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Suddenly, in 2009, safety experts at Johns Hopkins and others decided that even though the “no fault, no blame” attitude had helped many confess their errors and provide information so that others did not commit the same mistakes, that it was time to take the efforts to the next level. Above all else, the balance between no blame and individuals being held accountable would help to save lives. The idea streaming from Johns Hopkins was, for those clinicians who fail to comply, habitual offenders would have penalties if retraining and re-education did not stop unsafe practices. Dr. Peter Pronovost and patient safety expert, Robert Wachter, of the University of California, San Francisco, struck up the call for accountability due to the nearly 100,000 US deaths per year from infections contracted during treatment. No blame worked to a certain extent, but in actuality, no more than 70% of healthcare workers were found to be routinely washing their hands before entering a room according to the New England Journal of Medicine.

Thus far, most of the discussion of medical errors has revolved around inpatient facilities, and then in 2011, information concerning errors occurring in outpatient facilities began to come under scrutiny. In a study published in JAMA (Journal of American Medical Association), a study that even the researchers admitted was very crude, the Weill Cornell Medical College, looked at malpractice awards given between 2005 – 2009. What the study found was that outpatient care accounted for more than half of all dollars paid in 2009. In other words, almost $1.3 billion of malpractice awards were due to outpatient care. Even though the study was again, admittedly very crude, it brought light to the fact that more attention had to be placed on outpatient care.

One of the most significant changes that occurred during the time these malpractice numbers were researched was that a huge push came to move more and more procedures to outpatient surgery centers and physician offices and away from the high tech surgery suites in the hospital setting. An interesting study would be to look at how many of those cases would have originally received care at an inpatient facility before the push to outpatient.

During 2011, AHRQ provided 20 tips to help prevent medical errors for patients. One of the main objectives of the 20 tips is for patients to become more active members of their healthcare team by doing simple things including: speak up if you have questions or concerns and “brown bag” your medicines when going to a physician appointment to ensure everyone is clear on the medications the patient is taking. These tips are just as valid today as they were in 2011. The list can be accessed at http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html

The last important milestone we will cover in 2011 is the controversy in continuing to use the 1999 numbers released in the report IOM-1 and to look at what is happening today. Dr. Leape, Dr. David Classen (one of the leading developers of the Global Trigger Tool), and Dr. Marty MaKary, a surgeon at Johns Hopkins and author of the book, “Unaccountable”, all believe it is time to stop using the 98,000 number. Akin Demehir, AHA (American Hospital Association) spokesman said that the group is sticking with the IOM’s estimate and is not attempting to come up with it’s own estimate.

An alarming statement came from the president and CEO of The Joint Commission, D. Mark Chassin, in 2012. Dr. Chassin stated, “only about 1/4th of the nations 6,000 hospitals are involved in some sort of quality improvement efforts”. To add insult to injury, all these years, Medicare has reimbursed regardless of outcomes, so if there were errors and more care was needed, the hospitals made more money. So finally, CMS (Center for Medicare and Medicaid Services) has stated that it will stop paying for two major problems that cost taxpayers billions of dollars: 1) preventable readmissions; and 2) health care facility-acquired conditions, such as infections. More recent national health reform legislation (The Patient Protection and Accountable Care Act/PPACA) contains several provisions for improvement including: 1) ACOs – accountable care organizations; and 2) value-based purchasing.

Oddly enough, the numbers debate from 2011 continued on into 2013, when the Journal of Patient Safety suggested that the numbers for people who suffer some kind of preventable harm that leads to death might actually be much higher and in the range of 210,000 – 440,000. The new numbers presented are based on 4 studies developed by John T. James, a toxicologist at NASA’s space center in Houston, who runs an advocacy organization called Patient Safety America. ProPublica asked 3 leading safety researchers to review the data from John T. James and all determined the methods and findings to be credible. The AHA is still confident in the IOM numbers, but if we use James numbers as our base, then the three leading causes of death in the US become: 1) heart disease; 2) cancer; and 3) Medical Errors. Another staggering thought is that even if these numbers are not correct, they bring awareness to the fact that this is a major health issue and it has not improved despite decades of effort.

2013 brought about two important releases from the AHRQ. In July, a resource was released that gave hospitals four evidence-based strategies to engage patients and families in their care. “The Guide to Patient and Family Engagement in Hospital Safety and Quality” contains strategies that were field-tested and can help hospitals make care better and safer by ensuring quality communication among patients, families and their healthcare providers. In September, a toolkit was released to help make patients safer in medical offices. Jeff Brady, MD, associate director of AHRQ Quality Improvement and Patient Safety, said, “the new toolkit is designed to improve safety in office-based settings by giving doctors and their staff a practical, easy-to-use resource to help manage lab test results and patient follow-up”.

After reviewing a significant amount of history surrounding medical errors, each clinician should have a strong sense of correcting the wrong so that this trend reverses in the US Health Care System. A closing item for the history comes from the 2014 Joint Commission and Transforming HealthCare report which states that for “Never Events” – wrong side/wrong patient, as many as 40 patients suffer these events each week in the US. We have a long way to go…but in looking to the future, in 2015, for the first time, physicians will see mandatory individual performance reports published on the CMS website. Will this approach work to improve care…we will have to wait and see.

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