Dismay? Disappointment? Frustration?
I’m trying to come up with a word that would adequately describe the reaction Minnesotans ought to have to the state’s annual report on adverse events at health care facilities. The Minnesota Department of Health released the 98-page report last week. It lists which of the state’s hospitals, surgery centers and community behavioral hospitals reported a “never” event in 2010.
There are 28 harms that meet the reporting threshold. They range from wrong-site surgery and serious medication errors to patient falls, severe bedsores, injuries caused by medical devices, and abduction or sexual assault involving a patient.
Minnesota was the first in the United States to institute a formal reporting system. The sharing of error rates and the factors that contribute to them has produced a wealth of information to help make care safer.
But in spite of all this, the latest report shows little, if any, improvement. We need to be asking why.
I’ve blogged before about the difficulty of reducing medical errors and adverse events. Health care is complex, and safety seems to be far harder to achieve than anyone ever dreamed. How much of this, though, has to do with the difficulty of the task itself and how much lies within health care culture and an apparent lack of collective will to do better?
To be sure, there are organizations that get it – Rice Memorial Hospital here in Willmar, for one, where the employees chipped in $52,000 last year to the Rice Health Foundation for patient safety projects. It takes commitment to put your money where your mouth is, and it speaks to the value that Rice employees clearly place on providing safe care.
But the fact that many organizations continue to struggle with this suggests that at bottom, there is a disconnect between the concept of “patient safety” and what it actually means in day-to-day care.
One of the recommendations from state officials is rather novel. They are urging health care organizations to share stories about the bad things that sometimes befall patients – in other words, putting a human face on this issue so health care professionals can begin to more clearly understand the real-life consequences when something goes wrong with patient care and, it’s to be hoped, become more engaged in making health care safer.
Well, it’s about time. They can start with my story.
Back in 1995 I developed an aggressive form of non-Hodgkin’s lymphoma and was promptly transferred to an inpatient cancer unit at a Twin Cities hospital. During my first chemotherapy treatment one of the drugs accidentally leaked out of the vein and into the surrounding tissue of my arm. The tissue ultimately was destroyed down to the bone. I had to undergo surgery to remove a chunk of my arm, followed by skin grafting. The scarring is disfiguring and permanent.
This incident cost somewhere between $3,000 and $5,000. Although my health insurance covered it, that isn’t the point.
It took staff, resources, time and energy to deal with this – from the plastic surgeon and the OR team down to the pharmacy, the lab, the surgical supplies and the people who handled the scheduling, billing and claims.
For me personally, it meant additional doctor visits, additional co-pays and daily futzing around with wound cream and bandages. After the surgery my right arm was immobilized in a splint from my elbow to my fingertips. I couldn’t drive, couldn’t work, couldn’t put in my contact lenses. I was forced to take sick leave at a time when I’d already used up a substantial amount of paid time off and couldn’t be sure I wouldn’t have more complications – or worse yet, a cancer recurrence – that would exhaust my sick benefits. The surgery delayed the start of radiation therapy and prolonged the overall time I spent undergoing cancer treatment.
I haven’t even touched on the distress and anxiety this incident caused, nor the apprehension of something else going wrong that hung like a cloud over the entire remainder of my cancer treatment.
Now multiply all of this 100-fold or 1,000-fold for serious injuries that lead to severe or permanent disability or death.
While I believe the vast majority of health care professionals are caring, dedicated individuals who feel badly whenever a patient is harmed, there seems to be an industrywide tolerance of adverse events as the inevitable cost of doing business. There is too much focus on health care’s inability to be perfect and not enough focus on the concrete things that can be done to make adverse events less inevitable. All too often, health providers are unaware of, or underestimate – or perhaps don’t want to know – the physical and emotional price patients must pay when something goes wrong.
Like a stone thrown into a pond, the consequences of medical harm spread outward in a series of ripples, disturbing and altering the universe contained within the patient experience in ways both large and small. It is a burden on patients and families. It is a burden on the system.
Look me in the eye, health care providers, and tell me again why you can’t do better.