A new study published in the New England Journal of Medicine found that hospital related adverse events were identified in nearly one in four hospital admissions, and that approximately one in four of the events were preventable.1
“The authors’ findings are disturbing. These findings suggest that the safety movement has, at best, stalled,” said Donald M. Berwick, MD, MPP of the Institute for Healthcare Improvement in Boston.2
Institute of Medicine Report in 2000 Was Intended to Improve Patient Safety
In 2000, the Institute of Medicine’s Committee on Quality of Health Care in America released a report known as To Err Is Human: Building a Safer Health System that brought awareness to medical errors and the consequences, thus making patient safety a priority in the American health care system. That report was based in empirical research using the 1991 Harvard Medical Practice Study as a basis for the report.3
At the time, it was estimated that as many as 98,000 people died annually from medical errors in hospitals. This number exceeded the number of people who died from motor vehicle accidents, breast cancer, or AIDS, all of which received much more public attention. The report stated that more people died each year from prescription errors than from workplace injuries, making medical error among the top public problems in the United States.4
The report was based on the premise that the root cause of problem of medical errors is not bad people working in health care but rather good people working within bad systems that need to be made safer. The report provided recommendations on how to improve patient safety in health care settings in the U.S.5
Patient Safety Has Not Improved
After a decade of implementing strategic tools to improve patient safety that included national campaigns, research studies, training programs for patient safety and changes in Medicare payment, some medical professionals describe findings from the new study as “disturbing”.6
The results of the study showed that at least one adverse event was identified in 23.6 percent of hospital admissions and nine percent of the admissions included an adverse event in a hospital setting that was rated as serious, life-threatening or fatal. 22.7 percent of the adverse events were identified to be preventable.7 With respect to preventability, Dr. Berwick stated, “The more valuable approach is to regard all injuries as potentially preventable.”8
The types of adverse events that were identified in the study included 39 percent related to adverse drug events; 30.4 percent related to a surgical or other procedure; 15 percent related to general patient care, and 11.9 percent were hospital-acquired infections.9
The authors of the study pointed out that many hospitals in the U.S. rely on voluntary reporting of adverse events. As a result, there is underreporting of drug reactions and medical care errors and, in some cases, this creates misleading reports that no adverse occur at all in hospital settings.10
Dr. Berwick noted that millions of patients, families and health care personnel are being harmed by lack of executive leadership, accountability and proactive action taken to address adverse events, injuries and deaths occurring in hospitals that potentially could be prevented:
’First do no harm’ remains a sacred obligation for all in health care, and success requires constancy of purpose for improvement. Without renewed board and executive leadership and accountability for safety and without concerted, persistent investment in and monitoring of change, a summary study 34 years from now may again look all too familiar, with millions upon millions of patients, families, and health care staff paying the price for inaction.11
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1 Bates DW et al. The Safety of Inpatient Health Care. The New England Journal of Medicine 2023; 388:142-153.
2 Berwick D. Constancy of Purpose for Improving Patient Safety — Missing in Action. The New England Journal of Medicine 2023; 388:181-182.
3 Institute of Medicine. To Err Is Human: Building a Safer Health System. National Library of Medicine 2000.
6 Berwick D. Constancy of Purpose for Improving Patient Safety — Missing in Action. The New England Journal of Medicine 2023; 388:181-182.
7 Bates DW et al. The Safety of Inpatient Health Care. The New England Journal of Medicine 2023; 388:142-153.
8 Phend C. Healthcare-Related Injury Found in Nearly One-Fourth of Hospitalizations. MedPageToday Jan. 11, 2023.
9 Bates DW et al. The Safety of Inpatient Health Care. The New England Journal of Medicine 2023; 388:142-153.
11 Phend C. Healthcare-Related Injury Found in Nearly One-Fourth of Hospitalizations. MedPageToday Jan. 11, 2023.