Erin McCann, Managing Editor
The way IT is designed remains part of the problem
WASHINGTON | July 18, 2014
Tejal Gandhi, MD, president of the National Patient Safety Foundation and associate professor of medicine, Harvard Medical School, spoke at the hearing.
It’s a chilling reality – one often overlooked in annual mortality statistics: Preventable medical errors persist as the No. 3 killer in the U.S. – third only to heart disease and cancer – claiming the lives of some 400,000 people each year. At a Senate hearing Thursday, patient safety officials put their best ideas forward on how to solve the crisis, with IT often at the center of discussions.
Hearing members, who spoke before the Subcommittee on Primary Health and Aging, not only underscored the devastating loss of human life – more than 1,000 people each day – but also called attention to the fact that these medical errors cost the nation a colossal $1 trillion each year.
“The tragedy that we’re talking about here (is) deaths taking place that should not be taking place,” said subcommittee Chair Sen. Bernie Sanders, I-Vt., in his opening remarks.
Among those speaking was Ashish Jha, MD, professor of health policy and management at Harvard School of Public Health, who referenced the Institute of Medicine’s 1999 report To Err is Human, which estimated some 100,000 Americans die each year from preventable adverse events.
“When they first came out with that number, it was so staggeringly large, that most people were wondering, ‘could that possibly be right?'” said Jha.
Some 15 years later, the evidence is glaring. “The IOM probably got it wrong,” he said. “It was clearly an underestimate of the toll of human suffering that goes on from preventable medical errors.”
It’s not just the 1,000 deaths per day that should be huge cause for alarm, noted Joanne Disch, RN, clinical professor at the University of Minnesota School of Nursing, who also spoke before Congress. There’s also the 10,000 serious complications cases resulting from medical errors that occur each day.
Disch cited the case of a Minnesota patient who underwent a bilateral mastectomy for cancer, only to find out post surgery a mix-up with the biopsy reports had occurred, and she had not actually had cancer.
In terms of how to address this crisis, the recommendations put forth were diverse – including boosting the number of registered nurses, supporting AHRQ, CDC and establishing incentives. There did, however, exist common agreement with one thing: information technology is falling short in many arenas.
“Medicine today invests heavily in information technology, yet the promised improvement in patient safety and productivity frankly have not been realized,” said Peter Pronovost, MD, senior vice president for Patient Safety and Quality and director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins.
Jha agreed. There’s been so much hype around electronic health records, with the industry showing “phenomenal progress” with adoption and use. “But the potential is not going to be realized unless those tools are really focused on improving patient safety,” he said. “The tools themselves won’t automatically do it.”
Peter Pronovost, MD
Tejal Gandhi, MD, president of the National Patient Safety Foundation, added: The IT needs to be improved. “We need better systems to minimize cognitive errors…such as computerized algorithms,” she said, speaking on behalf of ambulatory patient safety.
One of the more significant issues relating to ambulatory medical errors involves missed and delayed diagnoses, she pointed out, for instance failing to order appropriate tests or initiate follow up. The IT systems, she continued, need to be designed to better manage test results.
And other key recommendations?