In 2000, the Institute of Medicine published a report entitled “To Err is Human: Building a Safer Health System”. It created shock waves by revealing the large number of injuries caused by hospital medical errors. Patient safety became a major goal of health institutions, and generated numerous national conferences and meetings about how to make health care safer. The fact is, hospital mistakes continue to cause serious injuries.
A new study is now out, concluding that a quarter of hospital stays still involve adverse events, and nearly one in 10 cause serious harm. A third of the adverse events required substantial intervention or prolonged recovery, and more than 20% were judged to be preventable.
A closer breakdown of the numbers shows that almost 7% of hospital admissions involved preventable medical errors, and a serious, life-threatening or fatal event occurred in 1% of the admissions. Given the fact that there are thousands of hospital admissions occurring every day in the U.S., the number of serious and preventable injuries must be huge.
Dr. Donald Berwick, of the Institute for Healthcare Improvement, called the findings “disturbing” and commented that they “suggest that the safety movement has, at best, stalled.”
Comparing the 2000 study with the recent one is difficult, however, since there have been so many changes in how health care is provided. Included are the shift to electronic medical records and much care moving from inpatient to ambulatory settings. Hospital mergers and the development of huge multi-state health care systems has also changed the setting in which hospital health care is now provided. The growth in “ancillary” providers, such as physician assistants and nurse practitioners may impact the data.
Analysis of the numbers revealed that drug events were the most common error, followed closely by surgical or procedure incidents. Other events included nursing care (such as falls and pressure ulcers), and preventable infections. Surgical errors were most likely to be life-threatening, while infections were most likely to be fatal. In light of this study, Dr. Berwick emphasized that patient safety must again be pushed to the top of health care priorities. After all, he noted, it is a sacred obligation of the medical profession to “first do no harm.”
