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(Robert Couse-Baker/flickr)

Three years ago, on a Friday afternoon, I received a frantic phone call from my mother. My active and healthy father was in the hospital with a suspected stroke. I immediately started driving to New Jersey, where they lived. I knew I had to be there to ensure that my dad would be safe. He had been taken to one of the most dangerous places in the world: a hospital.

The story of my dad’s three day stay in a major American teaching hospital is remarkably unremarkable.

On Saturday afternoon, he was given an infusion of a medicine intended for another patient — an infusion that was stopped only after I insisted that the nurse double-check the order. After she realized the error, she tried to reassure me by saying, “Don’t worry, this happens all the time.”

On Sunday, the neurologist ordered the wrong type of MRI, which yielded no useful information, left my dad’s diagnosis still in question, and cost American taxpayers thousands of dollars (my dad is on Medicare).

On Saturday afternoon, he was given an infusion of a medicine intended for another patient — an infusion that was stopped only after I insisted that the nurse double-check the order.

On Monday, he was discharged without the right prescriptions.

I am a practicing physician and spent most of the weekend by my father’s side, and even I couldn’t ensure that he received high-quality and safe care. The good news is that his “stroke” turned out not to be a stroke at all and after surviving his hospital stay, he has been able to manage his condition effectively.

When I tell this story, most of my colleagues shake their heads but they are rarely surprised. We have come to expect such failures as a routine part of health care. Yet the consequences are devastating. The Institute of Medicine estimates that as many as 100,000 Americans die each year in American hospitals due to medical errors. In 2011, a New England Journal of Medicine paper found that despite all the talk about improving safety, we have made little progress in reducing harm to patients. A recent federal report estimated that 27 percent of Medicare patients are harmed during hospitalization. That works out to a 5.2 percent chance of suffering an injury every day a Medicare patient is in the hospital.

The story of unsafe hospital care has no villains; the breakdown stems from the incredible complexity of the system. In 2013, a patient having a heart attack might spend five days in the hospital, including time in an emergency ward, cardiac catheterization lab, intensive care unit, and regular floor unit while receiving care from 20 to 30 nurses, a dozen or more physicians, and countless other providers. She would receive thousands of blood tests and dozens of doses of medications. The requirement for effective information flow due to hand offs is immense. And that’s just for a heart attack patient. Hospitals care for thousands of different conditions each year, each with its own challenges.

Complex health care delivery has been with us for decades, as has the evidence that we routinely harm patients. So why do we tolerate such a high defect rate in health care? Industries like aviation, auto manufacturing, and food handling have complex processes. Yet, these industries have figured out — for the most part — how to consistently perform safely. Providers and patients alike have given health care a pass. It’s different, we say.

When people die in a plane crash, it’s obvious why they died. When patients die in the hospital, it’s easy to blame their underlying disease. When auto manufacturers produce unreliable cars, the financial consequences can be devastating. Unsafe hospitals experience few financial consequences. When there is a salmonella outbreak because a food producer failed to use appropriate techniques, we hold them accountable. But when errors occur in hospitals, it is rare that anyone is held to account. The lack of transparency, financial consequence and accountability work together to ensure that when your loved one goes to the hospital, the likelihood that they will be harmed is unnecessarily high.

Complex health care delivery has been with us for decades, as has the evidence that we routinely harm patients. So why do we tolerate such a high defect rate in health care?

So what do we do? First, we need a systematic approach to tracking harm in the hospital. Doing so will let us know when patients are injured or even killed due to medical care, and help clinicians and health care leaders understand the magnitude of the problem in their institutions. Making this information public is even more important. Yet, this will not happen until patients and consumers demand it.

Second, hospitals need to feel the financial consequences of providing unsafe care. A large proportion of hospitals have not adopted cheap and easy interventions that substantially reduce harm. This is unacceptable. If we had a functioning market for health care, where patients got to choose with their feet and their wallets, unsafe hospitals would not survive. As the biggest payer of health care, Medicare is in a prime position to act, but has chosen not to. It’s time for policymakers to make a different choice.

Finally, we need to create accountability for patient safety. Senior health care leaders have to feel that their jobs depend on delivering safe care. Yet, most hospital boards never hold senior management accountable for safety. This is a choice that our health care leaders have made, and hospital boards can do better.

