Preventable medical errors are on the decline — 4 possible reasons why

An opinion piece published in JAMA Tuesday suggests hospitals have been making significant progress in reducing harms over the last few years and highlights factors contributing to the progress.

The lead author of the viewpoint is Richard Kronick, PhD, a health policy expert with UC San Diego. Two officials from the Agency for Healthcare Research and Quality — Deputy Director Sharon Arnold, PhD, and Director of the Center for Quality Improvement and Patient Safety Jeffrey Brady, MD — co-authored the piece.

The analysis was based on data from the AHRQ/CDC's Medicare Patient Safety Monitoring System, the "only source of reliable nationwide estimates on a broad range of patient harms," according the authors.

The data show the adverse events rate for all hospitalized adults fell from 145 adverse events per 1,000 hospitalizations in 2010 to 121 events per 1,000 hospitalizations in 2014 — a decrease of roughly 4.5 percent each year. Additionally, analysis of the data suggests there were 2.1 million fewer adverse events between 2010 and 2014 than would have occurred if the adverse event rate had remained at the 2010 rate. The decline in patient harm was associated with an estimated tens of thousands fewer deaths and billions of dollars in cost savings by the authors.

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Drs. Kronick, Arnold and Brady outlined the following four potential factors behind the decline in adverse events.

1. Progress stemmed from the existence of previous evidence about how to improve safety

2. Tools and technical assistance enabled hospitals to implement evidence-based protocols to improve safety

3. Hospitals used data and measures to assess their patient safety culture and track progress in their adverse events rates

4. Hospital leaders were committed to success and took steps to get involved in the process

"Despite the progress made to date, much work remains to be done," the authors wrote. "The most important question moving forward is how to maintain, or if possible accelerate, the annual decline in adverse events."

 

 

More articles on medical errors:
Pictures that identify patients may reduce errors, but can make patients uneasy
Patient safety tool: AHRQ's new toolkit to help communicate with patients after errors
New Mexico Hospital establishes Zero Harm Committee

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