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States' efforts to improve patient safety have grown in number and scope in recent years—prompted by rising health care budgets and evidence of the excessive costs associated with medical errors.
The Institute of Medicine's groundbreaking 1999 report, To Err Is Human, estimated that between 44,000 and 98,000 deaths are attributable to medical error in the U.S. each year—a higher death rate than for car accidents, breast cancer, or AIDS. [1] The report estimated that the total national costs of preventable adverse events in terms of lost income, lost household production, disability, and health care costs are between $17 billion and $29 billion each year, with more than half attributable to direct health costs.
This wake-up call led states, along with health care researchers and practitioners, to expand their efforts to improve patient safety and reduce "adverse events," generally defined as "injuries resulting from a medical intervention, not the underlying condition of the patient." [2] A critical first step has been surveillance, whereby hospitals and other health care institutions report harmful and/or potentially harmful events to the state. According to Jill Rosenthal, project director of the National Academy for State Health Policy, 26 states and the District of Columbia have enacted legislation, regulation, or executive orders creating reporting systems for adverse events. Similarly, states are establishing reporting systems for health facility–acquired infections. Later this month, NASHP will publish a new analysis of state adverse event reporting systems by Rosenthal and colleagues on www.nashp.org.
The initial goal of these reporting systems is to understand the scope, types, and distribution of adverse events in health care settings. Aggregating and monitoring data from multiple sources over time can reveal patterns and problem areas. This, in turn, can lead to changes in practice or health care delivery that reduce the number and severity of adverse events.
Range in State Activity
While they share common goals, states' patient safety strategies vary. Some monitor only adverse events, while others track adverse events as well as "near misses," or events or situations that did not produce patient injury, but only because of chance. Reporting may be voluntary or mandatory, and patient safety responsibility may be assigned to an independent authority or housed within state agencies. Most states are still in the collection and analysis stage, while a few leaders are working with health care providers to change their practices. Some successes from these leading states are described in the Snapshots, below.
A key challenge for states is to overcome providers' reluctance to report negative events for fear of litigation or damage to their reputation. To alleviate such fears, many states guarantee confidential reporting and strict "whistle-blower" protections. Most release data in aggregate or facility-blinded form, but a few are working toward publication of facility-specific data.
States also must find an adequate and stable funding source for their patient safety activity. Some establish dedicated funding sources, such as assessments on health facilities, while others rely on general revenues. Staffing and budgets range widely. For example, Utah has a patient safety budget of about $200,000 per year, which funds two staff members, while Pennsylvania's Patient Safety Authority, only one of the state's patient safety initiatives, has a $4 million annual budget.
Moving in the Right Direction
Despite these variations, "most states recognize the patient safety issue and are taking steps to address it," according to Rosenthal. For example, officials understand that collecting information about adverse events and health facility–acquired infections is only an initial phase. To help facilities learn from mistakes and improve patient safety, states must analyze data and feed it back to providers. They also can recommend changes in procedures and protocols, offer training, and support implementation of best practices. Eventually, states hope to hold health care providers accountable for improving patient safety.
Some states are integrating patient safety initiatives into comprehensive health policies. "States such as Pennsylvania, Vermont, Massachusetts, and Oregon are looking at how cost, quality, and access relate to each other, and are incorporating patient safety efforts into broader health reform," says Rosenthal. In this issue of States in Action, we profile Pennsylvania, Utah, and Oregon—states that are combining data collection with education, communication strategies, and/or collaboration to improve patient safety.