{"id":462,"date":"2024-09-11T16:19:58","date_gmt":"2024-09-11T16:19:58","guid":{"rendered":"https:\/\/medical-article.com\/?p=462"},"modified":"2024-09-11T16:19:58","modified_gmt":"2024-09-11T16:19:58","slug":"why-we-still-kill-patients-and-what-we-need-to-stop-doing-it","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=462","title":{"rendered":"Why We Still Kill Patients (And What We Need to Stop Doing It)"},"content":{"rendered":"
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By MICHAEL MILLENSOM<\/p>\n

This article is adapted from a talk given Sept. 7 at the 11th Annual World Patient Safety, Science & Technology Summit in Irvine, California, sponsored by the Patient Safety Movement Foundation. World Patient Safety Day is Sept. 17, with a series of events in Washington, D.C. from Sept. 15-17 sponsored by Patients for Patient Safety (US). An agenda and registration, which is free, can be found <\/em>here<\/em><\/a>.<\/em><\/p>\n

Since I started researching and writing about patient safety, one question has continually haunted me: given the grievous toll of death and injury from preventable medical harm that has been documented in the medical literature for at least 50 years, why have so many good and caring people \u2013 friends, family, colleagues \u2013 done so little to stop it?<\/p>\n

To frame that question with brutal candor: Why do we still kill patients? And how do we change that? The answer, I believe, lies in addressing three key factors: Invisibility, inertia and income.\u201d<\/p>\n

When it comes to invisibility, we\u2019ve all heard innumerable times the analogy with airline safety; i.e., plane crashes occur in public view, but the toll taken by medical error occurs in private. That\u2019s true and important, but there are other factors that promote invisibility that we in the patient safety movement need to address.<\/p>\n

For instance, while I\u2019m not a physician, I can say with certainty that every patient harmed in the hospital had a diagnosis (right or wrong), and often more than one. Yet disease groups such as the American Heart Association and American Cancer Society have been uninvolved in efforts to eliminate the preventable harm that\u2019s afflicting their presumed constituents.<\/p>\n

Why have we let these influential groups sit on the sidelines rather than make them integral partners in raising public and policy visibility? For instance, there a number of Congressional caucuses \u2013 bipartisan groups of legislators \u2013 focusing on cancer. While much attention is paid to the Biden administration\u2019s cancer moonshot, what about the safety of cancer patients treated today, while we wait for an elusive cure?<\/p>\n

In a similar vein about missed opportunities for visibility, the stories told by patient advocates about the harm a loved one has suffered are always powerful. However, the specific hospital where the harm took place is typically not mentioned, perhaps for legal reasons, perhaps because it\u2019s become a habit. The effect, however, is to dilute the visibility of the danger. The public is not confronted with the uncomfortable reality that my reputable hospital and doctor in a nice, middle-class area could cause me the same awful harm.<\/p>\n

Finally, one time-tested way to hide a problem is to use obscure language to describe it. Back in 1978, RAND Corporation published a paper provocatively entitled, \u201cIatrogenesis: Just What the Doctor Ordered<\/a>.\u201d It concluded: \u201cIn terms of volume alone, we are awash in iatrogenesis.\u201d \u00a0<\/p>\n

That would have been a compelling soundbite decades before the 1999 T<\/em>o Err is Human<\/em><\/a> report if everyone in America studied ancient Greek. \u201cIatrogenesis\u201d is a Greek term meaning \u201cthe production of disease by the manner, diagnosis or treatment of a physician.\u201d In short, patient harm is \u201cwhat the doctor ordered.\u201d Although there was plain English in the paper, the technical focus allowed the stunning prevalence of patient harm to remain publicly invisible.<\/p>\n

Of course, today we don\u2019t need to use a foreign language to hide unpleasantness. We can use jargon and euphemism. We have \u201chealthcare-acquired<\/em> conditions\u201d and \u201chealthcare-associated<\/em> infections.\u201d At least the Greek term acknowledged causality and responsibility.<\/p>\n

The invisibility of the scope and causes of patient harm leads inevitably to inertia and complacency. <\/p>\n

