From the June 2021 issue of HealthCare Business News magazine
By Donna Prosser
Millions of Americans are harmed, and more than 200,000 die, due to preventable medical error every year.
While there will always be adverse events in healthcare that are unavoidable and harmful, such as a patient having a deadly allergic reaction to a medication they have never received, preventable harm is avoidable. Preventable harm can range from wrong site surgeries to a patient receiving a medication that they have a documented allergy to.
The cost of preventable harm
Preventable medical errors are estimated to cost the U.S. healthcare system at least $19.8 billion annually due to additional medical care and lost productivity. Additionally, the fragmented systems and processes that lead to preventable harm result in unsatisfactory quality outcomes. Last year, 774 U.S. hospitals were penalized for poor performance and fined 1% of Medicare payments as a result, which can significantly impact financial health as most hospitals are surviving on a 2-3 percent margin.
The case for high reliability
Most healthcare systems rely on quality and safety data to inform whether they are safe and efficient. However, this data isn’t representative of all quality and safety processes. In addition, healthcare is focused on improving what is reported, so those data points may look good despite the lack of a solid foundation for safe and reliable care. To truly minimize preventable harm, healthcare needs to become a highly reliable industry, such as aviation or nuclear power, which anticipate problems before they occur and are transparent about errors and root causes when they do happen. Designing safer, more highly reliable systems in healthcare can reduce the incidence of preventable harm, save lives and improve financial performance.
Understanding if your health system organization is highly reliable
Healthcare leaders can start by completing an assessment of the current state of the organization. Some questions to consider include:
1. Are clinicians and staff comfortable speaking up when there is a problem? Is the reporting of near misses an expectation that is easy for staff to complete? When an error occurs, are processes examined for gaps, rather than blaming individuals for making mistakes?
2. Are patients and families actively involved in their own care and an equal part of the care team? Are they invited to participate in performance improvement activities?
3. Is there a standardized, consistently applied framework for continuous improvement? Is there alignment between improvement activities and the strategic plan?