Why We Still Kill Patients: Invisibility, Inertia, and Income

December 25, 2010

25 Dec/AHRP – Between 1978 and 1999, 2.5 million American men, women and children died preventable deaths in US hospitals and 17 million suffered preventable injuries.  Two recent reports confirm that American hospitals continue to cause serious preventable harm to patients.

The question, that Michael Millenson asks in HealthAffairs is, WHY?  Why has the medical profession failed to take proven corrective safety measures to prevent the killing of patients?

In 2009, this JAMA commentary noted that “Clinicians have labeled virtually all harm as inevitable for decades.”  However, there are numerous examples of preventable harm that refute the “inevitability” defense.

1. Letting children die:

Children’s hospitals refused to join a collaborative to learn what steps are needed to slash catheter-associated blood infections which kill a quarter of children infected.

At the 2009 AcademyHealth meeting, Dr. Richard Brilli of Nationwide Children’s Hospital presented data showing how a collaborative backed by some of the most respected organizations in pediatric care had slashed the rate of catheter-associated bloodstream infections (CA-BSIs). CA-BSIs are relatively common, very expensive and can be quite deadly (up to one quarter of victims die). Brilli said his collaborative had tried to recruit 330 pediatric intensive care units to join the initial participants, but after three years, just sixty had accepted. The reasons Brilli said he’s been given indicated to me that few had taken the time to examine the collaborative’s methodology or results. Instead, respondents asserted that their patients were sicker, their hospital was busier than the others in the study, that joining would make them look bad to others, or that the mortality reduction didn’t apply because “I am in a world famous center.

2. Hospital providers fail to wash their hands:

According to a Joint Commission project, 8 hospitals that volunteered to participate had a baseline hand hygiene rate typical of hospitals nationwide:

… only 48% follow hand-washing guidelines: that is worse than the worst rate at the worst big public men’s room in the U.S.

Compare:  “ Hand Washing, a Key Anti-Flu Strategy, Often Neglected by Health Care Workers, ” JAMA,2009; 302: 1850-1851 with NYC Train Station Bathroom Yields Cleaner Hands than Hospitals

But, as Millenson correctly notes, “rather than giving providers an ultimatum, we launch campaigns to ask patients to ask providers to please wash up…”

The profession is quick to absolve itself from professional responsibility and culpability for contributing, if not causing, preventable patient deaths and injuries.

Indeed, the authors of this NEJM/Harvard study acknowledged as much in carefully couched language:

The absence of large-scale improvement is not evidence that current efforts to improve safety are futile. On the contrary, data have shown that focused efforts to reduce discrete harms, such as nosocomial infections and surgical complications, can significantly improve safety.

But the real reason that the killing continues unabated is professional inertia, patients’ invisibility, and added income for hospitals.

This is a shocking confirmation about the prevailing culture of arrogance: contrary to the rhetoric, for America’s medical professionals, patient safety is simply not a priority.

Absent public or peer pressure, doctors and hospitals are reluctant to adopt interventions whose efficacy they mistrust to prevent an epidemic they really don’t see and which is profoundly discomfiting to confront.

Michael Millenson is a nationally recognized expert on improving the quality of the American health and the author of the book “Demanding Medical Excellence: Doctors and Accountability in the Information Age.”