Learning from mistakes generally is considered the upside to failure. But in healthcare, where staff members regularly face stressors and systemic issues that impede a strong culture of safety, creating that standard can be difficult.
In the more than 20 years since the Institute of Medicine released its landmark 1999 report To Err Is Human: Building a Safer Health System, the healthcare industry has failed to make significant progress on eliminating preventable medical errors, which contribute to more than 250,000 deaths annually.
Earlier this year, Kaiser Health News spotlighted 55 hospitals with high rates of patient complications that CMS has penalized for eight consecutive years under the Hospital-Acquired Conditions Reduction Program. The initiative, launched in 2014, aims to reduce patient harm by providing a financial incentive for hospitals to prevent hospital-acquired conditions, such as infections and blood clots. Every year, Medicare cuts payments by 1 percent for hospitals that fall in the worst-performing quartile.
To understand why medical mistakes and care complications occur repeatedly — even in the face of financial penalties — Becker's spoke with Patricia McGaffigan, RN, vice president of safety programs for the Institute for Healthcare Improvement.
"The challenges that we've had in turning the tide on errors and harms and sustaining progress is really very multifactorial," she said. "It is highly dependent upon how well people perform in their jobs and how well and how diligently organizations address the systems and safety realities that are essential to attain and maintain progress."
Ms. McGaffigan, who is also president of the Certification Board for Professionals in Patient Safety, outlined three factors that contribute to repeat medical errors, care complications or lost progress on quality improvement initiatives.
1. A "whack-a-mole" approach to safety. It's not uncommon for healthcare organizations to address patient safety via piecemeal initiatives, versus broader, systemic efforts, Ms. McGaffigan said.
Standalone safety efforts are typically guided by goals to reduce a complication by a specific percentage. Often, once that target is hit, hospitals take the win and move on to other projects, according to Ms. McGaffigan. This approach can set up a "whack-a-mole" type mindset that makes it easy for progress to slip in certain areas.
"Safety is an incredibly dynamic property," she said. "We're never really able to claim that we're safe or not, or that we have successfully met our goal of wiping out a particular problem."
2. Lack of focus on systemwide changes. Many healthcare organizations fail to think about patient safety from a system approach. For example, a hospital may deploy certain clinical and technical practices to address a high rate of catheter-associated urinary tract infections and then reduce the emphasis on them once the infection rate falls, Ms. McGaffigan said. These types of interventions usually focus on what individuals or smaller teams can do at a patient-specific level, without considering what the healthcare organization needs to do more broadly to support safe care.
Healthcare systems must ensure they have a strong foundation in place to proactively and intentionally design systems to refine safety efforts and sustain improvements, according to Ms. McGaffigan.
"If we codify our focus on safety in a mindset where we want to get to improvement but also continuously aim for zero harm to patients and the workforce, and recognize that this is the daily core work of an organization for everyone across the enterprise, then we will have better success with our goals," she said.
3. Unhealthy or unsafe work environments. Healthy work environments and positive safety cultures play a key role in safety efforts. If staff members feel like they can't speak up and report errors, there is no system of honesty and transparency, and leaders can't begin to understand how or why something went wrong, let alone prevent the mistakes from happening again, according to Ms. McGaffigan.
"If transparency was a medication, it would be a blockbuster with millions of dollars in sales and accolades for the world over," she said, adding that transparency within and across organizations, along with patients and the public, is crucial to create learning systems to prevent errors.
Transparency and open communication with patients after a preventable medical error can not only improve safety efforts, but also help a hospital's bottom line, research suggests. A 2018 study published in Health Affairs found hospitals with communication-and-resolution programs for cases of avoidable medical harm had a lower rate of new malpractice claims and legal defense costs.
"There is a collective opportunity for healthcare organizations to understand and improve safety," she said. "It's not only ethically correct, but it is essential for promoting accountability and stimulating improvements that result in error reduction."