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Patient Safety: Long Way to Go?

July 6, 2012
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Hospital readmission rates and other patient safety measures score poorly in recent report

I’ve been reading a great book lately about the death of President James Garfield, the 20th president of the U.S., and the second to be assassinated while in office. The book, Destiny of the Republic, written by Candice Millard, details the rise of the self-made Garfield, his unlikely ascension into the highest office in the country, and why a delusional, deranged Charles Guiteau shot him in the back on a summer’s day in 1881 at a Washington, D.C., train station.

What does this book have to do with healthcare? Well, the book talks about how President Garfield’s medical team, led by Dr. Doctor Bliss (yes, Doctor was his first name), royally screwed up his care, and ultimately caused his death. According to Millard’s book, it wasn’t the bullet that entered Garfield’s back that killed him, but rather the infections in his blood, caused by a lack of antisepsis treatments that were not yet popularized in American medicine.

Moments after Garfield was shot, he was informally treated on the dirty train station floor, where numerous doctors put their unwashed fingers in his wound, allowing infections to enter his body. The lack of un-clean treatment continued until Garfield died approximately two months after he was shot.  Though Garfield’s death was unfortunate, it did lead to the acceptance of antisepsis treatment in the U.S. Millard says had Garfield been shot only 10 years later, he would have survived. Had he been shot today, she says, he’d be on his feet in weeks.

A recent report which discussed patient safety at-length, made me think of Garfield’s story through Millard’s highly entertaining historical non-fiction narrative. The report, from Consumer Reports, looked at the safety rankings of U.S. hospitals in six measures. The results were not positive for the healthcare industry, according to Consumer Reports, which said more than half (51 percent) of the hospitals rated received a score below 50 (on a scale of 1-100).

Safety scores, Consumer Reports says, could be improved across the board. Even the hospital that scored the highest, Montana-based Billings Clinic, only received a safety score of 72.  

One of the safety measures examined is an old enemy of healthcare executives:  readmissions. According to Consumer Reports, research suggests that up to three-quarters of readmissions may be preventable. In addition while no hospital earned Consumer Reports’ highest score for readmissions, 166 hospitals received its lowest score.  Considering Consumer Reports rated 1,159 hospitals across 44 states, this equates to roughly 14 percent that received the lowest score, which is fairly high.

Another measure related to health IT that could be improved is communication. According to the report, no hospital earned the top score while almost 500 hospitals earned the lowest score for communication about new medications and discharge plans.

The report also highlighted the risks associated with infections and radiation overload. According to the report, 202 hospitals reported infections at rates higher than the national benchmark, and only 148 reported zero infections. In terms of radiation overload, there were a high number of hospitals that had a high double CT-scan rate, which according to a doctor interviewed for the report, is necessary in less than one percent of the patients.

If this truly is reflective of the industry, these kinds of numbers are alarming, this day and age. We know how much effort is being put into curbing readmission rates at hospitals. We also know how organizations like the Institute of Medicine have made internal patient safety improvement a focal issue, through extensive reports. Clearly this is an issue, but I had no idea how much progress has still yet to be made.

“Medical harm is probably one of the three leading causes of death in the U.S., but the government doesn’t adequately track it as it does deaths from automobiles, plane crashes, and cancer. It’s appalling,” said Peter Pronovost, M.D., senior vice president for patient safety at Johns Hopkins Medicine in Baltimore, to Consumer Reports.

When I read about Doctor Bliss, and how President Garfield’s life was taken by poor medical care, I realize how far we’ve come in 130 years. But as this report shows, we may have a lot longer to go.

What do you think? Is this report overblown, or does it signify a real issue for providers?  Please leave your comments below to continue the discussion.




Great article Gabriel.

Working for a technology provider that provides iris biometrics for patient ID, we have witnessed a very sharp increase in our solution from hospitals over the past year. Many are looking to these types of enterprise products as technology soldiers to help protect patients from misidentification, the creation of duplicate medical records which can jeopardize the quality of care and also to prevent medical identity fraud. We certainly can attest that these surveys (and the one recently conducted by The Leapfrog Group) are making hospitals stand up and pay attention to the problems that medical harm bring to the healthcare industry.

Really enjoyed your analogy to the Garfield story and you have motivated me to download that book to my iPad for a weekend read.

Thanks Gabriel!

Thanks for your comments! Definitely going to be looking out for this issue in the coming months. Recently, the NY Times about a 12-year-old boy who died from sepsis made me think of poor President Garfield. Mark Hagland, our EIC, will have more on that story in an upcoming blog. Enjoy the book.