Slow progress made in preventing medical errors

Five years ago, the authors of the Institute of Medicine’s landmark report on medical errors, To Err is Human, said it would be “irresponsible to expect anything less than a 50% reduction in errors over five years.” But Harvard School of Public Health adjunct professor Lucian Leape, a co-author of the report, and Karen Davis, president of the Commonwealth Fund, have looked at the situation five years later and concluded that, irresponsible or not, we haven’t seen anything approaching a 50% reduction in errors. “The most we can say is that we’ve made progress,” they said in a Commonwealth Fund President’s Report.

In response to the Institute of Medicine report, hospitals have launched programs to prevent errors and improve safety. The Joint Commission on Accreditation of Healthcare Organizations has identified and incorporated new safe practices into its inspections and requires hospitals to disclose errors to patients. Congress has appropriated $50 million a year for patient safety research, greatly increasing work in the field and helping to build and support a research infrastructure.

Mr. Leape and Ms. Davis said that all of this is still far short of what’s needed.

They said error prevention efforts are isolated and uncoordinated and federal funding for patient safety research is only “a tiny fraction of what it should be.”

They said the nation loses more lives each year to medical errors than are saved by the technological advances of the National Institutes of Health, a statistic that calls for creation of a National Institute of Health Safety.

“When it comes to improving patient safety, we have plenty of recognition of the problem but no real commitment to solving it,” they wrote in the Commonwealth Fund column. “As a result, hospitals are still dangerous places to be if you are sick. Even if you live across the street from a world-class hospital, you are at risk for receiving poor care. For example, up to 2 million hospital patients a year [one of 20 of all those admitted] contract serious infections while in the hospital.”

Mr. Leape and Ms. Davis noted that Pennsylvania recently became the first state to collect data on hospital-acquired infections. That state’s Health Care Cost Containment Council, using conservative measures, found that nearly 12,000 Pennsylvanians contracted infections during 2004, resulting in at least 1,500 preventable deaths and costing an extra $2 billion in care.

“We can’t afford this kind of health care anymore,” the two wrote, “and we shouldn’t pay for it.” They called attention to the decision made by Minnesota HMO HealthPartners to stop paying for 27 major medical mistakes from a list developed by the Washington, DC-based National Quality Forum. They said they are mistakes that never should happen, such as surgery performed on the wrong body part or serious harm from contaminated drugs or medication errors.

Paying for performance only can inject reason into the current reimbursement system, they said, which now blindly compensates for services provided, including defects. “By saying no to unacceptable errors, payers will strengthen incentives for hospitals, doctors, and other health care professionals to provide high-quality, safe care. When hospitals are paid more for getting it wrong then for getting it right, it’s clear we have a perverse system of incentives.”

They also noted that Medicare’s fee-for-service payment system penalizes providers who try to improve quality. As an example, they pointed to hospitals that set up programs to help coordinate post-discharge care for patients with congestive heart failure. Such patients have a chronic condition that can’t be cured but can be treated, and they can be encouraged to maximize quality of life and minimize acute episodes resulting in expensive hospitalization. However, Medicare payment is not set up to encourage such coordination. While Medicare pays for outpatient visits, it does not pay for coordination activities or reimburse providers for the costs of these activities. And since Medicare pays only for visits and hospitalizations, if a hospital succeeds in preventing re-hospitalization, Medicare will pay it less than for inferior care that results in repeated hospital care.

“Indeed,” Mr. Leape and Ms. Davis wrote, “most payers pay for volume rather than quality because volume is easier to measure. To encourage payers to pay for quality, we need to develop better measures of quality. Medicare and other payers are working on this. The Centers for Medicare & Medicaid Services has posted information on 10 measures of hospital quality on its web site (see chart), and many managed care plans, nursing homes, and home health agencies also have posted quality measures on-line. But much more information needs to be made available and widely disseminated. Infection rates for individual hospitals should be made available to the public at large, just as access to the National Practitioner Data Bank maintained by the Health Resources and Services Administration should be publicly available.

(More information is available from The Commonwealth Fund at www.cmwf.org.)