Fifteen Years Later: No Improvement for Patient Safety

Submitted by on Friday, July 18, 2014 - 03:48

We watch with horror as children are bombed in Gaza and blown out of the Ukraine sky, and the world's indignation mounts – Closer to home, Ashish Jha and other Patient Safety experts testify that U.S. hospitals aren't any safer today than they were 15 years ago when the IOM issued its sentinel report on the quality of health care. While some progress has been made, there remains substantial and unjustified variation in simple things like getting timely lab test results on child allergies for moms to understand potential dangers. The lack of timeliness, which is widespread, has caused hundreds of children to suffer permanent disability and even death. They're not getting bombed or blown out of the sky, but they're dying nonetheless because someone or some organization doesn't care enough to act differently. And so we must ask ourselves what's the difference between those who pull the trigger on a missile, and those who fail to pull the trigger on process change? The former are guilty of a direct violent action, while the latter are guilty of direct omission of a saving action. This lack of taking action to save lives has landed GM in front of Congressional hearings for several months in a row. There have been similar hearings for the leaders of the VA. But where are the hearings for the heads of HCA, Tenet, CHI, and the other large hospital groups?

What this means to you – The spotlight that has shined on the VA and GM is appropriate. Their lack of action has led to hundreds of Americans being harmed or killed needlessly. But the lack of action from the heads of the country's hospitals and health systems is leading to tens of thousands of Americans being harmed or killed needlessly, many of them children and babies. As Jha testified: "Until we get to the point where the CEO of the hospital is lying awake at night worrying about patient safety, I don't think we're going to move the needle." There's not much doubt in my mind that if Trevor Fetter and R. Milton Johnson were dragged in front of Congress every month to account for the avoidable deaths in their facilities, they would start lying awake at night worrying about patient safety and taking concrete action to significantly reduce these horrific and unjustifiable deaths. They might not be lobbing bombs or shooting missiles in the air, but they're killing a lot of kids and adults nonetheless and have to be held accountable for it. They will, eventually, when they wake up in the fiery pits of hell, but that doesn't do much good to all those who will have lost their lives needlessly in the interim. What will do good is to continue to insist on full and complete transparency in patient safety failures, and to get as much scrutiny and attention to every single avoidable death as we're rightfully getting for the avoidable deaths from bombings and shootings. After all, a life is a life, and its sudden and preventable end is tragic irrespective of the cause, and should lead to our, the entire country's, and the world's indignation.