When Mistakes Multiply: How Inadequate Responses to Medical Mishaps Erode Trust in American Medicine.
adverse events
bioethics
communication-and-resolution programs
patient safety
public reporting
trust
Journal
The Hastings Center report
ISSN: 1552-146X
Titre abrégé: Hastings Cent Rep
Pays: United States
ID NLM: 0410447
Informations de publication
Date de publication:
Sep 2023
Sep 2023
Historique:
medline:
16
11
2023
pubmed:
14
11
2023
entrez:
14
11
2023
Statut:
ppublish
Résumé
In this essay, we explore consequences of the systemic failure to track and to publicize the prevalence of patient-safety threats in American medicine. Tens of millions of Americans lose trust in medical care every year due to safety shortfalls. Because this loss of trust is long-lasting, the corrosive effects build up over time, yielding a collective maelstrom of mistrust among the American public. Yet no one seems to notice that patient safety is a root cause, because no one is counting. In addition to identifying the origins of this purblindness, we offer an alternative policy approach. This would call for government to transparently track safety threats through the systematic collection and reporting of patients' experiences. This alternative strategy offers real promise for stemming the erosion of trust that currently accompanies patient-safety shortfalls while staying consistent with Americans' preferences for a constrained government role with respect to medical care.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
S22-S32Subventions
Organisme : Gordon and Betty Moore Foundation
Informations de copyright
© 2023 The Hastings Center.
Références
NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute, Americans’ Experiences with Medical Errors and Views on Patient Safety (Cambridge, MA: Institute for Healthcare Improvement and NORC at the University of Chicago, 2017), 28.
M. Panagioti et al., “Prevalence, Severity and Nature of Preventable Patient Harm across Medical Care Settings: Systematic Review and Meta-Analysis,” BMJ Quality and Safety 366 (2019): doi:10.1136/bmj.l4185.
A. B. Christiansen, S. Simonsen, and G. A. Nielsen, “Patients Own Safety Incidents Reports to the Danish Patient Safety Database Possess a Unique but Underused Learning Potential in Patient Safety,” Journal of Patient Safety 17, no. 8 (2019): e1480-87. Also see the 2002 survey “Medical Errors: Practicing Physician and Public Views,” by the Harvard School of Public Health and Henry J. Kaiser Family Foundation, distributed by the Roper Center for Public Opinion Research (https://ropercenter.cornell.edu).
The number of adverse events from medical products is itemized as “metric MPS-3” at https://www.healthypeople.gov/2020/data-search (accessed August 22, 2022), on the Healthy People 2020 website, which is archived.
J. C. Prentice et al., “Association of Open Communication and the Emotional and Behavioural Impact of Medical Error on Patients and Families: State-wide Cross-Sectional Survey,” BMJ Quality and Safety 29, no. 11 (2020): 883-94.
NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute, Americans’ Experiences with Medical Errors and Views on Patient Safety, 31.
Panagioti et al., “Prevalence, Severity and Nature of Preventable Patient Harm.”
Ibid.
NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute, Americans’ Experiences with Medical Errors and Views on Patient Safety, 16.
Panagioti et al., “Prevalence, Severity and Nature of Preventable Patient Harm.”
Ibid.
E. McGlynn, K. M. McDonald, and C. K. Cassel, “Measurement Is Essential for Improving Diagnosis and Reducing Diagnostic Error: A Report from the Institute of Medicine,” Journal of the American Medical Association 314, no. 23 (2015): 2501-2.
M. Sengupta, J. P. Lendon, and C. Caffrey, “Post-acute and Long-Term Care Providers and Services Users in the United States, 2017-2018,” Vital and Health Statistics 3, no. 47 (2022): doi:https://dx.doi.org/10.15620/cdc:115346.
