Interview Series: Dr. Kumar discusses PMEs and Fatal Care

As part of our interview series with today’s thought leaders in patient safety, we spoke with Dr. Sanjaya Kumar, author of the just-released book Fatal Care.

Each year as many as 98,000 patient deaths occur in the United States as a result of preventable medical errors (PMEs) in hospitals--with PMEs impacting or harming at least 5 million Americans annually and costing more than $17-21 billion.

These sobering statistics from the Institute of Medicine (IOM) and the Institute for Healthcare Improvement (IHI) provide a glimpse into a national crisis that harms or kills hundreds of innocent people each day. But they are only nameless, faceless numbers and can't illustrate the human cost behind the data. Moreover, they only reveal the problem and not the underlying causes or potential solutions.

Unique and unlike other healthcare-related books, Fatal Care blends true, real-life dramas that illustrate gaps in the healthcare system with factual information and analysis for healthcare consumers and professionals.

What inspired you to write Fatal Care?

"There is an epidemic in this country called preventable medical errors. They, for the most part, go unnoticed while claiming the lives of hundreds of people in the United States each day.These deaths are sacrifices that are unreported, unrecognized and not acknowledged.

I wrote Fatal Care in an effort to provide a voice and a face to those nameless and faceless victims. I want the world to know that this epidemic exists and that they can easily become the next victim. My hope is that this book helps both those accessing care and those who provide that care."

In your opinion, what are the "top actions/priorities" that will move the industry much closer to eradicating PMEs and HAIs?

"First and foremost the actions and priorities outlined are long-term solutions. There are no easy fixes to complex system issues such as preventable medical errors. That said, there are several high priority actions healthcare providers and consumers need to address in order to drive positive change. First, healthcare providers need better cataloging of errors in a standardized fashion. This will allow for accurate trend and intervention identification leading to preventable medical error reduction.

Secondly, the industry needs increased shared knowledge access for cross industry learning. Also, healthcare organizations have to embrace adherence and compliance to evidence-based best practices as this ensures known mistakes are not repeated.

Finally, consumers really need to become educated advocates for their own care. Gone are the days where people can go blindly to their healthcare provider and expect that everything will be taken care of for them."

What are hospitals doing to improve patient safety, where are they lacking in their initiatives--and what factors are holding them back?

"Consumers need to know that the vast majority of healthcare providers have a genuine concern for safety and quality improvement that protects patients. Further, there are incremental advancements taking place. These changes are being driven by increased technological, clinical and cultural advancements.

That said, healthcare providers are faced with continually mounting financial pressures. While they continue to invest in an infrastructure for error reduction, they are constantly making hard decisions concerning each dollar invested. Another huge barrier to improvement is the litigious and punitive society in which we live. Healthcare providers are discouraged from sharing data due to discoverability issues and potential lawsuits."

• For the Fatal Care website, please go here.
• To listen to an audio excerpt from Fatal Care, please go here.
• Is there a thought leader that you would like to see interviewed? Please email us here.
• For all interviews with today's patient safety thought leaders, please go here.