Seven years ago, the Institute of Medicine rocked the medical world with their report: To Err is Human. What was published was really no surprise to those within the medical profession, but it was a rather shocking report for the trusting American “consumer” of health care: that a reasonable estimate would place the number of deaths that occur annually in this country as a result of various medical errors somewhere between 48,000 and 96,000. Although as a percentage of medical “encounters” this represents an extremely small number, the number itself is somewhat staggering. Even more provocative is the fact that death is only the most extreme manifestation of medical error infection, wrong site surgery, medication toxicity, etc all of which may cause serious and even permanent injury to patients, are most likely not going to result in patient death. Therefore, these mortality estimates really only represent the most extreme tip of a dangerous iceberg of which those outside the medical community had previously harbored a sort of a hazy awareness or unspoken acceptance.
Medical quality improvement efforts are not a new phenomena. The Joint Commission which certifies hospitals, medical facilities, disease management programs and more was actually the outgrowth of an effort made in the early part of the last century by the American College of Surgeons to attempt to improve and standardize surgical outcomes throughout the country. However, with the accelerating cost of health care, the increasing portion of the population without insurance coverage, and the realization that the United States, which likes to consider itself a leader in health care, spends twice the dollars per person on health care as its nearest “competitor” while ranking in the low teens in terms of national health statistics, there is well-justified pressure to examine the actual value of our national investment. Value=quality/dollars. However one defines “quality” in medicine, medical errors are certain to constitute negative value. Therefore, it becomes essential to eliminate all preventable error, and minimize all potentially non-preventable error.
Obvious analogies with the airline industrys safety efforts and the resulting performance are appropriate. There are many situations in medicine where systematic changes can eliminate circumstances conducive to or permissive of errors. Research then becomes essential to both discover not only occurrence but context of errors, as well as to document the success or failure of a system implemented to prevent this error. Software products, such as the Medical Error Reporting System developed by the research arm of the Department of Surgery at Columbia University, merge and analyze data throughout the hospital system to identify correlations which identify the source (and thereby suggest the potential solution(s)) of medical errors.
Unfortunately, the Centers for Medicare and Medicaid Services, in their “pay for performance” zeal to pressure hospitals to eliminate preventable errors have recently decided not to pay for surgical readmissions for various complications. In some cases this is quite reasonable. Re-exploration for a retained foreign body left at the time of surgery is a preventable complication by merely using radiopaque markers on all pads or instruments which are not themselves radiopaque, and then performing an xray of the operative field with the patient on the table before leaving the operating room. If there is need for re-exploration, it can be performed immediately, with the patient still asleep and the surgeon and operative team still present. However, certain other complications may be unavoidable. Certain infections may occur even with the most scrupulous adherence to hospital policy and protocols designed to minimize infection. Sick people are just thatsick people, who may not have the ability to resist infectious challenges posed by necessary medical interventions.
Bottom line: what is a preventable “error” and what is not? How can it best be prevented? How can public policy address the issue most realistically? These are questions which fall in the domain of ongoing and essential research. The Florida Heart Research Institute is committed to improving the quality of medical care. We therefore work with physicians to help collect and analyze data which will help them understand their performance in a national context, as well as to identify opportunities for improvement.
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