My dad’s experience in the hospital may have been common, but that certainly doesn’t mean it’s acceptable. Each of the key players in health care — consumers, payers, and providers — has a critical role to play in improving patient safety. We tolerate things in health care that we would never tolerate in other parts of our lives. It’s time we became a little less tolerant.

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The views and opinions expressed in this piece are solely those of the writer and do not in any way reflect the views of WBUR management or its employees.

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  • Jlmp

    Thank you for this essay. I sat with my father for close to 3 months in one local Boston hospital or another, while he was treated for a broken hip/hip replacement, then what the docs and staff characterized as dementia–even though my father had shown no sign of dementia before his stay in the hospital. Finally, 4 weeks after his hip surgery, they discovered why he was not getting better and why he was so confused! AN UNDIAGNOSED STAPH INFECTION. My sister and I asked millions of questions, including why, why why was his wound not healing. We were pushed off and ignored, while Dad was shuffled off to another ward or a rehab hospital. We had no answers. I have a Ph.D–not in the medical field, but I sure know how to ask questions and not be intimidated by the medical community. My sister is a nurse. None of this did any good to save our father. By the time they discovered a simple staph infection, he was so debilitated that when they removed his artificial hip, where the staph resided, he did not survive. A relatively health elderly man with a broken hip never came home. Even though he had the most vigilant advocacy of two intelligent and thoughtful women. I pity all of us because we’ll all be in that system sooner of later. And God help us…

  • daniel

    One step toward accountability is transparency and information. Yet like most such published accounts, this one does not name the hospital where the writer’s father was treated. Is everyone (the writer, WBUR. . . ) really so scared of a lawsuit? Enough to let that impede the very change you advocate? Quite disappointing.

    • http://www.facebook.com/profile.php?id=1451162950 Jim Brown

      Good point. Instead of saying “someone should do something”, let’s just start taking action ourselves. What hospitals are we talking about here? I want to be able to know which ones to avoid in the future.

      • JDaveP

        Well, my mother spent a couple of months in a major New Jersey hospital in the ’90s. My sister and I traded places to be with her almost constantly, protecting her from innumerable errors. I shouldn’t tell you its name, but its initials are …MOUNTAINSIDE, in MONTCLAIR!!

    • jtilbe

      One step in the right direction would be to force hospitals to make post-op infection rates public. It’s a dirty little secret at the moment.

  • http://www.justinlocke.com/author.htm Justin Locke

    One book on topic worth reading is “Transforming Health Care,” which tells the story of one hospital using “Toyota lean” techniques” to address these issues.

  • http://twitter.com/campaignZERO Karen Curtiss

    Leapfrog publishes hospital ratings on safety, grading them on terms we all understand, A-F (hospitalsafescore.org). And, after losing my dad to a host of preventable medical errors under my watch as his advocate for a hospital stay, I wrote the guide I wish I’d had: Safe & Sound in the Hospital: Must-Have Checklists and Tools for Your Loved One’s Care (on Amazon). We can’t wait for health care to heal itself… we must know what to watch for, what to do, and what to say. If I’d known what I learned when doing research for Safe & Sound in the Hospital, my dad would be alive today. It’s hard to think about preparing for illness, or a hospital stay, but please do. Find out about safe hospital choices from the Safety Score — and arm yourself with my simple checklists to safeguard hospital care. You can learn more at http://www.SafeAndSoundBooks.com.

  • http://www.facebook.com/BartWindrum Bart Windrum

    Last year I appended a 4th end of life trajectory to Joann Lynn’s 3 legacy trajectories: medical error (it shows a precipitous drop and then a flatline in a blackzone indicating lost life). I have also authored an opinion piece, currently under peer review for possible publication in a medical journal, inquiring why med error never appears in popular and professional “top ten causes of death” charts. Third, nor is med error ever mentioned (in my experiences) during public end of life panels where an interested, ready public convenes to learn from medical professionals what they might do to better ensure peaceful dying.Were medicine to adopt and publicize these 3 things, they alone might stimulate some positive change.

