A Closer Look At Preventable Harm

Sophia Bernazzani

When faced with a serious medical issue, most of us think about direct outcomes. Will there be a scar? How long will it be until I can go back to work or pick up my daughter? We spend much less time considering that things could go wrong: a surgery on the wrong site, a fall in the hospital, or an infection from improperly sterilized materials. Sadly, these types of medical errors, referred to as preventable harm, affect up to 1 in 4 discharges and cause an estimated 1,000 patient deaths per day. Only heart disease and cancer kill more Americans. It would seem the solution to the preventable harm question would be easy… find a way to “prevent” the harm. Unfortunately, it is not nearly that simple.

The Issues

There are major issues facing those who seek to reduce preventable harm. First, we don’t really know how often preventable harm occurs. There are wildly conflicting rates published by very reputable, peer-reviewed studies. The first comprehensive study, the landmark To Err is Human, estimated 98,000 Americans die due to preventable harms per year, a shocking number at the time. More recent studies suggest this number is far underreported and is closer to 440,000 per year. Even with the conflicting research, everyone agrees, there is too much preventable harm being afflicted upon patients and something must be done about it.

What exactly is “preventable harm”? There is no universally agreed upon definition of what constitutes a preventable harm. The medical community agrees that it must be attributable to medical care or “identifiable,” and that it must be possible to avoid or “modifiable”. Not all medical treatment-related harms are preventable. Identifying potential harms must be evaluated retrospectively, making the application of the terms identifiable and modifiable somewhat subjective based on who is doing the incident evaluation. For more examples of preventable harm, view this handy chart.

Without a standardized definition of preventable harm, it should come as no surprise there are not standardized reporting mechanisms to track, evaluate, and record preventable harm events. Almost all systems of identifying preventable harm rely on either self-reporting by hospital staff, administrative discharge/billing codes, retrospective chart reviews, or the use of trigger tools that scan electronic medical records to detect preventable harms and adverse events. All of these approaches have their flaws, but the use of trigger tools, like the Institute for Healthcare Improvement Global Trigger Tool, along with chart reviews is the current gold standard to identify and report harms.

The Costs, and Who Pays?

It is very difficult to estimate the costs of medical errors such as preventable harms. There are direct costs such as additional treatments, lost wages, disabilities, and death, in addition to indirect costs such as stress on the healthcare system and time taken off of work to care for loved ones. Studies estimate that the combined indirect and direct costs of preventable harm to be a staggering $1 trillion–$10 trillion per year (Depending on which set of prevalence statistics used).

So, who is footing the bill for these mistakes? Hospitals and medical providers pay for any additional procedures themselves for the most egregious errors as insurance contracts and regulations expressly forbid passing along these costs to the patients or the patients’ insurers. But not all errors are covered by these regulations. The Leapfrog Hidden Surcharge Calculator helps employers with self-funded insurance and other insurance purchases calculate how much of their medical expenditures are the result of hospital errors. The tool uses claims data and Hospital Safety Scores to reveal annual hidden hospital error costs and average surcharge per admission. Otherwise, it is the medical consumer in the form of rising bills, stressed systems, and economic stress who pays the costs related to preventable harm.

So, what do we do now?

New research from the Government Accountability Office suggests that even among the Veterans Administration hospitals, with their sophisticated trigger systems and codified standards, there remains troubling inconsistency and lack of analysis. What can be done? Recent research by authors, J. Matthew Austin, PhD, and Peter J. Pronovost, MD, PhD, FCCM, from the Armstrong Institute for Patient Safety and Quality, suggests that efforts to reduce preventable harm should be data-driven and that this data should be transparent and standardized.

• Step 1: Define and standardize the definition of preventable harm
• Step 2: Establish standards to drive accuracy of reporting (especially from administrative data such as billing codes) and publicly report on these standards.
• Step 3: Report events with transparency

• Step 4: Create and share best practices

Conclusion

Even under the best of circumstances, harms will continue to happen. There must be a concentrated and organized effort on the part of administrators, insurers, regulators, information technologists, the medical community, and patients to push for evidence-based guidelines and best practices to do our best prevent medical harm. The root causes of preventable harm are multifactorial and so too should be the solutions.

Sophia Bernazzani is the community manager for MHA@GW, the masters in health administration online offered by the Milken Institute School of Public Health at the George Washington University. She’s passionate about global health, sustainability, and nutrition. Follow her on Twitter.