Healthcare organizations still struggle to ensure patient safety
The Institute of Medicine issued its groundbreaking report on safety in 1999; clinician burnout and the aftereffects of the pandemic are raising new concerns.
In 1999, a report from the Institute of Medicine rocked the healthcare universe by putting in black and white what most medical professionals knew from their experiences – healthcare can be dangerous to your well being.
Specifically, the research in “To Err is Human,” estimated that as many as 98,000 people died in hospitals annually as a result of preventable medical errors.
Since then, almost a quarter of a century later, there’s been scant progress on the patient safety front, and instead, there are rising concerns that a variety of factors are amplifying risks in care delivery.
Clinician burnout is rising, and many experts believe that provides a correlated risk that boosts the risk of medical errors. Technology has provided some patient safety capabilities, but it’s also increased the amount of information and alarms that clinicians must process. And safety issues appear to affect some populations more than others, raising concerns that there’s disparity in how different social groups experience safety in healthcare.
The rising risks inherent in current patient care are drawing more attention and efforts, both from federal agencies, and from private and industry groups trying to make care safer.
Years of frustration
Recent reports and studies have underscored the lack of progress on patient safety, some 24 years after the IoM report.
A study co-authored by David Bates, MD, published in January 2023 in the New England Journal of Medicine found that nearly a quarter (23.6 percent) of a random sample of 2,809 admissions were associated with at least one adverse event. Of the 978 adverse events, 22.7 percent of them were deemed preventable, and nearly a third (32.3 percent) “had a severity level of serious,” which caused harm that “resulted in substantial intervention or prolonged recovery.”
The research by Bates corroborates multiple other studies showing unstaunched risk in medical care. An accompanying editorial to NEJM’s focus on patient safety bemoans the fact that “the safety movement, has, at best, stalled,” notes Donald Berwick, MD, currently lecturer of healthcare policy at the Department of Health Care Policy at the Harvard Medical School, and former administrator of the Centers for Medicare & Medicaid Services.
Berwick’s column notes that preventable medical errors have become even more dangerous even as the COVID-19 pandemic is winding down. The industry lacks “constancy of purpose” for improving patient safety, he says.
Top safety concerns
The risk of making mistakes has grown as care delivery becomes more complex, as patient acuity has increased over time in care settings, as clinicians deal with higher volumes of patients, and with more data being available on patients from clinical records and other sources, including the recent growth of patient-generated data.
Patient safety concerns are diverse and varied, reflecting the complexity of care and range of issues facing providers today, according to ECRI, which produces an annual report listing top patient safety concerns. The 2023 ECRI report includes the following:
- • The pediatric mental health crisis
- • Physical and verbal violence against healthcare staff
- • Clinician needs surrounding maternal fetal medicine
- • Impact on clinicians expected to work outside their scope of practice and competencies
- • Delayed identification and treatment of sepsis
- • Consequences of poor care coordination for patients with complex medical conditions
- • Risks of not looking beyond the "five rights" to achieve medication safety
- • Medication errors resulting from inaccurate patient medication lists
- • Accidental administration of neuromuscular blocking agents
- • Preventable harm related to omitted care or treatment
In addition to these concerns, healthcare organizations have more general issues that have impacted patient safety for years. These include issues such as medication errors, patient falls, infections specific to inpatient care or treatment, such as central line infections, botched patient identification and more.
Some organizations have made patient safety grading and improvement their focus. For example, Healthgrades rates hospitals for patient safety and experience. In 2023, it recognized 445 hospitals across 44 states (the top 10 percent of all hospitals with its Patient Safety Excellence Award.
In its analysis, Healthgrades contends that patients treated at its top recognized hospitals are less likely to experience the following safety events than patients treated at non-recipient hospitals:
- • In-hospital fall resulting in hip fracture (61.6 percent less likely)
- • Collapsed lung due to a procedure or surgery in or around the chest (52.7 percent)
- • Pressure sores or bed sores acquired in the hospital (66.1 percent)
- • Catheter-related bloodstream infections (67.3 percent)
Taken together, the ECRI analysis and Healthgrades assessments provide a glimpse of the wide range of concerns that healthcare organizations, its clinicians and administrators must monitor for, measure and seek to minimize occurrences.
