An estimated 200,000 to 400,000 patients are harmed in US hospitals every year. The harm can take many forms, most commonly, a fall, pressure ulcer, medication error, venous blood clot, a diagnostic error or a healthcare-associated infection. Recently, the Government Accountability Office was asked to review implementation of patient safety practices in US hospitals to prevent harm to patients.

GAO selected six hospitals, of which some were high performers and some low performers with respect to central line-bloodstream infections, catheter-associated urinary tract infections, and venous blood clots. The hospitals are located one each in California, Indiana, Kentucky, Mississippi, New Jersey and Texas. Between April 2015 and February 2016, they interviewed patient safety officials from these hospitals in addition to experts and researchers in patient safety, and officials from Health and Human Services, The Joint Commission, National Patient Safety Foundation, and American Hospital Association, to understand challenges that hospitals face in implementing patient safety practices.

The report described three key challenges that hospitals face in implementing patient safety practices. Firstly, hospitals have difficulty obtaining data on patient harm within their own organizations. Secondly, they have difficulty prioritizing and selecting which practices should be implemented. Thirdly, they face challenges while ensuring that hospital staff and licensed independent practitioners consistently implement the practices over time.

Challenges with data include difficulties in mining data from the electronic health records and obtaining real-time actionable data in order to provide timely feedback. In my own practice, I find that some safety events like medication error or blood borne pathogen exposure provide immediate feedback to the clinician as in the consequence of a bad practice is immediately apparent. In contrast, safety events like healthcare-associated infections, pressure ulcers and falls are more insidious. The other issue is that numerators, i.e., number of events are more readily available than the denominators. Metrics to reflect overall care or ‘best care’ are mostly not available or standardized.

Choosing from multiple evidence-based practices is a real challenge. In 2013, AHRQ published a set of 41 evidence-based patient safety practices that are effective in preventing common safety events in hospitals. In spite of this knowledge, there is very limited evidence on the relative effectiveness of interventions or the adaptability to different settings. Hospitals try different interventions at the same time or try interventions outside of the ‘known’ best practice bundles, and frequently turn to outside partnerships with collaboratives, universities, and other resources for expertise.

Consistent implementation and standardization of practices and behavior change are a constant challenge as well. Detection of implementation difficulties is not always easy either. A frequent refrain among my peers is, “When are we going to achieve 100% adherence to hand hygiene?” To overcome these challenges, hospital officials told the GAO that they dedicate resources to patient safety efforts including staff with patient safety expertise and systematically involve hospital management and staff including physicians in patient safety efforts.

Notwithstanding these challenges, significant progress has been made nationally. For example, AHRQ identified a 17 percent reduction in healthcare acquired conditions including adverse drug events, falls and select healthcare-associated infections from 2010 through 2014, and estimated that this reduction was associated with nearly 87,000 fewer deaths and a savings of approximately $19.8 billion in health care costs. The Partnership for Patients program by the CMS met with similar success. According to CMS officials, the agency spent approximately $461 million on the program between 2011 and 2014, and established program goals of reducing certain preventable adverse events—including central line-associated bloodstream infections, catheter-associated urinary tract infections and venous thromboembolism by 40 percent and reducing hospital readmissions by 20 percent. Over 3,700 hospitals participated in this program. The report acknowledged that the effects of financial incentives for hospitals need to be tracked and that payers need to get continual feedback on effectiveness of programs.

Per the GAO report, the department of health and human services generally agreed with their findings and is planning to launch several initiatives to address the challenges. My own assessment of the report is that it takes an honest and realistic look at the current state of implementation of patient safety practices in hospitals and acknowledges the inherent challenges. It is interesting that hospitals did not invest in separately calculating financial costs of achieving reductions. One reason may be that the cost of implementing patient safety is stacked against unquantifiable costs like reputational costs. Another reason could be resource requirement for collecting such data. Overall, it was good to see that feedback was sought on potential barriers to progress in patient safety.

Additional information available at:

http://www.gao.gov/products/GAO-16-308

http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/ptsafetyII-full.pdf

http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2014.html

Note: In general, it’s a challenge to make prevention visible. How does one show something that has gone away? The picture above shows how one hospital displays harm prevention. The pink, blue, turquoise or black crystals represent one of the four types of potentially preventable complications tracked. For every single reduction in a potentially preventable complication of care, a crystal in the measuring jar is replaces with a clear crystal. The overarching goal is to have only clear crystals in all measuring jars.