Mistakes, Mix-ups and Medicine

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Hospitals Embark on Major Effort to Prevent Errors

Imagine going through the trauma of a breast cancer diagnosis and a grueling double mastectomy operation—only to be told that it was all unnecessary. You don’t have breast cancer, and never did.

That’s what happened to Darrie Eason, a 35-year-old single mother from Long Island, N.Y., who told her story on “Good Morning America” in early October. A laboratory pathologist mixed up the slides from her biopsy—meaning both that Eason had disfiguring, irreversible surgery for no reason, and that the woman whose slides were mixed with hers, who did indeed have cancer, got diagnosed and treated later than she would have otherwise.

It’s been eight years since the Institute of Medicine (IOM) issued its groundbreaking report “To Err Is Human,” which found that at least 44,000 Americans—and possibly as many as 98,000—die every year due to preventable medical errors. Many of these—such as the death of Boston Globe health reporter Betsy Lehman due to a chemotherapy overdose, or the death of an 8-year-old boy from a drug mix-up during minor surgery—occur in hospitals. (The IOM study report was based on the results of major studies involving hospitals in Colorado, Utah and New York.)

Clearly, Darrie Eason’s story demonstrates that devastating medical errors are still happening, despite the wake-up call provided by “To Err Is Human.” But key changes in how hospitals manage care are making impressive progress in reducing the error rate.

In 2004, the Institute for Healthcare Improvement (IHI) launched what it called the 100,000 Lives Campaign—a strategy to reduce preventable in-hospital deaths by at least 100,000 over an 18-month period. IHI initially hoped to convince at least 2,000 of the approximately 6,000 hospitals in the nation to sign onto the campaign, but ultimately more than 3,000 agreed to pursue six deceptively simple interventions aimed at error reduction.

These included reconciling medications at every transition point in patient care, rapid response teams to be deployed at the first sign of a patient decline, and specific interventions aimed at preventing surgical-site infections, central-line infections and ventilator-associated pneumonia.

At the end of the 18-month period, IHI estimated that deaths in participating hospitals had dropped by 122,000—nearly 25 percent more than its original goal. The exact number may be open to debate—IHI President and Chief Executive Officer Dr. Donald Berwick conceded that the 122,000 figure is a “good faith estimate”—but there’s no doubt that the campaign moved the numbers in the right direction.

Last December, IHI expanded the campaign with a much more ambitious goal and name: the 5 Million Lives Campaign. To be accurate, they’re not aiming to prevent 5 million deaths this time, but instead, to save 5 million people from what the IHI calls “incidents of medical harm.”

By the end of 2008, the goal is to sign on 4,000 hospitals (an additional 1,000 over the original participants) and have them commit to 12 interventions, which include the original six plus six new targets. So far, they’ve signed up more than 3,500 hospitals. If the campaign meets its goal, it would cut “total national medical harm” by one-sixth.

The 5 Million Lives Campaign isn’t the only game in town. In fact, medical error reduction is the new watchword at almost every hospital. The national Surgical Care Improvement Project (SCIP), sponsored by the Centers for Medicare and Medicaid Services, is seeking to reduce the instances of surgical complications by 25 percent by the year 2010. Participation is voluntary, but many hospital administrators assume that ultimately, reimbursement rates may be tied to meeting SCIP goals.

Hospitals are also getting to the bottom line of medical errors in a much more literal way. Medicare announced earlier this year that as of October 2008, it will no longer pay hospitals for care resulting from eight complications, including falls, objects left inside patients during surgery, pressure ulcers, and three types of hospital-acquired infections—with the goal of reducing these types of errors (although some worry that hospitals will just pass the costs along to patients).

In Massachusetts, 33 of 61 hospitals reported in September that they have already begun to waive charges related to serious medical errors known as “never events,” which include things like operating on the wrong surgical site, serious medication errors, leaving an object behind in a surgery patient, giving a baby to the wrong mother, and falls that lead to death or serious disability.

But can medical errors in hospitals (and elsewhere) ever be cut to zero? The conventional wisdom used to be “no way.” After all, hospitals are run by human beings and, as the IOM report said right in its title, to err is indeed human. But experience is showing otherwise.

Dr. Lucian Leape, an adjunct professor of health policy at Harvard whose work paved the way for the IOM report and who is generally considered the father of the patient-safety movement, told Health Affairs journal in October that “it is now apparent that we can use perfection as a benchmark. This means we can stop talking about reducing medication errors by 50 percent or improving hand washing by 30 percent, and so forth. We now have convincing evidence that when the effort is made and new practices are implemented, we can actually eliminate certain adverse events.”

For example, Leape cited the use of protocols for reducing central-line infections and ventilator-associated pneumonia that were developed by Johns Hopkins intensive care unit physician Peter Provonost. After cutting rates of these adverse events in his own ICU to zero, Provonost worked with Blue Cross and Blue Shield to spread the protocols throughout 100 Michigan hospitals—which in turn had no cases of central-line infections or ventilator-associated pneumonia over a period of six months.

So it’s not unreasonable to ask that there be no more cases such as that of Darrie Eason—ever.

About the Author

Gina Shaw is the medical writer for The Washington Diplomat.

Last Edited on November 29, 1999