Occasional improvements, but risks remain
Patient safety leaders agree that while some progress has occurred, it has not been significant and has come in fits and starts.
“Over the last 30 years of the most recent patient safety movement, we have arguably not made the progress that we need to make,” says Patricia McGaffigan, vice president, safety, Institute for Healthcare Improvement (IHI), and president of the Certification Board for Professionals in Patient Safety, an entity of the Institute for Healthcare Improvement. “Very often, it’s through individual projects that are chipping away at some of the specific hospital-acquired or healthcare-acquired conditions and problems, such as infections.”
The industry’s made progress when it focuses on specific problems, such as patient falls, central line-associated bloodstream infections or hospital-acquired infections, agrees Jeff Salvon-Harman, a vice president at IHI. But he notes an ominous pattern after initial improvements are achieved.
“We see these rates decrease, but over time, it is very challenging to preserve some of these wins,” he says. “Some has to do with staff turnover, also complacency and ‘drift,’ especially when introducing new safety practices. There’s a tendency to revert back (to previous delivery practices) over time. One of the big challenges is, when we get really good in some areas, how do we hold gains in the first and make gains in the second?”
Pressure washes over clinicians
Clinician capacity to maintain patient safety gains are compromised by rising rates of burnout among physicians, nurses and other caregivers in provider settings.
There’s heightened awareness of the growing tide of burnout among clinicians, and patient safety experts see the shrinking and less experienced workforce as a contributing factor to increased risk of medical errors. (See related story here).
Indeed, the risk posed by burnout to patient safety was recognized as early as 2017, when a paper published by the National Academy of Medicine related increased likelihood of medical errors because many healthcare professionals “are burned out, a syndrome characterized by a high degree of emotional exhaustion and high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work.”
For clinicians struggling with motivation and a sense of being overwhelmed, maintaining focus on patient safety looks like just one more task that they are required to do, McGaffigan contends.
“We just keep layering on more work on folks, more and more projects,” she says. That underscores the logic that “if we do more projects, we’re just going to get more safe. And that’s not the reality. I think the main project we need to work on is the safety ecosystem, creating the conditions in the environment where all of these safety initiatives can be more successful.”
For healthcare organizations to create such an ecosystem, they need to strip away unproductive tasks and administrative/billing record-keeping, says Tim McDonald, MD, chief patient safety and risk officer at RLDatix, a technology provider that offers a platform designed to support hospitals and other providers with risk mitigation, regulatory compliance and workforce management resources.
“So many people are being asked to do more with less, so we do need smart people to come in and figure out how can we do this more efficiently,” McDonald says. “One of the great projects I love following is referred to as GROSS, which stands for Get Rid Of the Stupid Stuff. So, for example, we know the number of keystrokes a doctor needs to make is directly correlated to the level of burnout. And we've really begun to look at how can we get rid of the stupid stuff and make it simpler.” Whether it’s including information in the electronic health record or in event reporting systems, “we need to make it easier and more efficient and quicker for people to put reports in so we can learn from it.”
Culture shift needed
Healthcare organization leaders need to prioritize a culture of safety and implement systems that protect patients, says Kenneth Deans, president and CEO of Health Sciences South Carolina, a collaborative that represents leading healthcare organizations and medical education institutions in the Southeast.
“From a leadership perspective … do no harm is the first rule. It’s not just a goal – it's really our objective to protect patients across the spectrum,” Deans says. “As leaders, we have to create a shared vision around that.”
The pandemic prompted a renewed focus on patient safety, McGaffigan contends. “We saw amazing resilience and commitment of the healthcare workforce to be able to adapt and do real-time problem solving and to be able to broker learning systems,” she says. “And I think that went an incredibly long way toward ensuring that we were able to ensure that our workforce was cared for.”
