Much Progress but Many Challenges Remain
Richard Kronick, PhD; Sharon Arnold, PhD; Jeffrey Brady, MD, MPH
The 1999 publication of To Err Is Human from the Institute of Medicine focused attention on the need to improve the safety of medical care and spurred a variety of public and private responses. Despite this attention, at the 10-year anniversary of that report, there was little evidence that safety had improved, and concern that progress in reducing patient harms in hospitals has been slow.1
It is now clear, however, that over the past few years hospitals have made substantial progress in reducing harms. This Viewpoint reviews the evidence demonstrating progress and what is known about the factors contributing to progress.
The Medicare Patient Safety Monitoring System (MPSMS) provides the only source of reliable nationwide estimates on a broad range of patient harms. The MPSMS uses a structured protocol to review medical records to detect indications that adverse events associated with harms have occurred to patients while hospitalized.2 The system captures 21 different types of harms, including adverse drug events, falls, pressure ulcers, and a variety of hospital-acquired infections such as central line–associated blood stream infections and catheter-associated urinary tract infections (CAUTIs).
Analysis of data from the MPSMS showed that from 2005 to 2011 the rate of adverse events declined by approximately 8% and 5% per year for Medicare patients hospitalized for acute myocardial infarction and congestive heart failure, respectively, but did not change significantly for patients with pneumonia or those who had been hospitalized for major surgery.3 The analysis was among the first to demonstrate systematic nationwide improvement in safety. However, the analysis showed a mixed picture, with safety improving for some patients but not others, and was restricted to Medicare beneficiaries.
More recent results released by the Agency for Healthcare Research and Quality (AHRQ) showed that the rate of adverse events among all hospitalized adults declined from 145 adverse events per 1000 hospitalizations in 2010 to 121 events per 1000 hospitalizations in 2014, a decline of approximately 4.5% per year, and provided evidence of substantial improvements in hospital safety across the nation.4 The analysis considered a broad range of adverse events, including central line–associated blood stream infections, CAUTIs, falls, pressure ulcers, and adverse drug events. Many of these adverse events resulted in serious harms to patients. The analysis estimated that there were a cumulative 2.1 million fewer harms to patients over the period 2010 to 2014 than would have occurred if the adverse event rate had remained at the 2010 level, with a projected estimate of tens of thousands fewer deaths and billions of dollars in cost savings.4
The AHRQ report was not published in a peer-reviewed journal, and some have raised concerns about the validity of the estimates. There are at least 2 main sources of concern. One concern is that because Medicare now imposes financial penalties on hospitals with high rates of adverse events, hospitals may have increased the use of “present on admission” (POA) coding in administrative data. As a result, analyses of adverse events using administrative data may incorrectly conclude that patient safety has improved when the main change is that coding of POA has improved. However, the AHRQ analysis is based on a review of data in the medical record, not administrative data. There is no clear evidence that the type or quality of the information entered into the medical record has changed substantially over the period 2010 to 2014. Pressure ulcers are the adverse event that is most likely to be subject to better documentation of POA in administrative data, but as pressure ulcer rates declined, there was no corresponding increase from 2010 to 2014 in the frequency with which pressure ulcers were documented as POA in the medical record.
Another potential concern is that the AHRQ analysis estimated the rate of CAUTIs declined by 38% from 2010 to 2014,4 whereas analysis of data from CDC’s National Healthcare Safety Network (NHSN) showed no change in CAUTIs over the same time period.5 The differences between the results stem from differences in definitions between the measurement systems. The MPSMS measures physician-diagnosed and -treated CAUTIs, defining a CAUTI as a urinary tract infection that was diagnosed by a physician for a patient with a urinary catheter and for which an antibiotic was prescribed. In contrast, the NHSN definition requires laboratory confirmation of an active bacterial infection. Further, the NHSN reports data on the number of infections per catheter day, whereas the MPSMS reports data on infections per hospital admission; the NHSN has in the past focused primarily on measurement in the intensive care unit (ICU), while the MPSMS measures CAUTIs throughout the hospital. Catheter days per admission have been declining, and more progress has been made on preventing CAUTIs outside of the ICU than in the ICU. Thus, it makes sense that MPSMS and NHSN estimates would differ.
While it is clear that the frequency of adverse events declined substantially from 2010 to 2014, it is less clear why this improvement occurred. There are several plausible hypotheses. First, progress was dependent on the existence of evidence about how to improve safety. For example, previous studies6 demonstrated how to virtually eliminate central line–associated blood stream infections. This work and additional research sponsored by AHRQ and others demonstrated the importance of creating a culture of safety and provided concrete, evidence-based recommendations for how to do so. Second, progress was dependent on the creation of tools and technical assistance to enable hospitals to implement the available evidence about how to improve safety. Many of those tools were developed by AHRQ as part of projects and initiatives such as the Comprehensive Unit-based Safety Program. The Centers for Medicare & Medicaid Services Partnership for Patients initiative provided extensive technical assistance, reaching more than 80% of acute care hospitals throughout the country. Third, hospitals needed data and measures to be able to assess their patient safety culture and determine their rates of adverse events to be able to gauge progress. Fourth, and perhaps most important, hospital leadership needed to be committed to making progress and seriously engaged in the process. The Partnership for Patients initiative was instrumental in catalyzing these commitments. Medicare’s Hospital-Acquired Condition Reduction Program, which assesses financial penalties on hospitals with a high rate of adverse events, was likely also important in capturing the attention of hospital chief executive officers (CEOs) and chief financial officers. As a result, improving safety was not simply the responsibility of a sometimes-marginalized quality and safety officer, but rather a shared obligation that required commitment of the entire care delivery team.
Despite the progress made to date, much work remains to be done. The most important question moving forward is how to maintain, or if possible accelerate, the annual decline in adverse events. If the average annual reduction in adverse events observed between 2010 and 2014 were to continue for the next decade, the rate of adverse events in 2025 would be approximately 50% of the rate in 2010. However, the adverse event rate in 2014 was similar to the 2013 rate, raising concerns about whether progress has stalled.
If the suggested hypotheses about the causes of the 2010 to 2014 progress are correct, then the implications for further progress are clear. Additional evidence about how to address the patient harm that persists is needed to continue to make care safer. Producing appropriate scientific evidence will require additional investment in programs that support patient safety research. Second, hospitals need better tools to make improving safety the easy thing to do and support for implementing those tools. Third, hospitals need less burdensome and more reliable methods of measuring adverse events. AHRQ has been working on the development of the Quality and Safety Review System, which should allow hospitals to efficiently and reliably measure their rate of adverse events from a review of medical records. Pilot testing is in progress for this much-needed resource. Fourth, it will be essential to ensure that improving safety becomes and remains a high priority for hospital boards of directors, CEOs, and senior leadership teams. To maintain safety as a priority, it makes sense to appeal to both the intrinsic motivation of professionals to improve patient outcomes as well as the extrinsic motivation to improve financial performance and reputation.
Improving safety has focused on hospitalized patients, but it is equally important in other settings, particularly long-term care and ambulatory care. The recent National Academy of Medicine report on diagnostic errors found that the average US patient can expect to be harmed by a diagnostic error at some point in his or her lifetime.7 To parallel the effort that has been made to date on hospital safety, substantial effort is needed to determine how to measure and reduce diagnostic errors and ensure that this information is integrated into practice where it will translate into meaningful benefits for patients.
JAMA
