The 1999 Institute of Medicine (IOM) report “To Err is Human: Building a Safer Health System” has widely been recognized as opening the eyes of the public and the medical profession about the enormity of the issue of medical errors. It estimated that up to 98,000 patients might die each year as the result of their medical care rather than from their underlying medical conditions. While some criticized the study as overestimating the numbers or noted many of the patients may have died anyway, most of us who have been hospital medical directors or been involved in quality improvement and patient safety felt the numbers were likely underestimates.
Then in 2011 (see our May 2011 What’s New in the Patient Safety World column “Just How Frequent Are Hospital Medical Errors?”) we noted a study (Classen 2011), using IHI’s Global Trigger Tool to identify hospital adverse events, that found that the numbers may be 10-fold higher than what was noted in the IOM report. Potentially avoidable adverse events occurred in a third of hospital admissions. In our January 2011 What’s New in the Patient Safety World column “No Improvement in Patient Safety: Why Not?” we noted a study (Landrigan 2010) that showed there has been little improvement in hospital adverse events overall over a long time frame. That study, done on data from 10 North Carolina hospitals, used IHI’s Global Trigger Tool to estimate rates of patient harm and preventable harm over a 6-year period. They found essentially no reduction in harm over that period.
The IHI Global Trigger Tool clearly identifies more adverse events than are found either via chart review or voluntary reporting or using administrative data tools like AHRQ’s PSI indicators. While the IHI Global Trigger Tool measures events somewhat differently than in the studies that formed the basis of the IOM report, the global trigger tool methodology is “doable” with limited resources and provides a more reliable comparison over time. See our October 30, 2007 Patient Safety Tip of the Week “Using IHI's Global Trigger Tool” and our April 15, 2008 Patient Safety Tip of the Week “Computerizing Trigger Tools” for more details on how to use it.
Now a new study (James 2013) provides a new evidence-based estimate of patient harms associated with hospital care. It’s “evidence-based” because it analyzed those published studies which utilized the Global Trigger Tool (GTT) methodology to identify cases of potentially preventable medical errors. Using a weighted average of 4 studies utilizing the GTT, James estimates that the lower limit of deaths per year associated with preventable harms in hospitals is 210,000 deaths per year. And, given the limitations of the GTT and fact that these studies do not include deaths related to diagnostic errors which may not show up for years, James further estimates that the number of deaths associated with preventable harm may be more than 400,000 per year. He also notes that the frequency of serious harm may be 10- to 20-fold higher than that for lethal harm.
This is a well-done analysis and James has a good discussion of the difficulties involved in accurately assessing the frequency of adverse events related to medical care.
But we’ll come back to a point we’ve made frequently. You’ve often heard us use the phrase “Stories, Not Statistics” (see our December 2009 What’s New in the Patient Safety World column “Stories, Not Statistics”). When we first began doing presentations on patient safety in the early 1990’s we often began with some of the statistics on medical error from Lucien Leape’s work. But we began to notice physicians and medical students begin to zone out when we talked about statistics on medical error. What they liked were the anecdotes we would tell about cases that really happened. So we changed our focus. While we still often show statistics on medical error to put things in context, we no longer highlight them. Instead, we really rely on the stories. That’s what gets people’s attention. That’s what makes people say “I wonder if that could happen here?” and what makes them go back to look at the systems in their health care systems. It is those stories that hit home hard and make people remember. Who cannot remember their own reactions when they first heard the Josie King story, or the story about the nurse who administered Bicillin intravascularly, or the little boy who died from concentrated epinephrine injection during a simple surgical procedure, or any nurse who inadvertently administered concentrated potassium solutions? We could even begin with the story of the death of the son of the author of the most recent study. In his book “A Sea of Broken Hearts” (James 2007) James writes about his son, who died while running, and a variety of issues related not only to prolonged QT interval syndrome but also to multiple other problems in our healthcare system (communication breakdowns, fragmented care, unnecessary tesing, regulatory boondoggles, etc.).
In fact, the lack of compelling stories is one of the reasons we feel IOM’s “To Err is Human: Building a Safer Health System” failed to gain traction despite considerable initial media attention. Everyone focused on the statistics from that report. It lacked the stories about real people you need to tell in order to get people and systems to change.
Yes, the new study further clarifies the magnitude of the problem. But telling stories about real people experiencing such problems is what will get your healthcare colleagues to perk up and take notice that many of those problems could happen in their hospital or their practice. And, by the way, you’ve probably also noticed in your state that legislators are also more likely to enact patient safety legislation in response to personal stories rather than statistics! So use the statistics as background information but lead with the stories.
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999
Classen D, Resar R, Griffin F, et al. ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Affairs 2011; 30(4): 581-589
Landrigan CP, Parry GJ, Bones CB, et al. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. N Engl J Med 2010; 363: 2124-2134
James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety 2013; 9(3): 122–128
James JT. A Sea of Broken Hearts—Patient Rights in a Dangerous, Profit-Driven Health Care System. Bloomington, IN: AuthorHouse; 2007
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