Patient safety awareness focus of new report as preventable medical errors kill thousands

Patient safety likely remains the nation's third leading cause of death and addressing it needs to be a key national priority, a presidential panel said this week. The panel released a report outlining a plan for reining in "never" events, improving transparency and use of data, advancing research and appointing a national patient safety coordinator.

"Finally, we are putting patient safety at the top of the national agenda where it belongs," said Leah Binder, who was not involved in the report but is president and CEO of The Leapfrog Group, which rates hospitals and other healthcare facilities on their safety. "For far too long we've overlooked it."

Preventable medical errors kill 250,000 Americans per year, according to a 2016 study by researchers from the Johns Hopkins University School of Medicine. There's no reason to think that number has dropped since, Binder said, though it likely increased during the spikes of the pandemic when hospitals and caregivers were overwhelmed.

"We know how to prevent the errors and accidents that kill too many Americans," Binder said. "We know how to fix it. It's just having the will to fix it. This set of recommendations, if enacted, can get us there."

What will happen to the FDA?Could the ruling on abortion pill mifepristone access limit the agency's authority on all drugs?

The Working Group on Patient Safety, set up by the The President’s Council of Advisors on Science and Technology, spent a year studying patient safety before releasing its report Thursday. Key recommendations include:

• Establishing and maintain federal leadership for improving patient safety as a national priority;
• Ensuring patients receive evidence-based approaches for preventing harm and addressing risks;
• Partnering with patients, families and communities that are disproportionately affected by medical errors and substandard care; and
• Accelerating the development and deployment of new technologies and highlight outstanding systems of safe care.

Not about placing blame

If airplanes were crashing, people would be universally outraged, said Dr. Harlan Krumholz, a member of the working group, but because medical errors tend to happen quietly to individuals, they tend to get ignored.

Improving safety is not about blaming individuals or getting them to working harder, but about building better systems, said Krumholz, a cardiologist at the Yale School of Medicine.

The aviation industry figured out decades ago how to create a system of checklists, accountability and early interventions that have virtually eliminated catastrophic errors. But in health care, "we still have failed to create a system that's very safe and highly reliable," he said.

Paralysis can rob people of speech.Researchers hope to give it back

Pilots, like doctors, are used to being the heroes at the center of the action, but they long ago realized that they were dependent on strong teams, systems, feedback and instruments, he said. It's time for medicine to make the same shift.

"This is a chance to say we need a reset," Krumholz said. "We need to institute the kind of initiatives that will ensure the safety of anyone who is seeking and receiving health care in this country."

The working group was also focused on health equity, he said. When bad things happen in medicine, they tend to happen more often to people of color.

"In helping everyone, we should be able to close the gaps that exist based on the color of your skin or your ethnicity, which shouldn't have anything to do with your risk as a patient, but do."

For her part, Binder singled out the requirement that each hospital list its rate of preventable infections, rather than allowing hospital systems to provide one figure across all its facilities. "I don't care about the infection rate of a corporation. I care about the infection rate of a hospital I'm about to trust my life to," she said.

She also said she's thrilled the report puts patients and their families at the center of the discussion about patient safety.

"Having a national patient safety team will make sure that patient safety at least has a seat at the table when major decisions are made about health care in this country," she said.

Contact Karen Weintraub at kweintraub@usatoday.com.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.