While the U.S health care system is considered one of the best in the world, many American’s may not realize the potential risks they face when seeking and receiving health care. This week marks National Patient Safety Awareness Week; a time meant to bring awareness to the immense problem of safety in our health care system.
Twenty years ago, the Institute of Medicine (IOM) published its landmark report, "To Err is Human," which for the first time brought to light the plague of health care errors occurring as part of the normal course of care delivery in the U.S. Two decades later, we have made little progress in improving the safety of our health care system.
The most recent figures put the rate of preventable health care deaths at around 400,000 each year. To put this in perspective, that is more than Alzheimer’s disease, lung cancer, and breast cancer combined kill each year and means that health care is the third leading cause of death in the U.S. That figure does not even reflect the hundreds of thousands of patients who are harmed during their care but do not die. While Americans have a habit of overreacting to generally rare diseases like the Corona Virus, traditional health care harms and kills far more people with little attention paid to it.
Despite efforts to improve patient safety, the lack of funding for patient safety research is severely limiting progress. According to a 2019 National Institutes of Health report, almost $4 billion of public research funding was allocated for Alzheimer’s research, $644 million for breast cancer, and $360 million for lung cancer, meaning nearly 5 billion dollars earmarked for illnesses in just one year that combined kill less than three-hundred thousand each year, over a hundred thousand less than die from patient safety breaches.
In 2017, the Agency for Healthcare Research and Quality (AHRQ), the leading government agency focused on health care improvement, received a mere $76 million for patient safety research. Unfortunately, this number is falling. The 2020 President’s Budget allocated only $33.5 million for patient safety research this year.
As a patient safety researcher, I am all too familiar with the scarcity of funding for battling the epidemic of health care related errors. Strides to reduce error rates can be made if the commitments for funding are increased.
Fortunately, there are numerous examples of simple ideas that have made huge impacts on patient safety. One of the most promising approaches is the use of health care simulation, a technique where medical professionals practice procedures and lifelike events in realistic settings using high-technology manikins that mimic human physiology such as breathing, heart sounds, and blood pressure.
Simulation-based education has been shown to improve patient safety in outpatient settings, teamwork and communication (two of the leading causes of health care errors), and to decrease infections caused by catheters. Despite these promising findings, health care simulation has had limited impact because, like patient safety research, it too does not have the necessary funding to study its broad applicability in reducing health care errors adequately.
Lack of funding is holding us back, undermining the care each of us receives and contributing to driving up the costs of health care. Quite simply, lack of funding is killing us and costing billions of dollars each year in the U.S and trillions globally. More than twenty years ago, the 1999 IOM report recommended investing $100 million annually for patient safety research. Yet since then, that number has never been reached any year. Based on this recommendation and considering inflation, an initial commitment toward investing $156 million in patient safety research — far more than the $33.5 million allocated for 2020 — would be a start and consistent with other global commitments toward funding patient safety research.
Funding isn’t the only way we have to impact change, of course. Bringing awareness through speaking up is a great way to make a difference. All of us can use this year’s National Patient Safety Awareness week to bring more attention to health care errors. If we can’t talk about errors, we can’t fix them.
As consumers of health care, we all have a role to play as members of the health care team. Ask your providers to wash their hands if you haven’t seen them do so. Ask to see your records and correct mistakes if you find them. Let each of your providers know what has been prescribed or recommended by your other providers. Each of these actions can help to drastically improve the care you receive and decrease potential errors.
Health care providers also need to talk about the errors we have made and what we believe caused them so we can learn from them to prevent future mistakes. Patients also need to talk about the mistakes that have happened to them and ask for more to be done to help improve systems and the burden of health care errors.
This week of National Patient Safety Awareness, let’s team up for patient safety — please join me in telling your health care error story, post your story with the hashtag #myhcerrorstory2020 to social media platforms like Twitter, Facebook, and Instagram. Collectively, we have a loud voice. Patients, providers, and families working together can bring this topic to light and help to be the agents of change.
Jill Steiner Sanko is an assistant professor of Nursing and Health Studies at the University of Miami and a Public Voices Fellow.