J. Zhu et al. “Can We Rely on Patients’ Reports of Adverse Events?,” Medical Care 49 no. 10 (2011): 948-55; L. I. Solberg et al., “Can Patient Safety Be Measured by Surveys of Patient Experiences?,” Joint Commission Journal on Quality and Patient Safety 34, no. 5 (2008): 266-74.
The longest look-back period was part of our survey of diagnostic mishaps: among respondents who had experienced a diagnostic problem five or more years in the past, 48 percent still reported that they were less trusting of medical care than before the adverse event.
NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute, Americans’ Experiences with Medical Errors and Views on Patient Safety, 2.
Ibid., 9.
Ibid., 10.
Prentice et al., “Association of Open Communication and the Emotional and Behavioural Impact of Medical Error on Patients and Families.”
Institute of Medicine, To Err Is Human: Building a Safer Health System (Washington, DC: Institute of Medicine, 1999).
F. Levy et al., “The Patient Safety and Quality Improvement Act of 2005,” Journal of Legal Medicine 31, no. 4 (2010): 397-422.
A. S. Mattie and R. Ben-Chitrit, “Patient Safety Legislation: A Look at Health Policy Development,” Policy, Politics and Nursing Practice 8, no. 4 (2007): 251-61; F. Levy et al., “The Patient Safety and Quality Improvement Act of 2005,” 397-422.
The regional networks, termed “patient safety organizations” (“PSOs”) do (sporadically) report to AHRQ, which is charged with providing them technical assistance and promoting a common event-reporting template.
L. L. Leape, “Patient Safety: Reporting of Adverse Events,” New England Journal of Medicine 347, no. 20 (2002): 1633-38.
J. Boulanger, C. Keohane, and A. Yeats, “Role of Patient Safety Organizations in Improving Patient Safety,” Obstetrics and Gynecology Clinics of North America 46 (2019): 257-67.
C. Hanlon et al., 2014 Guide to State Adverse Event Reporting Systems (Portland, ME: National Academy of State Health Policy, 2015).
N. Eldridge et al., “Trends in Adverse Event Rates in Hospitalized Patients, 2010-2019,” Journal of the American Medical Association 328, no. 2 (2022): 173-83; D. Tedesco et al., “Improvement in Patient Safety May Precede Policy Changes: Trends in Patient Safety Indicators in the United States, 2000-2013,” Journal of Patient Safety 17, no. 4 (2021): e327-e334; Y. Wang et al., “National Trends in Patient Safety for Four Common Conditions, 2005-2011,” New England Journal of Medicine 370, no. 4 (2014): 341-45.
National Academies of Sciences, Engineering, and Medicine, Peer Review of a Report on Strategies to Improve Patient Safety (Washington, DC: National Academies Press, 2021); Christiansen, “Patients Own Safety Incidents.”
Ibid.
McGlynn, “Measurement Is Essential for Improving Diagnosis and Reducing Diagnostic Error.”
M. Mello et al., “Communication-and-Resolution Programs: The Challenges and Lessons Learned from Six Early Adopters,” Health Affairs 33, no. 1 (2014): 20-29.
R. Sattar, J. Johnson, and R. Lawton, “The Views and Experiences of Patients and Health-Care Professionals on the Disclosure of Adverse Events: A Systematic Review and Qualitative Meta-ethnographic Synthesis,” Health Expectations 23, no. 3 (2020): 571-83.
Y. Birks et al, “An Exploration of the Implementation of Open Disclosure of Adverse Events in the UK: A Scoping Review and Qualitative Exploration,” Health Services Delivery Research 2, no. 20 (2014): doi:10.3310/hsdr02200.
NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute, Americans’ Experiences with Medical Errors and Views on Patient Safety, 16.
M. M. Mello et al., “Ensuring Successful Implementation of Communication-and-Resolution Programmes,” BMJ Quality and Safety 29, no. 11 (2020): 895-904.
Prentice et al., “Association of Open Communication and the Emotional and Behavioural Impact of Medical Error on Patients and Families.”
Ibid.
