A Decades-Long Delay in the Healthcare Safety Movement

In healthcare, an adverse event is an undesirable outcome in a medical procedure or treatment that is not caused by the initial injury or illness itself. A patient who suffers an allergic reaction to a medication has suffered from an adverse event. So has the patient whose hip replacement has deteriorated, and is now suffering from cobalt poisoning. Adverse events are not always life-altering or threatening, but they can cause serious harm to the patient. In some cases, these events were entirely preventable.

A recent study published in the New England Journal of Medicine has found that despite decades of so-called progress in healthcare treatment and safety, patients are still suffering from an alarming number of adverse events. Per their findings:

Nearly a quarter of hospital stays involve adverse events from healthcare errors, and nearly one in 10 cause serious harm, according to a study replicating the landmark 1991 Harvard Medical Practice Study (HMPS).

In a random sample of 2,809 admissions at 11 Massachusetts hospitals, 23.6% had at least one adverse event, 32.3% of which required substantial intervention or prolonged recovery…. Fully 22.7% of the adverse events were judged to be preventable, with a preventable event happening in 6.8% of all admissions and a serious, life-threatening, or fatal preventable event in 1.0%.

Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Boston called these findings “disturbing” in a companion editorial he wrote, saying they “suggest that the safety movement has, at best, stalled.”

Effectiveness of the data in determining cause of adverse events

The purpose of the 1991 study was to bring awareness to the importance of patient safety. Berwick stated that following the study, patient safety was the top priority in American healthcare.

However, the decades that followed showed little progress. One of the reasons was that there was no definitive answer about whether the national healthcare system was safer. The recent study did not convince researchers that safety had improved.

Decades of changes in the healthcare field

In the early 1990s, medical professionals weren’t relying on electronic records and telecare. Today, technological methods have helped transform the healthcare field.

Thanks to telecare, physicians can service their patients using technology. If patients want a remote doctor’s visit, that is possible because of telecare. But telecare may also lead to missed or incorrect diagnoses for patients who have underlying illnesses which do not present with symptoms. A patient with the flu and a patient with COVID-19 are likely to present with similar symptoms, for example. A patient complaining of chest pain may be experiencing an anxiety attack, a heart issue, or a bout of indigestion. There simply may be no way to tell over a 10-minute video conference.

Another key change is the transition of care. Many services have been shifted from inpatient care to emergency care. Emergency care is more unpredictable. There is not enough time to provide personalized care to each patient in this environment. In addition to the high-speed environment, the number of patients visiting emergency care has skyrocketed, especially during the pandemic. These recent changes have contributed to new types of adverse events for patients in some form.

Patient characteristics that can affect adverse events

Some patient characteristics can increase the risks of adverse events. These characteristics can include age, race, gender, and form of insurance. Patients with specific characteristics are at greater risk of suffering from adverse events. Older patients, for example, would be more at risk than younger patients. Older patients are more likely to take several medications than younger patients.

Adverse events and the size of healthcare centers

Another characteristic that can affect adverse events is the size of the hospital. The random samples revealed that larger hospitals had greater healthcare errors than smaller hospitals.

In addition to the size of the hospital, other factors like culture and strong leadership were considered. Like other teams, the hospital’s culture plays a vital role in its performance. Some hospitals have reputations for cutting corners and overlooking patient safety.

Potential ways to improve patient safety

The researchers from the most recent study believe that practical solutions can lead to improved patient safety. These practical solutions include more reliable and routine methods used to collect data. With the most accurate data, monitoring can be better and adverse events can be reduced. Conducting careful studies can also help to improve patient safety. Through these studies, medical professionals can suggest effective improvement strategies.

All healthcare professionals are expected to view adverse events as preventable. According to Berwick, however, this can seem misleading. Judging preventability in the medical field could be difficult at times. A more valuable approach would be to view each injury as potentially preventable. Berwick noted that the more one looks for harm, the more one will find it.

The researchers also stressed the importance of strong leadership. All hospital staff can do their part to engage in a culture that promotes patient safety. Many factors impact the healthcare field. The increase in patients and the number of professionals retiring can cause healthcare professionals to overlook important information. Hospitals need strong leadership to keep the team focused on improving the lives of their patients. These practical steps can help ensure that patient safety remains a top priority in healthcare.

The most alarming truth about adverse events is that they often result from medical negligence. Physicians can cause serious harm to patients when they deviate from the required standard of care. When this occurs, patients have the right to seek accountability and damages from the negligent parties.

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