Month in "Focus": March Review

March was a busy month that brought us the official launch of PatientSafetyFocus.com, our support for the first Patient Safety Awareness Week, key findings across several states, and some excellent recommendations for the industry.

And, once again, March was a month that delivered too many statistics that are nowhere near where they should be--as those numbers represent lives hurt and lives lost, all due to preventable medical errors.

Here's a wrap-up of what we've been covering over the past month:

Medicare's plan under fire before it begins: Interesting feedback in the Ann Arbor News article titled "Medicare Plan May Backfire in its results, Penalizing of hospitals is overly punitive". According to the piece: "Come October, Medicare will stop paying hospitals for certain medical mistakes." If you recall, they're not the only ones, as major insurers have just started saying no-pay to "never events" (events that never should have happened in the first place). More here.

AARP releases stifling statistics: Key findings from AARP's (American Association of Retired Persons) New Jersey chapter's recent "Does it Make You Sick?" survey shine even more light on the striking issue of preventable medical errors. According to The Record: More than a third of New Jersey residents surveyed say they or a family member have been a victim of a medical error. Read on here.

HRH works to improve trust: In efforts to not only increase patient safety but to maintain trust, Hendricks Regional Health (HRH) in Avon, Indiana formed a Patient Safety Committee in 2006 consisting of 25 members from all levels and buildings of the medical group. Learn about the interesting initiative here.

Celebrity as influencer for patient safety: An unlikely, but altogether welcome Patient Safety Advocate, Dennis Quaid's newborn twin babies were given almost fatal overdoses of an injectable anticoagulant in LA's Cedars-Sinai hospital--the babies were given nearly 1,000 times the normal 10-unit does of the drug Heparin.

While the twins have fortunately recovered, California regulators have fined the hospital $25,000 for giving overdoses of the blood-thinning drug to three children (two of which were Quaid's twins).The result is two-fold: first, it brings attention to the startling statistics now standing at "1 error per patient per day" which adds up to 100,000 deaths per year in the U.S. alone. But, second, it has brought an unlikely patient safety advocate to the fore in Dennis Quaid (view video here).

Oregon sees increase in number of deaths: Oregon's commission that collects voluntary reports of medical errors has reported that 24 patients died of preventable errors in 2007, compared with 21 in 2006. In 2007, 54 of Oregon's 57 acute care hospitals participated--with those 54 hospitals providing 99 percent of the hospital care provided in Oregon. (Note: Oregon is the only state in the country with a completely operational voluntary reporting program.) Read on right here.

Presenting the quality control is cost control argument: In an article that takes on the patient safety issue from a cost argument, Jamie Stevenson, vice president of the Consumer Health Quality Council, writes: "Our health care needs to become safer. The good news is we all can take a role in improving the system. Quality improvement and cost control cannot be separated. Medical errors cost the nation $17 to $29 billion each year. Quality control is the best form of cost control." Learn more about his views here.

Reading worth your while: If you haven't yet read, we highly recommend IHI's "Quality Rules!" report. IHI is extremely thoughtful in setting out 10 "new rules" including: more continuity, collaboration, control and safety as a system priority (vs. an individual responsibility), transparency as necessary (vs. secrecy), along with giving providers better tools and more efficient systems. Click here to learn more.

More accountability needed: A post by Bruce Bierhans of InjuryBoard.com provides an insightful and objective look at the pivotal area of accountability. His piece strikes a balance between explaining the extraordinary and positive experiences he has had with medical professionals...yet urges how we must press for more accountability when it comes to preventable medical errors. And he's right (one needn't look further than the deplorable statistics and fatalities). More on that piece here.

Plan ahead: On June 23 - June 24 in Washington, D.C., the Institute of Healthcare Improvement (IHI) will host a seminar focused on the "Triple Aim" of excellent health, ideal care and controlled costs. You can learn more about this advancing conference here.

We'll keep covering news, developments and solutions throughout April. Thanks for 'focusing' some of your time here as we all work to improve patient safety and decrease preventable medical errors.

Adam Aronson

CEO, Arrowsight, Inc.