CALL TO ACTION: CHANGE THE STATISTIC

July 30, 2016    |   By: Jennifer Lux

BY ALEX CHRISTGEN, BS, CPPS Center for Patient Safety

The article follows the 1999 IOM report which made the first attempt to determine preventable harm in healthcare. The IOM report estimated a staggering 44,000 to 98,000 patient deaths each year due to medical errors. In 2013, the IOM’s reported numbers were determined to be grossly underestimated based on a newer study suggesting the actual number was likely to be more than 400,000 deaths per year as result of medical errors. In 2013, the IOM’s reported numbers were determined to be grossly underestimated based on a newer study suggesting the actual number was likely to be more than 400,000 deaths per year as result of medical errors. Although the BMJ article specifically references medical errors in the inpatient hospital setting, CPS’ recently released annual report suggests medical errors in LTC, home care, and EMS settings may be just as prevalent. The following call to action is recommended:

  1. make errors more visible when they occur so their effects can be intercepted
  2. have remedies at hand to rescue patients
  3. make errors less frequent by following principles that take human limitations into account

This Call to Action aligns with the recent IOM update in 2015, which lists eight recommendations for improving patient safety, and specifically diagnostic errors, in healthcare. Two of the eight recommendations call for:

  1. an enhanced focus on a culture that supports the open discussion of errors
  2. a collaboration of patient safety across the continuum of care through organizations, such as a Patient Safety Organization (PSO), that support safe sharing and learning.

The Center for Patient Safety (CPS) has recognized these areas as strategic approaches to reduce harm for quite some time. We’ve embedded supportive culture improvement programs (Just Culture, CUSP, TeamSTEPPS, Second Victims Programs, and culture assessments) and offer safe sharing opportunities (as a PSO) that support CPS’ vision of improving patient safety for all patients and healthcare providers, in all processes, all the time. Through our program objectives of Protecting, Learning, and Preventing, CPS is currently working with hundreds of organizations and thousands of healthcare providers in 38 states across the country to improve patient safety every day. Together, we will reduce preventable harm in healthcare. Contact me if you have questions about any of the recently released reports or if you would like to talk about what you can do to join the healthcare movement to safer care.

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.