Читать книгу Quality and Safety in Nursing - Группа авторов - Страница 45

Contributed by

David Mayer, MD

CEO Patient Safety Movement Foundation

Executive Director, Medstar Institute for Quality and Safety

In 2016 a British Medical Journal article authored by Martin Makary (Makary and Daniel, 2016) estimated that 251,000 patients die in hospitals each year due to medical errors, making it the third leading cause of annual deaths in the United States behind cancer and heart disease. That number is staggering… a quarter of a million people in the United States receiving treatment for an illness or having routine preventative healthcare services die because of experiencing a medical error during their care each and every year. Parents, children, and spouses who should be home with their families for the holidays—there is now an empty chair at the once festive dinner table.

Making an error is a human condition. All of us, including health care workers, make mistakes every day. We go into medicine to heal, not harm, patients, but when we make a mistake our weak health care systems and processes fail to catch and trap our errors. Because of these safety gaps, many of our errors end up reaching our patients, causing preventable medical harm or death.

When patients are unintentionally harmed, there is little transparency in health care when it comes to clinical outcomes or open and honest conversations with patients and families after preventable medical harm occurs. Death certificates remain silent when it comes to mortality caused by medical error. While the first catastrophic life‐changing preventable harm occurrence to a patient is unintentional, the second harm we inflict on our patients and their families is very intentional, well resourced, and well calculated. The second intentional harm occurs because many hospitals today still hide preventable serious harm and death events by blocking patients and families from gaining access to medical records, not returning phone calls made to hospital leadership seeking answers to their questions, and in many cases flat‐out lying to patients and families in efforts to protect the hospital and physician from a medical malpractice lawsuit. This cover‐up legal strategy is known as “delay, deny, and defend.” When hospitals put up this legal defense, as described by Rosemary Gibson in her book Wall of Silence, the only recourse patients and families have is to seek legal counsel and fight to gain the truth. In many states, that legal battle can take years to resolve.

The preventable death numbers in the United States are staggering, yet receive little attention or interest from the public, the media, or our government officials. Despite all the passionate and caring people leading improvement efforts over the past 20‐plus years, progress to reduce preventable medical harm and deaths has been very slow.

The annual mortality numbers due to preventable medical harm have only gotten worse for both patients and health care workers due to the COVID‐19 pandemic. Even before the pandemic hit, being a health care worker was not a safe occupation. Health care workers suffered numerous work‐related injuries—things like needle stick injuries, lifting and back injuries, falls at work, and an alarming increase in the number of workplace violence injuries suffered while trying to care for patients. Injury and illness rates in hospitals are nearly double the rate for private industry as a whole and injury rates are also higher than the injury rates in construction and manufacturing—two industries traditionally thought to be relatively hazardous.

Since the start of the pandemic, concerns for health care worker safety and well‐being have only escalated. Thousands of healthcare workers—nurses, physicians, environmental services personnel, emergency medical personnel—have lost their lives due to COVID‐19. Many more became gravely infected from the virus, requiring hospitalization and intensive care admission. A majority of these deaths and hospitalizations were preventable if adequate protective equipment (gowns, gloves, masks), diagnostic tests, and training were in place at the start of the pandemic. In addition, the emotional toll and well‐being of our caregivers will impact the safety of our health care system for decades to come.

The Patient Safety Movement Foundation (PSMF) is a global nonprofit organization committed to zero preventable deaths by 2030. The PSMF offers free tools, seminars, and workshops to hospitals and care teams that can save lives. Its Actionable Patient Safety Solutions (APSS) provide evidence‐based processes that help hospitals eliminate preventable harm. Improving patient and health worker safety requires a collaborative effort from all stakeholders, including patients, health care workers, medical technology companies, government, employers, and private payers. Visit https://patientsafetymovement.org to learn more about the PSMF mission.

Urgency is vital. It is time for a patient and health worker safety “Moonshot” that achieves zero preventable deaths by the end of the 2020s. This “Moonshot” approach would involve:

1 Creating a National Patient and Health Worker Safety Authority similar to the National Transportation Safety Board in place for the aviation industry.

2 Incentives and reimbursements aligned with the quality and outcomes of care provided, not the quantity or volume of care provided.

3 Creating a culture of safety that embraces transparency so we can learn from, not hide from, our preventable harm events and near misses. A program like the AHRQ’s Communication and Optimal Resolution (CANDOR) tool kit is one example of an open and honest approach to preventable medical harm.

Source: Based on Makary, M.A., and Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, i2139.