The United States spends more on health care than any country in the world, but it has made almost no progress in reducing medical error harm. Best estimates indicate 210,000 – 400,000 patients continue to die each year from preventable harm in U.S. hospitals alone, a death toll that positions medical error as the third largest cause of death. Unsafe care in the form of poor infection control or lack of personal protective equipment has also fueled preventable death during the pandemic, including patient and staff losses. Some were by disease and others by an increase in errors.
Twenty years ago, the Institute of Medicine identified medical error as a national priority. Focused initiatives during the Obama administration saved lives, reduced injuries and saved more money than they cost. Yet progress stalled. Now we hear little in the public sphere about this crisis in safety, even during a pandemic. One plane crash or one pedestrian killed by an autonomous vehicle elicits widespread alarm, sympathy and rapid responses. However, the huge number of victims who have died from avoidable medical error and preventable pandemic deaths over the last year arouse far fewer demands for action. Is the problem too vast to comprehend? Have the anonymity and sheer volume of fatalities produced a confounding fatalism?
What is especially frustrating is that many deadly safety risks are solvable problems with existing remedies. Solutions are within reach if the will exists to address fragmentation of responsibility, particularly at the federal level. Numerous government entities have some role in patient safety, but no single agency has safety in health care as a sole focus. Consequently, available data go unanalyzed, learnings are not broadly shared and frontier safety technologies are not ingeniously applied. The result is that patient safety solutions are undiscovered, and preventable errors continue to cause injury and death during both pandemics and the day-to-day practice of medicine. Other high risk, complex industries have a federal agency solely devoted to worker and consumer safety and have made continuous dramatic progress. Health care needs one too.
The U.S. health care system can leverage its extraordinary technology and information systems to protect its patients and health care workers from harm. To make that happen, we should establish a National Patient Safety Board (NPSB) modeled in-part after the National Transportation Safety Board (NTSB), with the aim of centralizing and scaling remedies. The proposed NPSB can “break the code” by analyzing available data, identifying preconditions for major harms, inventing and spreading innovative solutions in a nonpunitive way. The value of a centralized agency to address patient safety is not a new concept. It has been proposed repeatedly for three decades, yet there has been no progress on making it a reality. Hopefully, this is a result of inertia and distraction and not direct obstruction.
We can make progress. Last year, the Patient Safety Movement Foundation launched a 10-year “Patient Safety Moonshot” to achieve zero preventable harm in health care by 2030. This dovetails with a comprehensive Global Patient Safety Action Plan 2021-2030 issued by the World Health Organization in May, calling on national governments to use “selective legislation” to protect patients and health care workers alike.
No one, regardless of income, position or race is invulnerable to harm. But the public often wonders, “What can I do? Does my voice matter?” It won’t if people don’t speak up, calling on our health care providers to own and address their safety problems. Congress and the Biden administration will mistake silence for indifference and continue to ignore the safety threat.
Here are three things Americans can do now to protect themselves and their families.
Let’s conquer 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 non-profit organization that uses the voice of the patient to improve care. He also is 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 operating arms, the Pittsburgh Regional Health Initiative (PRHI), Health Careers Futures (HCF), and the Women’s Health Activist Movement Global (WHAMglobal).