But post-pandemic, financial pressures are absorbing more focus from administrators, Salvon-Harman notes. He cited the most recent survey of hospital CEOs by the American College of Healthcare Executives, released in February, which listed workforce challenges and financial pressures as the top concerns facing hospitals. Patient safety and quality ranked fourth on the priority list.
“There’s a tension between these perspectives,” he says, contending that CEOs’ focus on finances and operations don’t align with clinicians’ sense that patient safety and quality need more attention. “This adds to the moral distress, leaving clinicians more distracted. So then there’s a greater likelihood of making errors, with clinicians more likely to cut corners to manage the productivity aspect of their jobs. This takes time and consideration away from patients.”
Tech – foe and potential friend
When it comes to impacting patient safety, technology is both villain and hero. Similar to its impact on clinician burnout, many experts see information and digital technology as adding to clinicians’ burden and thus adding risk to patient care, but they also see future potential for its capability of ameliorating risk.
“When you look at data and the complexity of technology, it hasn’t been static,” Salvon-Harman says. “While we haven’t really improved (patient safety), we’ve held steady when (healthcare) complexity and technology have added so many wrinkles, so some might say we’ve done OK to not lose ground, or even gain a little ground.”
Technology has enabled more expectations for data capture, and more data feeds into clinical records, and that has tended to increase clinician burden, leading to both burnout and more opportunities for medical errors.
Additionally, technology can give clinicians more inputs and warnings. This has led to the phenomenon of alert fatigue, where clinicians receive too many warnings or messages from information systems, and end up filtering out or ignoring them, raising the risk of missing a critical indicator of deteriorating patient conditions or potential risks, such as drug-drug interactions.
But technology offers promise to reduce errors. Right now, it’s illuminating risks, which then can be addressed, says Urmimala Sarkar, MD, professor of medicine at UCSF in the division of general internal medicine, whose work centers on innovating for health equity and improving the safety and quality of outpatient care. “Technology has transformed the way we think about patient safety,” she says. “It’s made things that are invisible in healthcare now visible. So care is transparent, so it’s much more easily viewable and digestible and able to be synthesized.”
Other experts predict a huge potential benefit from the use of technology (see related story here).
Bringing patients into the equation
But patient engagement could be one of the current trends in healthcare that could have a significant biggest impact on improving the safety of care. As care recipients, engaged and knowledgeable patients – and their families – represent an important line of defense against medical mistakes.
The need for family involvement became apparent during the pandemic, says Nicole Kerkenbush, chief nursing and performance officer at Monument Health, a Rapid City, SD-based community-based healthcare system. “When we stopped letting families come in to see our patients and be at their side – whether it was for a pandemic related issue or just for a wellness visit – I think that really had a negative effect. They didn't have their support system with them. They didn't have someone there to be that second set of eyes and ears, to ask questions.”
Structurally, healthcare organizations must engage patients so they feel empowered to ask questions and optimize their involvement in their care, says Deans of HSSC.
“We have to break down the barriers that prevent patients from communicating to us,” he says. “We must feel comfortable as patients asking the right questions, not just receiving one-way dialogue towards us – we have to be able to engage with our providers in a meaningful and intelligent way."
“We as providers have to really foster that level of patient engagement because frequently patients will not speak up on their own behalf,” he adds. “Most of the time, even though (patients) have questions … they they won't speak up. We've got to get at the root cause of why that is and then implement mechanisms to solve it. We need to make sure patients realize that no detail is too big or small to ask questions about.”
While engagement should be increased, it must be done in a way that doesn’t end up swamping providers, says McDonald of RLDatix. Portals and OpenNotes have increased the load in clinicians’ inboxes, he says, noting that “all these physician and nurse practitioner practices … tell me they have to spend an extra two hours a day just clearing out their inbox to be able to communicate with families.”
Technology has the potential to enable clinicians to anticipate potential safety concerns before they happen, enabling caregivers to head off healthcare errors before they occur, McDonald concludes. Their support must be a priority in delivering safe care.
“If our workforce does not feel safe and does not feel supported in the organization, they can't give safe care,” he notes. “So we need to do what we can to create peer support programs as a big part of the national patient safety movement.”