To Err is Human, To Continually Not Protect Against it is Institutional Failure

A recent study published in JAMA Internal Medicine estimates that hospital-acquired infections cost $9.8 billion every year.

These costs impact public payers, including Medicare and Medicaid (read: taxpayers), as well as commercial payers (read: employers, employees and individuals who pay their premiums).

A single case of a central line-associated bloodstream infection (just one of many HAIs) costs an average of $45,814 to treat. According to the World Health Organization (citing CDC data), an estimated 80,000 CLABSIs occur in American hospital ICUs each year, and of patients who acquire them, 12-15 percent will die.

Even more concerning? These are entirely preventable. That's right. Entirely preventable.

In fact, we've (meaning, American hospitals) have been making a big deal of trying to prevent them for nearly two decades.

In 1999, the Institute of Medicine published its now seminal "To Err is Human" report, bringing attention to the prevalence of medical errors within healthcare and the lack of an effective industry-wide effort to combat these entirely preventable occurrences.

The report estimated that up to 98,000 patient deaths occur each year because of medical errors, which include HAIs. It's hard to find an updated statistic on this; the last report of this magnitude, released in 2009 by Consumers Union and the Safe Patient Project, shows we haven't moved the needle much: It estimated around 100,000 deaths still occur annually due to medical errors.

Given the astronomical figure estimated by the JAMA article, it appears hospitals still haven't made much collective headway. (It should be noted that some hospitals — such as Memorial Hermann in Houston — have had remarkable improvements in this area and have been able to reduce the number of CLASBIs to essentially zero over several years.)

But, the industry needs to do more. The costs and lives lost are too high not to.

As the 1999 report states, human error is inevitable. But, many other industries (e.g., the aviation/airline industry) but have all but eliminated human error through institutional processes that protect against and catch errors before they are made.

Individual hospitals have successfully instituted processes that have achieved this, but they haven't spread as quickly as they need to. Said differently, these conditions are preventable in that the industry has proven methods for significantly reducing and even eliminating their occurrence. Yet, we haven't experienced a major tipping point that has caused these efforts to diffuse throughout the delivery system.

Will CMS create one?

The federal government has refused to reimburse hospitals for treating healthcare-acquired conditions since 2008, and beginning in 2015, it will further cut payments to hospitals with high rates of HAIs under its Hospital-Acquired Condition Reduction Program.

Let's hope that the additional penalty, along with other value-based payment reforms — from both public and commercial payers — which we are increasingly seeing, will be the catalyst for bringing about serious improvements to reduce preventable medical errors. Every day we delay, approximately 268 people will die because of our slow response.

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