J. Moore, M. Bismark, and M. M. Mello, “Patient Experiences with Communication-and-Resolution Programs after Medical Injury,” JAMA Internal Medicine 217, no. 11 (2017): 1595-1603.
Christiansen, “Patients Own Safety Incidents.”
National Academies of Sciences, Engineering, and Medicine, Peer Review of a Report on Strategies to Improve Patient Safety (Washington, DC: National Academies Press, 2021).
C. Keller, “A Health System That Won't Learn from Its Mistakes,” Health Affairs 41, no. 9 (2022): 1353-56.
A. Khan et al., “Families as Partners in Hospital Error and Adverse Event Surveillance,” JAMA Pediatrics 171, no. 4 (2017): 372-81; J. K. O'Hara et al., “What Can Patients Tell Us about the Quality and Safety of Hospital Care? Findings from a UK Multicentre Survey Study,” BMJ Quality & Safety 27, no. 9 (2018): 673-82; J. S. Weissman et al., “Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not?,” Annals of Internal Medicine 149, no. 2 (2008): 100-108; Christiansen, “Patients Own Safety Incidents.”
Prentice et al., “Association of Open Communication and the Emotional and Behavioural Impact of Medical Error on Patients and Families”; M. J. Ottosen et al., “Long-Term Impacts Faced by Patients and Families after Harmful Healthcare Events,” Journal of Patient Safety 17, no. 8 (2021): e1145-51; R. Suzuki et al., “Association of Patients’ Past Misdiagnosis Experiences with Trust in Their Current Physician among Japanese Adults,” Journal of General Internal Medicine 37, no. 5 (2022): 1115-21.
R. Iedema et al., “Patients’ and Family Members’ Views on How Clinicians Enact and How They Should Enact Incident Disclosure: The ‘100 Patient Stories’ Qualitative Study,” British Medical Journal 343 (2011): doi:10.1136/bmj.d4423; Moore et al., “Patient Experiences with Communication-and-Resolution Programs after Medical Injury.”
See surveys summarized here on the website of the National Center for Health Statistics at the Centers for Disease Control and Prevention: https://www.cdc.gov/nchs/index.htm.
See surveys summarized on the website of the Consumer Assessment of Healthcare Providers and Systems initiative at the Agency for Healthcare Research and Quality: https://www.ahrq.gov/cahps/index.html.
M. Schlesinger et al., Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, vol. 1, Why Patient Narratives Matter (Rockville, MD: Agency for Healthcare Research and Quality, 2023).
Prentice et al., “Association of Open Communication and the Emotional and Behavioural Impact of Medical Error on Patients and Families.”
Mello et al., “Ensuring Successful Implementation,” 895-904; Moore et al., “Patient Experiences with Communication-and-Resolution Programs after Medical Injury”; Iedema, “Patients’ and Family Members’ Views on How Clinicians Enact and How They Should Enact Incident Disclosure.”
R. Grob et al., “The Affordable Care Act's Plan for Consumer Assistance with Insurance Moves States Forward but Remains a Work in Progress,” Health Affairs 32, no. 2 (2013): 347-56.
A. Pasztor and A. Anderson, “Rethinking Use of Air-Safety Principles to Reduce Fatal Hospital Errors,” Health Affairs Forefront, August 26, 2022; L. Binder “Holding Hospitals Accountable for Patient Safety,” Harvard Business Review, August 30, 2021, https://hbr.org/2021/08/holding-hospitals-accountable-for-patient-safety.
C. R. Denham et al., “An NTBS for Health Care-Learning from Innovation: Debate and Innovate or Capitulate,” Journal of Patient Safety 8, no. 1 (2012): 3-14.
NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute, Americans’ Experiences with Medical Errors and Views on Patient Safety, 31.
A. S. Gerber, E. M. Patashnik, and D. Doherty, “The Public Wants Information, Not Broad Mandates, from Comparative Effectiveness Research,” Health Affairs 29, no. 10 (2010): 1872-81.