According to the Journal of Patient Safety study, Evidence-based Estimate of patient Harms Associated with Hospital Care, preventable adverse events (PAE’s) contributing to deaths from care in hospitals cause one-sixth of all deaths that occur in the United States each year, more than 400,000 deaths annually. The study’s author, John T. James, PhD, is the founder of Patient Safety America, which provides newsletters on patient safety and advances in medical technology and care that may affect patient safety.
The study utilizes the Global Trigger Tool (GTT) to assess patient adverse events leading to healthcare harm. The GTT measures adverse event triggers or “clues” documented in former patient records which can lead to adverse events. Based upon the results of the study, the number of deaths from hospital care is conservatively estimated at 440,000 patients each year.
The types of events taken into consideration included the following:
- Errors of commission – When the wrong medical action is taken or the right medical action is taken yet performed improperly. For example, during the surgery to remove a gallbladder, the intestine is nicked, leading to a future infection causing death.
- Error of omission – Obvious action was necessary to heal the patient, yet it was not performed at all. Errors of omission are difficult to detect, and at times can be the result of a patient not following given guidelines after discharge. Another example may be a necessary medication that was not prescribed.
- Error of communication – Miscommunication from physician to physician, or between patient and physician. For example, a cardiologist not informing a patient who experienced syncope, or fainting, while running, not to run or explaining the risks associated with running.
- Error of context – A physician may fail to take into account patient constraints that may impact the success of treatment after discharge.
- Diagnostic errors – Diagnostic errors can result in delayed, wrong or no treatment at all, which often leads to the death of the patient.
According to the study, the Office of Inspector General reported that 86 percent of patient harm events were not reported by hospital staff as they either did not perceive the event as reportable, or did not report an event that was commonly reported. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. On a more positive note, changes to the medical system are working. The U.S. Department of Health Services released a report showing that an estimated 50,000 fewer patients died and 1.3 million fewer patients were harmed in hospitals from 2010 to 2013 as a result of safer health care efforts.
If you really want to reduce the spiraling increases in the cost of health care, a good start would be to reduce the number of preventable injuries and deaths. Certainly the reduction of preventable injuries of 1.3 million over the past three years is a step in the right direction, however the number of injuries and deaths from these events is clearly too high.
Michael K. Gillis, Esq.
GILLIS & BIKOFSKY, P.C.
1150 Walnut Street
Newton, MA 02461
Phone: 617-244-4300
Fax: 617-964-0862
E-mail: mgillis@gillisandbikofsky.com