Better, Safer Healthcare: Take the Pledge

 In CHR Blog

This week is Patient Safety Awareness Week. Part of me delights in the idea of championing better, safer healthcare. It’s a time to celebrate the improvements made over the past ten to fifteen years. The national Patient Safety Chartbook describes recent trends. In five years since 2010, rates of “hospital-acquired conditions” were reduced by 21%. The improvement in patient care includes a 29% drop in the rate of adverse drug events, the single largest category of problems in 2010 tracked by the federal government.

Yet part of me cringes every time we must discuss this topic, because we know health systems still have a way to go.  Pressure ulcers, also known as bedsores, declined too, but only by 10% in five years.  The actual number of people who experienced a hospital-acquired pressure ulcer was about 1.2 million.  Nearly another 1.2 million experienced an adverse drug event while in-hospital.  Together, more than 6500 of these two types of events occurred every day in U.S. hospitals. At just one event per patient, and one family member or friend trying to respond to help each patient, 13,000 people impacted per day is a lot of people.

This week, I was looking at the recently published Minnesota Adverse Health Events Report for 2017.  It covers hospitals and ambulatory surgery center events that are required to be reported to the state.  Of the 341 reported events, 103 resulted in serious injury and 12 resulted in death. Given the number of people in Minnesota hospitals or surgical centers throughout the year, such numbers are undoubtedly low as a percent of cases.  Still, the few hundred events and the 12 deaths could easily represent friends of friends, former college classmates, neighbors or family of people I knew when I lived in Minnesota.  It’s painful to know patients sometimes suffer needlessly in our hospitals and surgery centers.


Mistakes can happen in a healthcare facility, as well as in life.  Not all are foreseeable or avoidable.  But looking at the Minnesota report, it was disturbing to see 36 instances of wrong site surgery (or other invasive procedure).  To be fair, 36 out of 3.1 million (a little over 1 per 100,000) sounds very good as a rate.  Some had to do with spinal injections where it may be difficult to count the vertebrae.  But others had to do with a mix-up in the right vs. left side.  The health industry has long had well-researched, well-accepted standards and procedures for marking the site of surgery and checking everything out before the surgery starts.  So, it’s highly troubling to know that a surgeon might skip the step of marking the site, and further, that the expected Time Out process gets taken lightly. These kinds of mis-steps are embarrassing to hospitals and surgery centers, and they’re dangerous to patients.  Accountability lies with the facility Board of Directors, the Chief Executive Officer, and the highest level of elected Medical Staff leadership.

Nineteen times last year in Minnesota, surgeons performed the wrong surgery – oftentimes putting in the wrong eye implant, or the wrong knee implant.  When such events occur, how rigorous is the analysis of root causes?  Are all surgeons and staff held to the highest standards?  It’s important to not give a “pass” to someone on the Medical Staff, even when that specialty is in short supply.


The Minnesota report also called attention to falls while in the hospital. Eighty-two falls with serious injury were reported, of which five patients died.  About half of the falls occurred on medical-surgical units.  We often associate falls with broken hips, and the rate of falls with hip fracture is a patient safety indicator that is widely tracked. But head injuries can – and did – occur in the Minnesota patient falls, sometimes resulting in death.  Just under 1/3 of falls occurred in patients under age 64, reminding us all, of the risks when you’re in the hospital for a serious illness. For Board members, it’s important to know that Falls are considered a “nursing-sensitive indicator”.  This means that nurse staffing levels can affect the rate of falls in your hospital.

Zero Harm

The Joint Commission, which accredits hospitals, has stated its commitment to a goal of zero patient harm.  When thirteen types of patient safety events in 34 states were studied in 2014 by the Agency for Healthcare Research and Quality (AHRQ), there were some encouraging results.  Among them was the finding that 69% of hospitals had NO pressure ulcers (Patient Safety Indicator PSI 03); 77% had NO in-hospital falls with hip fractures (PSI 08).  Zero harm may be achievable. But one of the biggest challenges was found in “PSI 04” – Death rate among surgical inpatients with serious treatable complications. Just 8% of hospitals had no PSI 04 events.  Universally, we can say there is room for improvement.  In 2014, there were nearly 12 such deaths per 100 qualifying elective surgical cases.  Instead of giving in to the fright of these potential harms, let us rise as leaders to achieve excellence.

Today, Consumer Health Ratings signed the pledge at the Institute for Healthcare Improvement initiative: United for Patient Safety*.  It reads simply: “I pledge to strive to implement and follow practices that increase the safety of my patients and my team.”  So far this week, nearly 7900 professionals across the US have made this commitment. Take the pledge. Make patient harm a thing of the past.


*To sign the pledge or to learn more about Patient Safety Awareness Week, visit United in Patient Safety Campaign

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Consumer Health Ratings Male patient and spouse getting instructions before going home from hospital