June 24, 2020 | Mark Paradies

Needless Fatalities at U.S. Hospitals [Patient Safety]

hospital errors

Needless Fatalities [Patient Safety]

This is an important article about Patient Safety and needless fatalities. All hospital administrators, patient safety professionals, and anyone who might be patient at a hospital should read it.

Mistakes at hospitals cause needless fatalities and patient injuries. Many studies have been performed to estimate the number of these fatalities. Why studies? Why don’t they just get a number from the database? Because there is no database of patients killed by mistakes in hospitals.

In 1999, the Institute of Medicine performed a study (“To Err is Human“) that estimated about 98,000 people were killed each year by medical errors in hospitals.

A 2013 study based on four published studies estimated that:

…the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year.

Another 2013 study by John James estimated 440,000 needless deaths by medical errors each year.

A 2016 John Hopkins study estimated the yearly toll at 250,000 needless deaths per year.

So is it 98,000, 250,000, or 400,000, or 440,000 deaths per year? We don’t know. but we think you would agree … It is too many.

And perhaps even more amazing is that the difference between the low estimate of deaths and the high estimate is 342,000 people. That’s enough to fill a pretty good-sized city.

Deaths at the Average Hospital

What is the average hospital? We don’t know. But we do know that there are about 6,000 hospitals in the USA.

If we simply divide the number of fatalities by the number of hospitals, we get the following range of results for needless deaths at the average hospital:

  • 98,000 ÷ 6,000 = 16 needless deaths per year or 1.4 needless deaths per month.
  • 250,000 ÷ 6,000 = 42 needless deaths per year or 3.5 needless deaths per month.
  • 440,000 ÷ 6,000 = 73 needless deaths per year or 6.1 needless deaths per month.

Wow! Tha’s shocking. Picture 73 people in a line to be killed at a hospital and the results have even more impact.

73 people killed per month at the average hospital

What Are The Odds You Will Die Needlessly By Hospital Error?

Fast Facts on US Hospitals, 2020, estimates that there are 34,251,159 admissions per year in US Hospitals. So, if you are admitted to a US hospital, what are the odds you will be killed by a medical error? Here is an estimate based on the data above:

  • 98,000 ÷ 34,251,159 = 0.29%
  • 250,000 ÷ 34,251,159 = 0.73%
  • 440,000 ÷ 34,251,159 = 1.3%

That per admission. What do you think? Should we be taking action to reduce human errors in hospitals? I bet if you were being admitted to a hospital, you would like to see that they have a robust program to reduce medical human errors. You would not want to go to the “average” hospital and face death.

In a previous article (Is Visiting a Hospital in Australia Like Playing Russian Roulette?) we publish the results of a different 2007 study that estimated the adverse event rate data (serious injuries or fatalities per admission) in several countries. The chance of an adverse event caused by a medical human error as outlined in that study is:

  • 2.9% in the U.S.
  • 5%-10% in the UK
  • 7.5% in Canada
  • 12.9% in New Zealand
  • 16.6% in Australia

Could it really be true that going to a hospital in Australia is nearly the equivalent of playing Russian roulette? 

Ask yourself … Do you know anything about the Patient Safety Program in any of the hospitals near you?

Patient Safety

What is a Patient Safety Program? A Patient Safety Program is a program at a hospital to eliminate or reduce mistakes (human errors) or at least reduce the harm caused by the mistakes.

Has the application of Patient Safety Programs been a success at hospitals around the world? Not by the numbers. The numbers indicate things are getting worse.

One problem is that the “numbers” (at least in the USA) are estimates. There is no requirement to report deaths caused by hospital errors in the U.S. I’ve heard of cases where even the family of the deceased was not informed of a mistake that led to the death of a patient. Instead of telling the family what happened and apologizing, the hospital hid the error and only admitted the mistake during discovery after a lawsuit was filed.

The Joint Commission (a hospital certification agency) has a voluntary reporting system. But the reports revealed in the Joint Commission’s stats are way below the estimated number of deaths.

By the Joint Commission’s guidelines, serious injuries or deaths caused by medical errors (Sentinel Events) must have a root cause analysis. But many of the root cause analyses are weak. They use simple root cause analysis techniques for these serious Patient Safety events. They don’t identify the real root causes (see our root cause definition HERE) and they don’t develop effective corrective actions (which is why the numbers aren’t improving).

The Problem of BLAME

Many hospital root cause analyses get bogged down in blame. It seems that malpractice lawsuits and defending against such suits make many healthcare professionals reluctant to participate openly in a hospital led root cause analysis.

If the blame focus of malpractice lawsuits isn’t enough to cause healthcare professionals to be reluctant to participate in a root cause analysis, healthcare professionals (mainly nurses) may face criminal prosecution for errors. Here is Marcus Miller speaking about one such case at Vanderbilt University Medical Center…

Here is a link to the story of a UK Doctor who was convicted of making mistakes and spent 16 months in a high-security prison:

https://www.taproot.com/the-blame-culture-hurts-hospital-root-cause-analysis/

And then there is the story of pharmacist Eric Crop. Here’s a picture of him at his sentencing…

After he made a mistake that killed a two-year-old girl (he didn’t catch an error made by a technician), he was convicted of involuntary manslaughter and sent to prison for six months. Here is a CNN interview with Eric while he was in prison…

After he served his time, he spoke at the Global TapRooT® Summit about his mistake and ways to Improve Patient Safety. It was an emotional event that touched all those present.

That’s three examples. There are many more.

What Can Be Done To Improve Patient Safety

First, it would be helpful to stop blaming doctors, nurses, pharmacists, and technicians for errors and start finding the real root causes of the errors.

