The United States spends more on health care than any country in the world, but it has made virtually no progress in reducing the damage caused by medical errors. Better estimates indicate that 210,000 to 400,000 patients continue to die each year from preventable damage in US hospitals alone, a number of deaths that positions medical error as the third leading cause of death. Dangerous care in the form of poor infection control or a lack of personal protective equipment has also fueled preventable deaths during the pandemic, including losses of patients and staff. Some were by illness and others by an increase in errors.
Twenty years ago, the Institute of Medicine identified medical error as a national priority. Targeted initiatives during the Obama administration saved lives, reduced injuries, and saved more money than they cost. Yet progress has stalled. We now hear little about this security crisis in the public sphere, even during a pandemic. A plane crash or a pedestrian killed by an autonomous vehicle arouses widespread alarm, sympathy and rapid responses. However, the large number of victims who died from preventable medical errors and preventable pandemic deaths in the past year has prompted far fewer requests for action. Is the problem too big to understand? Has anonymity and the large number of deaths produced a puzzling fatalism?
What’s particularly frustrating is that many deadly security risks are issues that can be fixed with existing remedies. Solutions are within reach if the will exists to tackle the fragmentation of responsibilities, especially at the federal level. Many government entities play some role in patient safety, but no agency has health care safety as its sole focus. As a result, available data is not analyzed, learnings are not widely shared, and border security technologies are not ingeniously applied. The result is that patient safety solutions go undiscovered and preventable errors continue to cause injuries and deaths during pandemics and the daily practice of medicine. Other complex, high-risk industries have a federal agency dedicated solely to worker and consumer safety and have made continued dramatic progress. Health care needs it too.
America’s healthcare system can leverage its extraordinary technology and information systems to protect its patients and healthcare workers from harm. To achieve this, we must establish a National Patient Safety Council (NPSB) inspired in part by the National Transportation Safety Board (NTSB), with the aim of centralizing and adapting solutions. The proposed NPSB can ‘break the code’ by analyzing the available data, identifying the preconditions for major damage, inventing and disseminating innovative solutions in a non-punitive way. The value of a centralized body in ensuring patient safety is not a new concept. It has been proposed repeatedly for three decades, but there has been no progress in making it a reality. Hopefully this is the result of inertia and distraction and not direct obstruction.
We can make progress. Last year, the Patient Safety Movement Foundation launched a 10-year program “Moonshot on patient safety”To achieve zero preventable harm in health care by 2030. This is consistent with a Global Patient Safety Action Plan 2021-2030 released by the World Health Organization in May, calling on national governments to use “selective legislation” to protect patients and healthcare workers.
No one, regardless of income, position or race, is invulnerable to damage. But the public often asks, “What can I do? Does my voice matter? This will not be the case if people do not speak out, calling on our health care providers to take responsibility and resolve their safety concerns. Congress and the Biden administration will confuse silence with indifference and continue to ignore the security threat.
Here are three things Americans can do now to protect themselves and their families.
Break the silence and achieve the safe health care system we deserve – for ourselves, those we care for, and generations to come. Silence kills.
Marty Hatlie is CEO of Project Patient Care, a nonprofit organization that uses the voice of the patient to improve care. He is also co-director of the MedStar Institute for Quality and Safety. Dr. Karen Wolk Feinstein is President and CEO of the Jewish Healthcare Foundation (JHF) and its three operational arms, the Pittsburgh Regional Health Initiative (PRHI), Health Careers Futures (HCF) and the Women’s Health Activist Movement Global (WHAMglobal) .