrong-site surgery and uses the exact same criteria set forth by The Joint Commission. The term of-the-mark procedure is offered as a substitute because the original term has contributed widespread confusion about what constitutes an event. Among other points of confusion, this category of event is not limited to surgeries.
Healthcare-associated infections account for about half of all hospital safety related deaths. Drug errors occur far more frequently than healthcare-associated infections with a substantial number resulting in harm, but a smaller number resulting in death (7,000 annually). Likewise, off-the-mark procedures are associated with much distress and harm, but less frequent deaths. However, all three conditions are similar in that effective error prevention is tied to specific behaviors that a layperson could learn to observe and/or request. Together, they account for over half of all preventable deaths.
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The author would like to thank Andrea Powell Arcona, Ph.D. for discussing certain ideas contained here many times and for helping to get them articulated on paper.
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Watson, G.L. The Hospital Safety Crisis. Soc 53, 339–347 (2016). https://doi.org/10.1007/s12115-016-0028-2
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DOI: https://doi.org/10.1007/s12115-016-0028-2