May 8, 2016 Recent research from Hopkins, published earlier this week, has once again identified medical errors as the third leading cause of death in the US. A patient is injured by a preventable medical error every 5 seconds in this country. Since the original report in 1999 by the Institute of Medicine, "To Err is Human" only modest inroads have been made. While hospital acquired infections have been reported to have decreased, basic hand washing compliance by health care providers remains very low, some reported at a dismal 60% rate. Diagnostic errors, medication errors, discharge errors, monitoring and communication errors dominate the healthcare system.
I am delighted to report that at the just concluded Annual Meeting of the Massachusetts Medical Society (MMS) the below resolution which I authored was unanimously passed by the House of Delegates
RESOLVED, That the MMS encourage the use of culture of safety surveys by physicians in their medical offices and where applicable in ambulatory surgical centers where they work.
The Culture of Safety (COS) survey has been widely adopted by hospitals and repeatedly validated. See Agency for Healthcare Research and Quality (AHRQ) website. Now the natural extension is to move it to the medical office and ambulatory surgical center setting and AHRQ offers tailored surveys for each of these settings. My hope is that the AMA in one month will adopt a similar position.
The long term solutions to the epidemic of medical errors will include system changes, attitude changes, behavioral, training and communication interventions as well as clinical decision support tools. Ultimately the rise of the engaged patient who demands evidence based medicine will drive the changes from a grass root level. If you or a family member have experienced a medical error please share the anecdote so we can publicize the events and identify opportunities to prevent needless future suffering and deaths.