Are Patients Safe Enough in Hospitals?

In this exclusive video, Harlan Krumholz, MD, director of the Center for Outcomes Research and Evaluation at Yale University and Yale New Haven Hospital in Connecticut, discusses his recent JAMA study that analyzed patient safety data over the past decade. Krumholz, a cardiologist, is also the Harold H. Hines Jr. Professor of Medicine and a professor in the Institute for Social and Policy Studies at Yale School of Medicine.

The following is a transcript of his remarks:

This is Harlan Krumholz from the Yale School of Medicine. I'm a cardiologist and an author of a study in JAMA: "Trends and Adverse Event Rates with Hospitalized Patients, 2010-2019."

Look, we've all had the experience in the hospital of seeing patients harmed by care that we're providing. [There's] a wide range of situations where, say, hospitalized patients got in-hospital infections and then suffered terribly as a result of oversight in our care -- missed opportunities to prevent it.

I don't want to say that they're all about people doing something that could be directly traced to the problem, but it's a risk environment where things can happen, where adverse events can happen, and in some cases, patients even die from these.

And so in 1999, the Institute of Medicine came out with the report To Err is Human and identified that many people were being harmed in U.S. hospitals as a result of care that wasn't optimal or wasn't necessarily as safe as it could be. The risk environment was such that people were suffering.

After that report, there was a lot of investment of time, effort, and attention towards making our hospitals safer and a focus on systems. Away from this sort of idea that medicine was about a maverick physician or nurse and trying to urge them to be more vigilant, to pay more attention, to make sure the patients got better care, to wash their hands, to try to avoid injury within the hospitalization episode.

But at that point there was a pivot. Those things were good. It's important for us to urge people to do better, but we recognize that we really need systems in place that make it almost impossible for us to do the wrong thing, that make it almost automatic that these are going to be highly safe and reliable environments for patients. So, we need to move away from urging individuals to do better and towards creating systems where it is almost impossible not to do the right thing.

So the question was, are we making any progress?

The government undertook a large-scale surveillance program in U.S. hospitals. That meant that, every year, they would go out to hospitals and would ask them to provide charts, and then those charts would go to professionals who would dig through them and see whether or not there was any evidence that any harm had accrued. They were looking at adverse events -- things that we think are linked to problems in patient safety that we think are likely highly preventable. That's harm that accrues in the course of the hospitalization.

Ultimately, there were 21 adverse events that were identified. A group of people at Yale, AHRQ [Agency for Healthcare Research and Quality], CMS [Centers for Medicare & Medicaid Services], and one of our valued team members from the University of Connecticut came together and said, let's try to consolidate our knowledge from this effort. Over that decade there were about 250,000 medical records that people dug through from over 3,000 hospitals across all these different domains.

So, what was the result? I mean, this has been a big prelude, so what do we find? Actually, over the last decade, there have been some marked improvements. There have been some substantial gains. There have been reductions in the number of these adverse events, preventable adverse events, for heart attacks, heart failure, pneumonia, and surgical procedures. That's great. In some cases, they've declined almost by half. Almost by half. In some cases less than that, but still there's been a steady decline every year.

Now, that's the good news. But, as we pursued this study, I think we had this sense that the journey is far from over. That we ought not to be celebrating this. I mean, it is certainly validation that these actually can be reduced because we've reduced them over the past decade. But the issue is, where do we stand?

By the way, in those "all other" conditions not counting those four, there was no real change. So, the improvements in those areas where we really focused on conditions -- a lot of our quality improvement has focused on heart attacks, heart failure, pneumonia, and surgical procedures, and it was paying off. But for all other conditions, we didn't see that kind of gain. Even at the end for those conditions that we improved, [adverse events] were still too high.

So we're thinking that this is good and we should celebrate a little bit, maybe not much, and we should be thinking that we need to double down. We need to increase the speed of improvement. We need to say that as long as anyone's being harmed in the course of hospitalization, we should be digging in and making that better. We should be leaning into that.

And for the "all other" conditions, maybe those areas that we were focusing most intently on did improve, but maybe we weren't implementing solutions that were having broad-based effect on all the other conditions.

So, we need to be thinking about how we can implement solutions across our health systems that have broad-based benefits and are really making the kind of gains that we think that our patients deserve.

Now, I had one person ask me recently, "Isn't it true that you really can't get rid of these? No matter what you try, it's inevitable. It's one of the costs of receiving care, that sometimes bad things are going to happen. People are going to fall. Is that my fault?"

And what I said was, "I think we have to put on a little different perspective, a little different thinking cap about this. Why can't we be audacious and say, 'Those shouldn't happen'? In fact, we can create an environment that is so safe that people don't fall. And, by the way, some of the falls might be because people are tired, they're not getting sleep, we're not strengthening them, they're malnourished in the hospital."

I mean, what are we doing to increase the risk, and what can we do to decrease the risk? We've been socialized, many of us through the course of our medical training, to think this is just going to happen; it's inevitable, it's futile to try to change it. But the improvements that we saw in these studies show it's not futile. This basic blocking and tackling on patient safety, on the basic kind of processes that occur every day, has a potential to yield a really big return in terms of benefit for our patients.

So anyway, that's what this study showed. It was really an effort to bring together the information that's been collected by the government over time, in partnership with the government and hospitals around the country. And the result was some progress, but not enough. Something to celebrate, but we really shouldn't be celebrating.

We should be saying that the journey really has just begun, and we've got to be able to dedicate ourselves to doing better.

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