Health and Human Services (HHS) Secretary Xavier Becerra startled a recent meeting of senior health system leaders by declaring in opening remarks that a plane crash had just killed all 200 passengers. He immediately added that this hadn’t really happened; he’d said it only to illustrate the toll taken by medical error.
“We’re losing pretty much an airline full of Americans every day to medical error, but we don’t think about it,” said Becerra. (The department’s fiscal 2022-2026 strategic plan actually estimated the death toll at roughly 550 daily, which would be a very large airliner.) “But the worst part about it is that it’s avoidable.”
Strategic Plan FY 2022 – 2026: https://www.hhs.gov/about/strategic-plan/2022-2026/index.html
While the formalities of the meeting were fluid and required no commitment, the tone and intent of this gathering of leaders of large healthcare systems from the #CDC, #HCAHealthcare, #KaiserPermanente, and #CommonSpiritHealth was critical and a call to action of these representatives to give feedback on how #HHS could best help health systems achieve #patientsafety goals.
Healthcare was in trouble before #covid 19. Now staff shortages, pandemic terminations, #burnout, corporate financial pressures, and the #covidhangover has placed patients in a dangerous and sometimes deadly situation.
By Covid-19 hangover, I mean patients presenting with exacerbated illness and staged out disease(s) because preventative care, early detection treatment, and #testing were not accessible for over a year. What was deemed not emergency surgery was postponed, and patients were forced to use #telehealth.
Telehealth works and is effective in certain circumstances, but it comes with a significant risk of missing symptoms that can only be assessed in person. In addition, many people could not manage the technology piece. I saw this firsthand with my Father in Law. He was 84 and, like many people his age, did not own a smartphone and could not use one. I brought my scale and blood pressure machine to his house and downloaded the software on my phone, and figured out how to make his check-up appointment happen. I know many like him could not do telehealth due to technical issues, user abilities, and insufficient equipment to make it happen. For these reasons, many of our seniors and other diverse and needy low socioeconomic populations without internet access fell through the cracks.
Finally, a lot of illness was missed or ignored due to a lack of appointment availability and facilities overburdened with Covid-19 patients, reducing the ability to treat non-covid patients.
The Alliance aims to recruit the nation’s largest health systems as participants.
The Nov. 14 meeting at which Becerra spoke signaled a renewed commitment by #HHS to preventing patient harm as it launched an “Action Alliance to Advance Patient Safety.” Though the meeting rhetoric was rousing and the invitee list impressive, specifics remained scarce.
National Action Plan to Advance Patient Safety: https://www.ahrq.gov/patient-safety/reports/safer-together.html
"Listening along with Becerra were leaders of the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS), and the Food and Drug Administration (FDA). HHS posed three questions to the provider group, with a #patientadvocate as moderator and three other advocates responding to what they heard."
The most supportive evidence that healthcare is in dire shape was the feedback difference from healthcare C Suite healthcare leaders versus the #patientadvocates in the room.
Many health system leaders emphasized the safety impact of workforce woes, financial stress and the burden of often confusing regulations, all exacerbated by the #pandemic.
Patient safety advocates, however, sounded in a very different tone.
“You are focused on financial issues, on staffing,” said Helen Haskell of Consumers Advancing Patient Safety. “But a failure to be transparent with patients [when harm occurs] is a key reason patient safety has not advanced.”
“For the past twenty years, there has been a focus on the private-public partnership,” said Armando Nahum of Patients for Patient Safety (US). “While we have seen some organizations step up to the plate, our system has not.
Our federal government has not enforced its own quality standards."
We need to move our country to the point where the consequences for non-reporting an event or for harming a person are worse than the incentives for staying silent.”
Historically President Bill Clinton and Barack Obama tried to tackle patient errors and mandatory reporting. Mandatory reporting turned to voluntary reporting in 2011 with similar goals and paying an initial $500 million to hospital groups to help individual facilities. The overall goal was to reduce readmissions by 20 percent and “hospital-acquired conditions” by 40 percent. There was success with this until government funds dried up and in came Covid-19.
In February 2022, The New England Journal of Medicine sounded the alarm again. "Since the pandemic began, U.S. healthcare safety has declined severely, suggesting that our system lacks a sufficiently resilient safety culture and infrastructure. We need to build a more resilient delivery system, capable of maintaining high safety levels in crises."
This attached "Forbes" article offers a more in-depth overview of the author's observations. It gives a historical look at healthcare, patient safety, government initiatives, and the current #perils and dangers facing healthcare today. While there are no black-and-white causes, a system that was taxed 20 years ago has only gotten worse.
"Absent this time, in addition to mandatory reporting, is any mention of federal funding and any specific financial or clinical objectives. Instead, there’s a promise to create a “learning community.”
We must do better. Please see some of my other #blogs on how to find your voice, how to advocate for yourself and your loved ones, ask the hard questions and never be afraid to speak up. It just may save your life.
You can also find my lessons learned and tips closing each cheaper of "Not in Vain, A Promise Kept. "