<\/span><\/p>\n

David L. Katz, a physician,\u00a0eloquently elucidated what happens in a HuffPost article entitled, \u201cHow Hospitals Kill Our Loved Ones and Conceal It<\/a>.\u201d Dangerous care persists not because of \u201ca nefarious conspiracy\u201d by any of the stakeholders, he wrote, but due to \u201cunwitting delusion\u201d in \u201ca system populated mostly by genuinely caring and often highly expert people that nonetheless devolves into routine and dangerous dysfunction.\u201d<\/p>\n

Or as a JAMA\u00a0commentary\u00a0pointedly put it<\/a>, \u201cClinicians have labeled virtually all harm as inevitable for decades.\u201d<\/p>\n

It\u2019s no surprise, then, that in the 2022 AHRQ Survey of Patient Safety Culture<\/em><\/a>, a majority of respondents \u2013 52 percent \u2013 said \u201chospital management seems interested in patient safety only after an adverse event happens.\u201d In a survey by the American Hospital Association<\/a>, just 50 percent of hospital boards had quality as one of their priorities. That is the sobering front-line reality we in the patient safety movement must confront.<\/p>\n

A last note on inertia. In 2021, the Joint Commission, the largest accreditor of hospitals, tightened its hand hygiene requirements<\/a>. It decreed that hospitals would now be required to set a goal for hand hygiene compliance and show they were making progress towards that goal. hand hygiene has been described as \u201ca critical component of infection prevention<\/a>,\u201d and in 2021 we were just emerging from the Covid-19 pandemic.<\/p>\n

But wait: this was not the cop who cracks down, it was actually the same old cop-out. The Joint Commission assured hospitals \u201cthere is no specific numerical target for this goal\u2026[and] no requirement for organization-wide surveillance.\u201d<\/p>\n

You could say the Joint Commission washed its hands of the matter. But where were the voices of patient safety activists denouncing this absurd rule to the media and the government?<\/p>\n

Finally, we get to income, a topic which infuriates and depresses me. For a moment, let\u2019s examine only what\u2019s written in public view. We regularly see articles in professional journals attempting to make the \u201cbusiness case\u201d for patient safety in a manner that, if the topic were any other issue critical to patient health, would be seen as a moral outrage.<\/p>\n

Two caveats. First, health care organizations must balance legitimate and often-difficult competing priorities. However, there is a difference between prudence and \u201cnot my problem.\u201d Second, we need to remember it\u2019s not the article authors who are at fault. They\u2019re only holding up a mirror to how decisions are actually made by too many of our friends, family and colleagues.<\/p>\n

What that mirror shows is an appalling amorality which, again, we in the patient safety community have not pointed to and cried out against.<\/p>\n

For instance, there\u2019s the business case for reducing bloodstream infections in the pediatric intensive care unit<\/a>. Or, in plain English, what\u2019s the economic justification for trying to prevent life-threatening infections in seriously ill children?<\/p>\n

A separate study focused on the \u201cattributable costs\u201d<\/a> of preventing those life-threatening, central-line associated bloodstream infections (CLABSIs) just in kids hospitalized with blood cancer. The purpose was to \u201cinform decisions regarding the value of investing in efforts to prevent CLABSIs in this vulnerable population.\u201d<\/p>\n

To be clear, these interventions are very modest in cost. But no mission without a margin, right?<\/p>\n

Not to leave out adults, particularly the elderly, how about a \u201ccost-benefit analysis\u201d of implementing an evidence-based program for preventing patient falls in hospitals, which are a \u201cleading source of nonreimbursable adverse events.\u201d (Non-reimbursable is the worst kind, right?)<\/p>\n

If you read the article in JAMA Health Forum<\/em><\/a> closely, a fall prevention program can be amortized to cost all of 88 cents per hospital bed, and you can get evidence-based materials on such a program in nine languages. A bargain!<\/p>\n

What I\u2019ve cited in just a portion of what\u2019s in the medical, health policy and administrative literature. How many of us have been in meetings where we\u2019ve seen even modest expenditures for preventing infections or medication errors or other patient safety improvements cut from the budget? Maybe we\u2019ve even heard that certain types of suboptimal care are very profitable.<\/p>\n

