But there is less sustained effort to do something about the hundreds of thousands of people who entrust their lives to medical facilities and suffer or die—not from their illness, accident, or surgery—but because someone did not observe sanitary precautions, or was careless in stocking the crash cart, marking a surgical site, delivering the right medications, or using a safety checklist. Somehow, we accept excuses about this tremendous casualty toll.
The nation is unforgiving when the National Aeronautics and Space Administration (NASA) loses one of its astronauts—a reflection of our national commitment to preserving life.
But we can’t accept or process the extent of death by medical error, so we challenge the validity of the data. If 150,000 Americans die each year, or 440,000, does it matter?
Hospital and nursing home boards, management, and frontline supervisors should commit to dramatic reductions, within a year, in one or two of the nine leading causes of death: adverse drug events, catheter-associated urinary tract infections, central-line blood stream infections, patient falls in health care facilities, obstetric adverse events, pressure ulcers, surgical site infections, preventable blood clots, or ventilator-associated pneumonia.
The Centers for Medicare and Medicaid Services (CMS) is making this easy, with value-based payment initiatives that penalize providers for high rates of medical errors. So, act with alacrity! Enter a new era of transparency, by tracking progress month by month, unit by unit, and sharing best practices. Make reporting errors safe for employees, solve problems by getting to the root cause (forget workarounds), and reward high-performing staff members and unit directors. Use patient safety checklists and tools and technology to speed improvements.
Do this every year until there are dramatic reductions in all nine of the leading causes of death. Management at the highest level must continuously walk around and observe. It sends a clear message: this institution is deadly serious.