Why we need High Reliability Organizing.
The Institute of Medicine published The first call to action to address preventable harm and failures of the healthcare system in 1999… everybody quotes it. They estimated preventable deaths from 44,000 to 98,000 per year.
You can read the full report here: To Err is Human: Building a Safer Health System
In October of 2008, the Inspector General assessed adverse events among Medicare Beneficiaries (i.e. your parents and grandparents). During that one month, 1 million senior citizens were discharged from the hospital.
13.5% of them (134,000) experienced an adverse event.
1.5% (15,000) experienced an event that contributed to their death. That projects to approximately 180,000 per year!
44% of events were deemed preventable.
The cost of these events to Medicare was $324 million.
You can read the full report here: Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries
In March of 2011, a HealthGrades Patient Study used 13 of the ARHQ patient safety quality indicators to look at national event rate, mortality, and cost among Medicare Beneficiaries. The study used data from 2007 to 2009.
Out of 40,348,218 admissions in U.S. hospitals, there were 708,642 total safety events. The study found:
79,670 deaths among patients who experienced one or more identified events
1 in 10 patients died after treatable complication of PE, DVT, pneumonia, sepsis, cardiac arrest, GI bleed
Four of the 13 indicators accounted for 229,664 events, including 29,917 deaths.
These four indicators are :
iatrogenic pneumothorax
postoperative respiratory failure
post-op PE or DVT
post-op wound dehiscence
Additional care due to adverse events cost 3.7 billion!
You can read the full report here: HealthGrades Patient Safety in American Hospitals Study
In November of 2011, research revealed that reporting of adverse events is rare. Digging into the chart showed adverse events to be ten times greater than current reporting systems captured. This report looked at three measurement strategies:
Voluntary reporting
Agency for Healthcare Research and Quality’s Patient Safety Indicators
Healthcare Improvements Global Trigger Tool (charts were scanned for clues of events, then confirmed by M.D. review)
Out of the 795 records reviewed from 3 hospitals, 393 adverse events were detected by all three methods combined.
Local hospital reporting identified 4 events.
Patient Safety Indicators identified 35 events.
The Global Trigger Tool identified 354 events.
Voluntary reporting is NOT POPULAR!
Adverse events occurred in 33.2% of admissions. Two powerful quotes from the report:
“The Institute for Healthcare Improvement’s Global Trigger Tool found at least ten times more confirmed, serious events that these other methods.”
“Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US healthcare system and misdirect efforts to improve patient safety.”
We are making mistakes about our mistakes!
You can read the full report here: ‘Global Trigger Tool’ Show Shows That Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured
The most recent estimate of preventable harm was published by The Journal of Patient Safety in 2013.
The widely cited statistic, “400,000 preventable deaths per year” originated from this article.
Reviewing four studies that used Global Trigger Tools, the author used a weighted average to calculate a more realistic estimate of preventable harm.
Estimated deaths from preventable harm are 210,000-400,00 patients per year
Serious harm occurs 10 to 20 times more often than death, approximately 2,100,000-4,000,000 cases per year
You can read the full report here: A New Evidence-based Estimate of Patient Harms Associated with Hospital Care
How is this happening?
Sometimes it’s what we do…sometimes it’s what we don’t do.
Crico, a malpractice insurance company, puts out patient safety alerts to increase understanding on how harm is happening. In their 22nd issue in 2014, they addressed the problem of failure to rescue. Failure to rescue is a death resulting from our inability recognize and/or treat a preventable complication during healthcare delivery.
The report determined two groups of factors contributing to failure to rescue and suggested strategies to combat the problem.
Contributing Factors:
Failure to recognize clinical deterioration
Barriers to escalation
Some Suggested Strategies:
train staff to notice small signs of deterioration
training on communication, situational awareness, and using chain of command
improving safety culture to remove fear of negative response to an escalation of deterioration event
In order to read the full article, click here and request a downloadable copy.
We need to INCREASE our capacity to recognize and respond to small signs something may be going wrong!
In 2015, Paula Garvey conveys how nurses are key in solving the problem of failure to rescue. She addresses four impediments and four solutions.
Impediments:
failure to recognize clinical deterioration
failure to communicate and escalate concerns
failure to physically assess the patient
failure to diagnose and treat appropriately
Activities to prevent FTR:
surveillance
timely identification of complications
taking action
activating a team response
You can read the full report here: Failure to Rescue: the Nurses Impact