It takes a village to combat errors and omissions that cause millions of deaths and sickness in our nation’s hospitals and care facilities. That’s the message that sets apart Your Patient Safety Survival Guide (Rowman & Littlefied Publishers, August 2017).
How Hospital Care Harms Patients
One out of every three hospital patients in the United States are harmed by the care they receive. Each year, over 400,000 die as a result. Most of these deaths are due to human and system errors—not faulty medical decisions or diagnoses—and they could be cut in half through the use of simple and nearly cost-free safety behaviors.
Your Patient Safety Survival Guide delivers a patient-centered blueprint on how to transform the patient safety movement so that millions of unnecessary illnesses and deaths in hospitals, outpatient facilities, and nursing homes can be avoided. It provides key safety habits that people must learn to recognize so they can be sure hospital personnel use them during every patient encounter. It also explains how addressing the most common safety problems will set the stage for tackling a wide range of issues, including healthcare’s role in the overuse of opiate painkillers and its related heroin epidemic.
Fortune 500 Countries Helped Launch the Patient Safety Movement
To understand why employers must help solve this problem, consider how the patient safety movement started. In1999, the Institute of Medicine released a report, aptly called To Err is Human. The report represented the first time the field of medicine disclosed to the public the extent to which hospital patients are needlessly harmed by the care they receive. It’s findings shocked people inside and outside the healthcare industry.
Leaders of Fortune 500 companies and other large public and private purchasers of healthcare benefits weighed in on the report. They were distraught over paying for healthcare coverage for their employees when such coverage might actually lead to harm. Concerned that they had no way to determine which hospitals were more likely to be associated with bad outcomes for their employees and high costs to their businesses, the following year they coalesced to form what is known as The Leapfrog Group.
Increasing Transparency for Informed Choice
Leapfrog is a powerful consumer-oriented consortium of business leaders with a mission to trigger giant leaps forward in healthcare safety. Leapfrog continually presses the envelope with respect to hospital transparency and public reporting of safety and quality metrics, making it easier for businesses and individuals to be more informed when choosing their healthcare providers.
As summed up by Leapfrog’s President and CEO, Leah Binder, who has been repeatedly named as one of the 50 most influential people in healthcare, “I run an organization…with a membership of highly impatient business leaders fed up with problems of injuries, accidents, and errors in hospitals.”
Leapfrog issues letter grades rating hospitals on how safety they are for patients, an A, B, C, D, or F on how well they protect patients from errors, injuries, and infections. Although hospitals have earnestly sought to reduce medical errors, there has been no widespread evidence of improvement.
More Regulation is Not the Answer
In 2013, the president and vice president of The Joint Commission declared that performance of American hospitals was predictably unreliable and unsafe and that no amount of regulation could make them safe. It’s an extraordinary day when leaders of the most significant healthcare regulatory agency assert that more regulation will not solve the problem at hand.
Doing Less to Achieve More
Your Patient Safety Survival Guide calls for a paradigm shift that centers on engaging patients for the purpose of collaborating with healthcare providers to eliminate a small but powerful subset of patient safety’s most frequently recurring problems—a decidedly narrow focus that simultaneously engages those who receive and deliver healthcare.
Three issues that make sense to immediately tackle through public engagement are hospital-acquired infections, procedural mix-ups (also called wrong site surgeries or off-the-mark procedures involving the wrong patient, wrong body part, wrong spot on a body part, or wrong procedure), and medication administration errors. Together, these three categories of harm represent the most prevalent, predictable, and preventable medical mistakes—a trifecta of sorts.
If it seems hard to believe that tackling just three problems alone could dramatically downshift the magnitude of the crisis, consider the fact that each year 100,000 people die from infections that they pick up as a result of their hospital care. That is a sizable portion of all preventable instances of hospital-induced harm. Medication errors are another leading cause of preventable death in hospitals, with a third of all such errors occurring during the bedside administration of drugs. As a category, procedural mix-ups don’t occur nearly as often as medication errors or hospital-acquired infections; however, every off-the-mark procedure signals, like a bellwether, that something may be seriously wrong with the facility's care delivery system.
Its About Behavior, Not Medicine
Moreover, these categories of harm can be avoided with simple, quick, and essentially cost-free behaviors that are performed during almost every patient encounter and in eyeshot of patients. They are essential and visible routines; however, for a myriad of reasons, providers don’t employ them or don’t do so consistently. If the public were to realize the use of these habits could mean the difference between life and death, who wouldn’t make sure they were used?
According to a recent Forbes article, a top workplace trend is more creative use of wellness programs to save on healthcare costs. With medical errors costing between employers and employees between $32 and $52 billion annually, businesses would be wise to advise employees that they can help combat common medical errors.
Praise for a Long Overdue Resource for Patients and Professionals
Binder described Your Patient Safety Survival Guide as “an accessible and definitive overview of the key issues in hospital safety, including what families, hospitals, clinicians, and communities can do to protect patients.” The book “provides a useful action plan, including concrete steps and actual scripts patients and families can use to become more effective advocates for their own safety,” according to Dr. Albert Wu Director of the Center for Health Service Outcomes at Johns Hopkins Bloomberg School of Public Health.
Susan Dentzer, President and CEO of the Network for Excellence in Health Innovation and former editor of Health Affairs says, “Anyone who anticipates undergoing health care, or who cares for loved ones who do, should read this book.”
Once American employees know how to better protect themselves and others from medical errors, we will be able to cut medical errors by 50 percent over a five year period—a national goal that was set in 2000 and that we’ve never come close to achieving.
Business Case and Blueprint for Engaging Employees
Your Patient Safety Survival Guide clearly outlines the business case and blueprint for engaging the public in hospital efforts to improve patient safety. “Someday all hospitals will earn an A, and our families will not have to endure unnecessary suffering…This book will guide us there, and help us to persevere,” according to Binder. American employers may be key to helping this happen.
Kohn, LT, JM Corrigan, and MS Donaldson (1999). "To Err Is Human: Building a Safer Health System." Washington, D.C.: Institute of Medicine.
Watson, GL (2016). "The Hospital Safety Crisis: Unifying Efforts of Healthcare Systems, Public Health, and Society." Society 53, no. 4: 1-7.
Watson, Gretchen LeFever (2017). Your Patient Safety Survival Guide: How to Protect Yourself and Others from Medical Errors. Lantham, MD: Rowman & Littlefied.