The healthcare webs are buzzing with the results of a new study by Landrigan and cohort from the November 25 issue of the New England Journal of Medicine (read it here). The medical establishment is understandably never eager to see studies in prominent journals highlighting the dark side of medicine, where mistakes result in increased morbidity and mortality, ethical controversies (when to admit mistakes?), legal hassles, and resulting increased overhead at a level that would give Croesus pause. Of course problems are opportunities, and an army of specialists and managers have done a brisk business in recent years working on improving the situation. Doing well by doing good, perhaps? Researchers are getting interested as well: the relatively new field of medical cognitive science is making efforts to help hospitals cut down on errors. But when a study focuses on the lack of improvement in adverse event statistics after years of targeted investments, certain big-shots may be getting nervous. The Landrigan paper implicitly calls into question what return on investment patients and taxpayers are getting relative to the tremendous sums spent on quality assurance, risk management, error control, continuous improvement of safety, and so forth. The authors are careful to note that they sampled from a specific geographical region, and that in any event efforts to reduce adverse events from care should continue. Nonetheless:
In conclusion, harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care. Since North Carolina has been a leader in efforts to improve safety, a lack of improvement in this state suggests that further improvement is also needed at the national level.
In a statewide study of 10 North Carolina hospitals, we found that harm resulting from medical care was common, with little evidence that the rate of harm had decreased substantially over a 6-year period ending in December 2007. Although there was a modest reduction in the rate of preventable harms on the basis of external reviews, the reduction did not reach statistical significance in adjusted analyses. This apparent reduction was not substantiated by the internal reviews, which by all measures were of higher quality than the external reviews (i.e., higher within-team reliability at both primary and secondary review stages and higher agreement with experienced reviewers).
Our findings validate concern raised by patient-safety experts in the United States and Europe that harm resulting from medical care remains very common. Though disappointing, the absence of apparent improvement is not entirely surprising. Despite substantial resource allocation and efforts to draw attention to the patient-safety epidemic on the part of government agencies, health care regulators, and private organizations, the penetration of evidence-based safety practices has been quite modest. For example, only 1.5% of hospitals in the United States have implemented a comprehensive system of electronic medical records, and only 9.1% have even basic electronic record keeping in place; only 17% have computerized provider order entry. Physicians-in-training and nurses alike routinely work hours in excess of those proven to be safe. Compliance with even simple interventions such as hand washing is poor in many centers.