The number of people who die from a preventable patient death is equal to a jumbo jet crashing every day of the year with no survivors. Statistics sound so scientific, but there is a story behind each life lost. There is a parent who will never see their child again. A child who never had a chance to know their mom or dad. A spouse who doesn’t know how they will go on without the love of their life. I’m not sure how or if the family of those lost can ever make peace with the fact that the death of their loved one was preventable.
Ask any clinician and I am sure they will tell you that even one preventable death is one too many. Medical errors are no longer seen as a normal part of practicing medicine. We are seeing more and more clinicians and others in the healthcare community step up and say that enough is enough. They are taking the lead on creating a culture of safety in their organization. At our annual Summit in January, we see doctors, nurses, and hospital administrators identify the challenges and the Actionable Patient Safety Solutions (APSS), and make measurable commitments in front of their peers and the media to implement the APSS. This is very different than just talking about the need for change. They are very honest about the problems and are quick to share their solutions and successes.
Working together, we will attain zero preventable deaths by 2020. The year 2020 will be here before we know it. We can either go in the direction we have been going and see the deaths keep rising or we can turn it around and work to eradicate them. We have already seen hospitals have some amazing results by implementing the APSS. A hospital in New York, which we will announce at the 2014 Summit, has already reduced preventable patient deaths in one area to zero. Change is possible and it doesn’t have to be slow.
Every single person needs to get involved. I can’t tell you how many times I hear from family members that they never thought this type of thing would ever happen to them. Many of them have turned their loss into a calling to make sure the same thing doesn’t happen to anyone else. You don’t need to experience a loss to get involved. We need the governmental agencies to make this a priority. We need legislation. I recently testified before the U.S. Senate Health, Education, Labor & Pensions Committee on some solutions that are needed to eradicate preventable patient deaths. As we introduce legislation, we will let you know how you can take the lead and support the issues by contacting your local representatives to make patient safety – the safety of you and your loved ones – a priority.
Joe Kiani Founder, Patient Safety Movement Foundation
According to the Journal of Patient Safety, up to 400,000 deaths in U.S hospitals each year are preventable. We will hear stories of those who unexpectedly lost loved ones and find out what can be done to put an end to this health care issue.
As if the family and friends of Lynne Spalding had not suffered enough heartbreak.
First they were confronted with news in early October that Ms. Spalding was found dead in a stairwell of a well-known San Francisco hospital, 2 weeks after she went missing from her room.
Then came a report from the San Francisco Chronicle, which said a hospital worker had seen and stepped over a body in the same stairwell location the week before Ms. Spalding’s corpse was found.
More than 200,000 patients die preventable deaths in U.S. hospitals every year. Ms. Spalding’s death highlights the need for a culture of patient safety in hospitals nationwide.
Hospitals remain one of our most valuable institutions. We count on the dedicated men and women who staff our hospitals to help bring our newborns into the world, and heal us when we’re sick. There can be no higher calling. And more than a few have made public commitments to patient safety through the Patient Safety Movement Foundation. But there is room for improvement.
Medication errors, failure to monitor patients, failure to rescue, healthcare-acquired infections, suboptimal blood transfusions, and the inability of medical devices to communicate with each other can lead to preventable deaths. Yet these and other causes of preventable patient deaths have solutions that can be implemented today – not only saving lives, but also money.
In September 2013, the American Medical Association published a study estimating that total annual costs for five major healthcare-associated infections were $9.8 billion. The study noted that it’s cheaper to prevent deaths.
An analysis released this year by the West Health Institute at a hearing before the House Energy and Commerce Subcommittee on Health estimated that medical device interoperability – the ability of medical devices and health care systems to seamlessly communicate and exchange information – could be a source of more than $30 billion a year in savings and improve patient care and safety.
On behalf of the Patient Safety Movement, I recently testified before the U.S. Senate Health, Education, Labor & Pensions Committee and laid out steps to help eradicate preventable patient deaths. Among them:
1. Create a System of Transparency
Current reporting systems do not require consistent, accurate, measurable and electronic reporting on the total number and causes of preventable deaths. We cannot improve what we do not measure.
Government should take the lead to create standardized processes for hospitals to define, measure, and report healthcare-acquired infections (HAI) and healthcare-acquired conditions (HAC). Congress should require HAI and HAC rates to be publicly reported to facilitate quality comparisons, much like the Security and Exchange Commission does for the finance industry.