    (Re:charting (acknowledging in a meaningful, comparative way): The trouble with using the government data appears to me to be that cause of death data comes from one agency and medical error data comes from another. An exacerbating factor is how to accurately reduce various causes of death by the number of erroneous deaths once error as a cause is factored in; since med error deaths are attributed otherwise on death certs, this seems impossible to do retrospectively. When I do so by a single percentage across all causes med error deaths rise from #4 to #3 in the hierarchy.

  • Dino Romano

    My own nightmarish experience with my father in 2000 mirrors this. Fortunately I was not intimidated by either the doctors in charge or “the hospital system” and demanded proper care and accountability. Regardless, they contributed to his decline and I will never forgive them for that. Stay at the hospital with your loved ones if you want to make sure they make it out of there alive.

  • Justsomeguy

    I read the title and thought to myself “Yep”. I work in EMS, and see the care you folks get all the time. Most of what I see is in nursing homes/rehab facilities. We pick you up and take you to your appointments when your knee goes or ya need a new hip or what have you… We also see you when the infection you got gets out of control. Typically (but not always) the person will have had a fever for quite some time before we get called which is fine. I’m not saying everyone with a fever should go to the ED, but yeah… or when you get a double dose of your pain meds and now you have an altered mental status (go figure).

    I really shouldn’t be saying anything here really. I’m a basic EMT. The reason I’m a basic EMT is because, as my instructor once told me, if I do my job right, at my level of training, I can’t kill anyone. But it does (at least thinking about it now) make me wonder how similar the rest of medicine is to EMS.

    So, in EMS (in MA), you go through a 3(ish) month course. Take a practical exam, then a written exam. Pass those you walk out with a card and are able to practice medicine (basic medicine). The problem is that when you actually get out into the real world, anatomy seems to be the only thing that applies, and I wonder how often this might be the case in hospitals. The difference between the person who wrote the rules on how to do a job and the practical knowledge on how to do the job (how to things are in real life) seem to often times be quite different.

    I’ve often equated what I do to playing chess… Someone tells me a story about a call they had and I can see everything in my head and know what’s going on and what they should do or should have done, but I rarely knock em if they screw up because I can’t say that if I was in their shoes I wouldn’t have screwed up too (don’t freak out. I didn’t say I don’t say anything). Like when your standing over two people playing chess. The perspective is totally different and you can see when someone is about to do something stupid. Put yourself if in that person’s shoes and at some point, as soon as you take your finger off the piece is when you notice it was idiotic…

    Sorry, I’ll stop talking now…

  • LJ Sloss

    Why? Here is the distillate:
    Institution-based, money-driven system indifferent to the individual, whether patient or caregiver
    Power vested without responsibility, and vice-versa
    Reward system driven by politics decoupled from creation of value
    Perverse incentives inherent and unavoidable in 3rd-party payment
    Management priorities over professional and humane considerations
    Primacy of process over outcomes
    Individual and personal care replaced by ad-hoc flashmobs of interchangeable strangers

    The long form would be a book

  • svs

    As a nurse, I know there are several things that contribute. Some nurses and doctors are just…well bad. Not paying attention, rushing, to arrogant to be questioned or ask questions. Other times excellent professionals are overwhelmed with the hospitals need to make money. Leaving a nurse to take care of too many patients at one time. From my experience as a charge nurse, I always had a full load (5-9, sometimes up to 11 patients) which I was primarily responsible for, overseeing 2-6 other nurses and CNA’s, often with a new nurse in tow who was training. How can the risk for mistakes NOT be high when nurses are often not put in a place to win to begin with. I’m not making excuses for mistakes, we should all take the time to pay attention to what we are doing, even if it puts us hours late going home. The hospitals need to help us out as well. Provide the technology that helps reduce mistakes, be willing to staff appropriately so that we are not stretched so thin we cannot concentrate. Sometimes it’s hard to think when you have not had anything to eat or drink for 12 hours.
    I could go on for hours. I left hospital work and hope to never have to go back until hospitals calm down their profit hunger, and focus more on patient care. Most of us really do WANT to do a good job, and nurses are leaving hospital nursing left and right because they don’t give us the tools to do good.

  • disqus_s18WFM2FBN

    I too rushed out to NJ when my mother was admitted to a hospital.. for good reason.Unfortunately, she died of an MRSA infection. Yes, I was the “annoying daughter who was a doctor” who asked people to wash their hands as they cared for her in the ICU.

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