If this all seems a bit discouraging, we should remember that the essential first step to solving any problem is to face it honestly, no matter how uncomfortable that might be. Though the problems I\u2019ve briefly examined here are deeply frustrating, there are also many positive signs. There are significant efforts to break through the barriers blocking change, and it\u2019s imperative that we recognize, encourage and strengthen them.<\/p>\n

For example, the Leapfrog Group patient safety scores are banishing the invisibility surrounding individual hospitals\u2019 safety performance. But Leapfrog not only shines a harsh light on failure, its safety grades also spotlight institutions moving seriously towards zero harm, which is also a goal of the Patient Safety Movement Foundation. We need to marshal those examples in a strategic manner to jolt out of inertia those who have not yet joined the patient safety journey and show them not only what must be done, but what can be done.<\/p>\n

Speaking of shattering inertia and exposing invisibility, listen to the words spoken at this meeting by Dr. Michelle Schreiber. Schreiber is director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services, which spends more than $1 trillion<\/em> on health care each year. She declared point-blank, \u201cThe federal government is truly committed to improving safety,\u201d and then gave us specific examples of rules meant to change culture and change practice.<\/p>\n

Listening to Schneider and to representatives of other U.S. government agencies; to speakers from England and other countries; to a presentation by the World Health Organization \u2013taken together we are seeing the beginnings of a worldwide determination to make inaction unacceptable.<\/p>\n

Still, there\u2019s the final issue of income. Yes, U.S. reimbursement rules are being tightened, and yes, progress towards value-based payment by the private sector should help. And yes, governments around the world are declaring that patient safety is a public health issue. But whether significant economic incentives will take hold remains to be seen. Call me a \u201ccautious optimist.\u201d<\/p>\n

If you step back, however, you can see a much greater reason for optimism. There is a growing community of individuals who care passionately about patient safety. There is organized support for them for the first time from a broad-based, patient-led group, Patients for Patient Safety. Moreover, this is an international network, one that includes clinicians, administrators, researchers, patients, policymakers and others who, slowly, are occupying positions of influence throughout the health care and policy ecosystems.<\/p>\n

We who care deeply about patient safety are slowly remaking culture. We who care deeply about patient safety are making a difference.<\/p>\n

Joe Kiani, the founder of the Patient Safety Movement Foundation, began this summit by calling upon us to \u201csave at least one life.\u201d Allow me to put that thought into a different context. There is a saying in the Talmud, \u201cHe who saves one life is as if he saved the entire world.\u201d<\/p>\n

Even if it\u2019s not always obvious \u2013 no lights flashing or monitors beeping \u2013 each of us in this movement is saving lives, is saving entire worlds. We cannot ever forget that as we seek to make the invisible visible; to replace inertia with accountability for action; and to ensure that a much-ballyhooed mantra about money and mission or somber reminders of limited government budgets don\u2019t become an excuse for decisions that will, as Dr. Elizabeth Papaila of Baylor Scott & White Health beautifully put it here, cause individuals who are \u201cat the most vulnerable they\u2019ll ever be\u201d to be hurt and, sometimes, die.<\/p>\n

Although former President Clinton couldn\u2019t be with us today, a part of his speech to the Democratic National Convention, in which he described how the American people should challenge the candidates for president, could also apply to the challenges we face. He said:<\/p>\n

\u201cHere are our problems; solve them. Here are our opportunities; seize them.\u201d\u00a0<\/p>\n

In patient safety, let us be the ones who make that happen.<\/p>\n

Michael Millenson is President of Health Quality Advisors<\/em>\u00a0and\u00a0a long time THCB regular<\/em><\/p>","protected":false},"excerpt":{"rendered":"

By MICHAEL MILLENSOM This article is adapted from a talk given Sept. 7 at the 11th Annual World Patient Safety, Science & Technology Summit in Irvine, California, sponsored by the Patient Safety Movement Foundation. World Patient Safety Day is Sept. 17, with a series of events in Washington, D.C. from Sept. 15-17 sponsored by Patients…<\/p>\n","protected":false},"author":0,"featured_media":459,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-462","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/462"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=462"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/462\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/459"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=462"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=462"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=462"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}