Each incident is an opportunity to improve the healthcare system. If the hospital fails to apply advanced root cause analysis and fails to get all involved stakeholders to participate honestly and openly, it is a FAILED opportunity to improve.

One way to help remove blame from the system is to use a root cause analysis system that avoids blame and concentrates on finding the fixable root causes of the Sentinel Event. A root cause analysis system that includes the fundamental principles of root cause analysis. That is what the TapRooT® Root Cause Analysis System does.

Second, to use advanced root cause analysis, hospitals need highly trained root cause analysis facilitators. This isn’t someone who has had a brief introduction to simple root cause analysis (like 5-Whys or Fishbone Diagrams). Rather, this is someone who has attended advanced training (for example, the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training).

Proactive Patient Safety Improvement

But Patient Safety initiatives should go beyond the reactive application of root cause analysis. They should have a proactive prevention program. A program designed to stop human errors. Healthcare professionals could learn techniques from other high-reliability industries and apply them to their healthcare setting.

Where would they learn techniques to stop human error? That’s easy. They should attend the Stopping Human Error Training. When is the next course? September 15-16. Where is the course being held? Knoxville, Tennessee. Click HERE to register.

Learn the Root Cause Analysis Basics

Want to learn more about how TapRooT® Root Cause Analysis is being used to improve Patient Safety? Here are three places to start…

Read our description of applying TapRooT® RCA in the healthcare industry at THIS LINK. And read a success story from a healthcare TapRooT® User at this link:

https://www.taproot.com/improving-patient-safety-by-using-taproot-root-cause-analysis/

Next, attend the upcoming Root Cause Analysis for Patient Safety Professionals Webinar. The webinar is being held on July 15. Register BY CLICKING HERE.

If you can’t attend the webinar, at least you can read the book, Improve Patient Safety with TapRooT® Root Cause Analysis. Get your copy at THIS LINK.

Did you know that we also have a short-course focussed on root cause analysis for the healthcare industry? It is called the 2-Day TapRooT® Root Cause Analysis for Patient Safety Improvement Training. And the next course is being held in Knoxville, Tennessee, on July 27-28.

Certified TapRooT® ® Instructor

Here is the course outline:

Course Outline

Day 1 (8:00am to 5:00pm)

  • Class Introductions and TapRooT® Introduction
  • TapRooT® System Overview – What you will be learning
  • SnapCharT® Basics – Gathering Information
  • SnapCharT® Exercise – Practice
  • Causal Factors – Identifying the Error
  • Root Cause Tree® – Eliminating Blame
  • Root Cause Tree® Exercise – On Your Own
  • Corrective Actions – Developing Fixes

Day 2 (8:00am to 5:00pm)

  • Software Overview – Practicing the Techniques
  • Generic Causes – Optional Technique
  • Causal Factors – Additional Practice
  • Reporting – Management Presentation
  • Frequently Asked Questions
  • Final Exercise – Putting What You’ve Learned to Work

Besides saving patient’s lives and preventing harm to the hospital’s staff, what can TapRooT® Root Cause Analysis do for a hospital?

  • Improve hospital financials
  • Reduce risk
  • Improve the quality of care
  • Help create a just culture
  • Reduce financial penalties for bad outcomes (never events)
  • Reduce litigation costs by reducing sentinel events
  • Increase efficient hospital operation

That’s why hospital administrators and their patient safety experts need to attend this course.

Hear Marcus Miller, the instructor for the course, talk about the course (in this video they talk about the course being held before the Global TapRooT® Summit last March)…

Participants will receive the book, Improve Patient Safety with TapRooT® Root Cause Analysis, a $99.95 value, a TapRooT® Root Cause Tree®, a custom healthcare-oriented Root Cause Tree® Dictionary, a Corrective Action Helper® Guide, and a 90-Day Subscription to TapRooT® VI Software, our dynamic online software that guides you through the TapRooT® process with ease and efficiency.

Register at this link:

https://store.taproot.com/2-day-north-american-taproot-root-cause-analysis-for-patient-safety-knoxville-tn-jul-27-2020

Hospital Administrators: How Many Will Die Waiting for Your Facility to Improve Patient Safety

Two? Three? Six? Seventy-three?

Many people reading this article have a loved one that suffered harm due to a medical mistake. My mother was misdiagnosed and spent three days being treated for the wrong condition before they realized that she had suffered from a stroke. If the correct diagnosis had been made early on, perhaps she would not have suffered so much memory loss and had so difficult a rehab.

Maybe that’s why I am so passionate about improving Patient Safety. I know that using the tools mentioned above can save lives. I’ve seen healthcare professionals use TapRooT® RCA to find root causes that they otherwise would have overlooked. They tell me stories about avoiding blame and improving their Patient Safety statistics (and that means saving lives) by using TapRooT® Root Cause Analysis.

Hear Dana Roca from the Military Healthcare System explain how the MHS is improving their management’s understanding of TapRooT® Root Cause Analysis to get better management support, how they share lessons learned between the different services hospitals, and how they use outside facilitators to improve Sentinel Event investigation results. Watch the video…

I hope to see you at the upcoming 2-Day TapRooT® Root Cause Analysis for Patient Safety Improvement Training in Knoxville, TN, on July 27-28.

 

Categories
Patient Safety & Healthcare, Root Cause Analysis
Show Comments

One Reply to “Needless Fatalities at U.S. Hospitals [Patient Safety]”

  • Mark Paradies says:

    I was looking at the recent COVID death stats in the USA and realized that medical errors are more deadly than COVID.

    We shut down the country and ruined the economy for COVID. Why aren’t we doing more to stop medical errors?

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