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Less is More but Zero is Best When it Comes to Preventable Injuries

Posted on | May 27, 2011 | No Comments

Judy Salerno

It’s been about 12 years since the Institute of Medicine (IOM) released its landmark report To Err is Human, shining a light on how commonly medical errors occur in our health care system. The report concluded that as many as 98,000 people die in hospitals each year as a result of such errors.  A more recent study published in the journal Health Affairs found that as many as one in three hospital patients suffer from a medical error. So, why are injuries from care still so prevalent?
Several leaders in patient safety—from both the public and private sectors— discussed this topic at a recent event held at the IOM. “We have made some progress,” said U.S. Department of Health and Human Services Secretary Kathleen Sebelius, “but not nearly enough.” The Secretary acknowledged that organizations such as Ascension Health have instituted systems that are achieving great results and reducing preventable deaths.  Another example in which we have seen significant progress is the decrease in the number of central line infections in intensive care units. But as mentioned by many of the panelists, we need to see continued progress on a larger scale. “If we can make improvements in some places, why not everywhere?” posed Don Berwick, Director of the Centers for Medicare and Medicaid Services.
One clear theme that struck me from the discussion is that the real culprit is systems failure. Brent James, Chief Quality Officer with Intermountain Healthcare, explained that “Almost all injuries track back to systems failures, not to human error.” If we are going to improve patient safety, we must first fix the systems currently in place. When setting a goal for reducing injury to patients, instead of aiming for a 20 percent reduction or a 40 percent reduction, why not set zero as the number? As Don Berwick stated, zero is the right number—it’s a different goal, but it’s the path to the future. While it is true sometimes that “less is more,” in this case, zero is best.
I believe that health care in this country could and should be a lot better than it is today. This sentiment was echoed by many of the panelists at the lecture, including Secretary Sebelius. The key going forward is to focus more on improving systems if we are ever going to reach the goal of zero injuries. Secretary Sebelius added that “if we only improve care as much in the next decade as we have in the last, we are failing the American public.”

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