Twenty years ago Friday, a landmark report by the Institute of Medicine (IOM) revealed that up to 100,000 people were dying annually from preventable medical errors. The human stories read like a catalog of patients’ worst nightmares: a woman who died after being injected with the wrong dye before back surgery; a diabetic whose left leg was mistakenly amputated instead of his right; a toddler recovering from severe burns whose condition quickly deteriorated when an undetected catheter infection turned fatal.
These deaths and injuries, along with millions of others over the past two decades, didn’t have to happen. Yet efforts to make patients safer in the wake of the IOM report have failed to move the needle. Today preventable medical errors are responsible for 250,000 to 440,000 deaths a year in the United States, making them the third leading cause of death after heart disease and cancer. Their financial cost is similarly staggering, with estimates suggesting $17 billion in direct medical costs and another $735 billion to $980 billion in economic impact from lost lives and livelihoods.
Research shows that the majority of medical errors can be traced to poor teamwork and communication as patients — and their medications, charts, labs, and scans — are passed between doctors, nurses, pharmacists, lab technicians, and other providers. In response, healthcare organizations have launched numerous initiatives to improve communication and coordination, such as checklists and structured information-sharing tools for high-risk moments like surgery briefing and debriefing.
So, two decades after the IOM report and a slew of attempts to prevent medical mistakes, why is it still more dangerous to have a medical procedure than to go sky diving? Although we’ve developed a number of promising approaches for increasing patient safety by improving teamwork and communication, integrating these changes across the healthcare system and embedding them in local healthcare contexts in a lasting way is a whole other challenge. Meanwhile, the importance of effective teamwork and communication has only increased as healthcare has become more complex.
In my experience studying and consulting on process improvement at hospitals across the country, I’ve seen how interventions fail when we don’t think carefully about how to implement them. We can’t just drop a generic checklist into doctors’ and nurses’ hands and expect them to immediately change deeply embedded ways of operating overnight. We need to adapt interventions to fit the local context, provide ongoing training, and identify and address barriers to adoption of new practices and processes.
In the wake of toddler Josie King’s death from a preventable central line catheter infection at Johns Hopkins Hospital, clinicians there developed a checklist of five simple steps to prevent similar infections. However, getting care providers to adopt the procedures into their routine practice was challenging. The checklist required them to gather numerous, sometimes far-flung items including antiseptic, gloves, masks, and sterile drapes and dressings. By grouping the necessary items into a single kit available at easy to access locations, hospitals have been able to increase compliance and reduce infection rates.
Many attempts to improve patient safety fail because they target individuals, not systems — even though the research is clear that most medical errors are made by well-intentioned people working within broken systems and processes. When Tampa surgeon Rolando Sanchez went to amputate Willie King’s leg, the incorrect leg had already been noted in the hospital computer system, listed on the operating room schedule, and sterilized and prepped for surgery. Since both legs were diseased due to diabetes, Dr. Sanchez had no reason to suspect he was about to remove the wrong leg. His was simply the final mistake in a cascade of errors and oversights across the system.
We cannot continue to put the burden for improving patient safety on care providers alone, expecting them to heal the system while they heal the sick. We have to ask more of our institutions. That starts with removing institutional obstacles to change, particularly within the legal, compliance, and risk management units where innovations often go to die. In numerous hospitals, I’ve encountered units that were so afraid of the potential risks associated with change that they perpetuated the very problems they were charged with reducing. We also need to learn from how other industries have improved teamwork and processes for implementing changes. For example, many hospitals have seen promising results adapting Lean Six Sigma from the manufacturing industry and Crew Resource Management from the airline industry.
There is no grand program or miracle pill for reducing preventable medical errors, but instead numerous changes that must be woven throughout the healthcare system. We need to make compliance as easy as possible for care providers and create channels for obtaining their input on proposed changes. We should educate patients and families to more effectively engage in their own care. We need to encourage hospital administrators and policymakers to pursue systemic change and prioritize quality alongside efficiency. Throughout the process, we must collect data to track progress and create opportunities for knowledge sharing and collaboration across organizations. When hospital systems work together to learn from each other rather than reinventing the wheel, everyone benefits.
There is no reason preventable medical errors should be the third leading cause of death in the United States. The good news is we know how to reduce these heartbreaking mistakes. What we are still figuring out is how to enable our healthcare system to implement the necessary changes. A first step is to renew the IOM report’s call to action twenty years later, with an appreciation for the consequences for the physical and financial health of the country if we fail to act. Then we must align our goals and take action to put patient well-being at the center of care. We must start now or we will make even less progress reducing unnecessary injuries and deaths over the next twenty years, as our healthcare system becomes more complex, dynamic, and, overburdened by the day.