Have We Made Progress?
October 30, 2009
Posted by chcablogadmin in : Quality
Barbara Spreadbury
A reporter from a national news agency calls to ask for your response to the following: “It has been 10 years since the Institute of Medicine (IOM) published its report entitled ‘To Err is Human.’ What has your organization done to improve quality and safety for the children you serve?” What would you tell the reporter?
The IOM study identified the death rate for medical errors in all U.S. hospitals to be somewhere between 44,000 and 98,000 lives per year. A great deal of debate ensued after the release of the study as to whether the number of lives quoted was accurate. In reality, even if the numbers were reduced to 10% of the estimate that is still too many needless deaths. The financial impact of the level of performance was dramatic as well – $17 to 29 billion per year in hospitals across the country.
So, what would you tell the reporter? In September 2009, attendees at the CHCA Quality and Safety Leaders Forum were asked to respond to the question as if it was posed by family members of patients who had been treated in their hospitals. The vast majority of responses were examples of new processes, policies, and activities that are now in place compared to 10 years ago, such as Rapid Response Team implementation, increased Board engagement in quality and safety, and improved medication reconciliation. Some responses did highlight measurable improvement, such as reduced narcotic adverse drug events, blood stream infections in the PICU, or improved hand washing rates.
It will be difficult to show that major progress has been made in reducing the death rate from medical errors in U.S. hospitals. The reasons cited for lack of substantial reduction in death rate vary from lack of leadership to lack of real solutions. The bottom line: Patients are continuing to die in hospitals from preventable errors and that should not happen.
Is the rate of improvement sufficient for your organization? If you were not a health care leader, would you be satisfied with your response? What should you tell the reporter when you are asked in 2019? What should we do differently now to achieve those results?
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