Thread by @MHHmeyer

On the 20th anniversary of the landmark report To Err is Human: Building a Safer Health System, Modern Healthcare finds the U.S. healthcare system is still a dangerous place for patients. A big reason is healthcare CEOs have not made safety a top priority.
modernhealthcare.com/safety-quality…

In a package of 7 reported articles, plus 3 expert commentaries & an editorial, we examine the state of patient safety & safety measurement in U.S. healthcare. Unfortunately, many Institute of Medicine goals and recommendations were never carried out.
modernhealthcare.com/topic/indepth

The 1999 report spurred action when it estimated that 44,000- 98,000 people die in hospitals per year due to preventable medical errors. It recommended a new agency to track safety progress; a mandatory reporting system for adverse events; & halving errors within 5 years.

One MH article looks at deadly safety problems at top hospitals inc. Baylor St. Luke’s, where physicians & staff warned executives about problems but nothing was done. The cases show holes in the culture of safety, transparency, and measurement of errors.
modernhealthcare.com/safety-quality…

“Patient safety is uniquely the responsibility of the C-suite, but CEOs haven’t paid attention to it or acquired the necessary knowledge,” said Kim Hollon, CEO of Signature Health, a safety-net hospital in Brockton, Mass.
modernhealthcare.com/safety-quality…

One exception is children’s hospitals, which formed a national safety collaboration that significantly cut infections & hospital-acquired harms. “We now realize that working alone on safety was a stupid idea,” said Cincinnati
Children's Dr. Muething.
modernhealthcare.com/safety-quality…

But you can’t improve safety if you aren’t tracking errors closely. MH's Maria Castellucci found only 28 states have adverse-event reporting systems. Even the better ones are limited in the types of errors they track & what they report to the public.
modernhealthcare.com/safety-quality…

Maria also examined federal quality reporting measures for hospitals and other facilities, and found that experts don’t trust the measures and don’t think they help healthcare providers do their job better.
modernhealthcare.com/safety-quality…

Safety advocate Linda Kenney recalled 2 medical errors 20 years apart, at the same teaching hospital, that nearly killed her. At least the providers in the recent incident acknowledged the error. She notes medical errors have a profound emotional impact on patients & providers..

In commentaries, three noted safety experts – Drs. Berwick, Cassel, & Chassin -- urge greater focus on moving toward zero harm. Berwick said the nation would quickly have mobilized to address tens of thousands of deaths if this were a disease outbreak.
modernhealthcare.com/opinion-editor…

“Perhaps in the case of patient safety, it will take an angrier public, more assertive payers, and a more surveillant government to ignite the response we really need," wrote Berwick, one of the authors of the 1999 report.

“If you walk into a hospital CEO’s office today & and ask how many people were injured from care last month, most CEOs could not answer that. That’s a travesty. If you aren’t tracking how much harm you’re doing, it’s hard to figure out how to manage it.”
modernhealthcare.com/safety-quality…

For a bonus feature, see our timeline of major patient safety developments over the past 30 years.
modernhealthcare.com/safety-quality…

"I’ve had two experiences with medical errors, 20 years apart, that almost killed me. The difference now is providers are acknowledging these things. Before it was deny and defend."
modernhealthcare.com/safety-quality…