2. Incentives and Disincentives
Congress should expand the current HAC Medicare policy to include a list of causes of preventable death. Congress should suspend payment to hospitals for the primary health condition until it is determined whether the cause of death was preventable. If preventable, and the hospital has implemented evidence-based strategies for prevention, the hospital would receive payment. If the hospital had not implemented the strategy, then payment would be denied.
Additionally, if hospitals implement evidence-based practices, they should be shielded from malpractice lawsuits to the fullest extent possible, such as through an affirmative defense and limits on damages.
3. Create a “Patient Data Super Highway.” Medical technologies should be able to communicate or interoperate with each other. Some technology vendors and providers pursue business practices to create “walled gardens” — strategies that block information-sharing between different systems to capture market share and/or additional future revenues. Technology solutions must be required to openly share information, particularly when their purchase is subsidized with taxpayer dollars. While respectful of patient privacy regulations under HIPAA, we shouldn’t provide incentives or reimbursement for products that do not openly share data with hospitals, patients, and all parties that can use the information to improve patient safety.
4. Safe Harbor
Today there are no incentives, only penalties, for medical technology companies to identify why a patient was harmed by their product. Hospitals are afforded protections for reporting adverse events through Patient Safety Organizations. Congress should extend the type of legal safe harbor afforded to providers through Patient Safety Organizations to technology vendors to promote transparency, which will benefit the system overall.
5. Patient Dignity
Too often a patient’s or a family’s cry for help is ignored. Patients and their families must be partners with healthcare providers. We believe there should be a Patient Advocate at every hospital whom patients or their families can access in real time if they experience lack of empathy or problems with communication related to their care.
Creating a culture of safety begins with one solution, one commitment, one hospital, one act of kindness and love, and one patient at a time.
It should not take a horrific tragedy such as the death of Ms. Spalding to rally us. The only encouraging aspect of this episode is that we have it in our power to do the right thing and take steps to eliminating preventable patient deaths, starting now.
Joe Kiani Founder, Patient Safety Movement Foundation
A common thread that bonds many of us is the need to make a difference in the world.
We want to leave the planet a little better than we found it. The challenge to some is to find that calling. I guess you could say that I was fortunate to find my calling earlier rather than later. I have to say that it was a much bigger dream than anything I could have come up with on my own.
My mother was a dedicated nurse and she instilled in me at a very young age the importance of patient safety. Her calling was to take care of those who could not take care of themselves.
As an engineer, I focused on innovations that improved patient care. I became convinced that I could solve the high rate of false alarms when noninvasively monitoring a patient’s oxygen level. In 1989, I founded my company in my garage and diligently worked on a solution. Masimo was born and today I’m proud to say that our monitors are significantly improving the lives of more than 100 million patients in hospitals and doctors’ offices around the world.
For some, the story would end there, but for me it was just the beginning. I heard about a father of a 12-year old boy who took his child to their doctor and later to the hospital after he had suffered from a minor cut from a fall in his school gym.
Within days, his son passed away from a serious infection called sepsis. This infection should have been picked up by tests, but was missed until he had passed away. As a father, this seemed incomprehensible to me. I read an alarming report that noted the 100,000 preventable patient deaths in U.S. hospitals in 1999 had doubled to 200,000 by 2011. I couldn’t believe that we are losing more lives to preventable deaths in hospitals than to highway accidents, breast cancer and AIDS combined. Globally, this number is closer to 3 million.
Last summer, I had the good fortune to travel with former President Clinton through Africa. I was amazed at how much he has done to bring millions of people access to health care. I realized then, that we need to not just provide our global citizens with access to health care, but to a health care system that guarantees patient safety and dignity. The Patient Safety Movement Foundation was born.
Never before have I had a bigger dream. Never before have I had better minds or more committed people to help realize this dream. At the 2013 Clinton Global Initiative, we formally announced our commitment to eradicate preventable patient deaths in the U.S. by 2020.
At the same time, we are working to make sure we are replicating our efforts globally. The good news is that we have already started to see results. Last month, we were part of a Senate hearing in Washington, D.C.
In January, we had many hospitals and medical technology companies sign up for the zero by 2020 challenge. Just recently, we had a hospital report zero preventable patient deaths from participating in our program. It is possible. We can’t do this alone. We need you to take this challenge on with us. Details to come. #0×2020
Joe Kiani Founder, Patient Safety Movement Foundation