200,000. Based on an investigation by Hearst Corporation, that is the number of patient deaths that occur each year in the United States due to preventable medical mistakes. The numbers surrounding medication errors are even more staggering –recent findings from the Institute of Medicine (IOM) suggest that 1.5 million medication errors harm patients each year, resulting in an estimated $3.5 billion in additional medical costs.
For each adverse patient event, a similar scenario has occurred approximately 200 to 300 times, but a barrier was in place that helped prevent a bad outcome. The lack of documenting and analyzing potentially harmful events represents one of the most common near misses that prevents healthcare organizations from learning from, and improving the patient care environment.
In fact, according to the Office of the Inspector General (OIG), 86 percent of reportable adverse events to Medicare patients are not disclosed. While these events are often documented in the patient’s medical record, only 14 percent of the actual data is used for quality assurance purposes and prevention action planning. Less than two percent of all medical safety events are reported by physicians. These statistics are indicators of a national epidemic: the underreporting of patient safety events.
By Douglas Dotan, CRG Medical
200,000. Based on an investigation by Hearst Corporation, that is the number of patient deaths that occur each year in the United States due to preventable medical mistakes. The numbers surrounding medication errors are even more staggering –recent findings from the Institute of Medicine (IOM) suggest that 1.5 million medication errors harm patients each year, resulting in an estimated $3.5 billion in additional medical costs.
For each adverse patient event, a similar scenario has occurred approximately 200 to 300 times, but a barrier was in place that helped prevent a bad outcome. The lack of documenting and analyzing potentially harmful events represents one of the most common near misses that prevents healthcare organizations from learning from, and improving the patient care environment.
In fact, according to the Office of the Inspector General (OIG), 86 percent of reportable adverse events to Medicare patients are not disclosed. While these events are often documented in the patient’s medical record, only 14 percent of the actual data is used for quality assurance purposes and prevention action planning. Less than two percent of all medical safety events are reported by physicians. These statistics are indicators of a national epidemic: the underreporting of patient safety events.
Time is Critical to Enact Change
A critical first step in overcoming the patient safety event epidemic is to develop a better means of examining the contributing factors and outcomes of each incident, primarily creating a collaborative environment within each healthcare organization and the industry as a whole. Without safely sharing patient safety information, organizations cannot learn from one another, and thus are unable to fuel continuous improvement.
Today’s healthcare organizations must be able to securely and effectively exchange patient safety information in order to help reduce the number of patient safety events and improve overall healthcare. The U.S. government has already recognized this need and addressed the issue with the Patient Safety and Quality Improvement Act (PSQIA) of 2005, which mandates the creation of Patient Safety Organizations (PSOs).
Taking another step toward improved national healthcare, the U.S. government enacted the Patient Protection and Affordable Care Act (ACA), which requires states to build health insurance exchanges (HIXs) for use by Jan. 1, 2015. Among the recommendations and mandates, the ACA includes a requirement that by Jan. 1, 2015, health plans that participate in an HIX cannot continue to contract with a hospital of 50 beds or more unless that hospital has a patient safety evaluation system (PSES) in place and submits their data to a PSO.
While 2015 may seem to be far in the future, time is critical for healthcare organizations to overcome the fear of sharing information and enact patient safety information sharing measures. Most health plan contracts, including those in the HIXs, are for terms of a year or more, which means that contracts taking effect just six months from now on Jan. 1, 2014, must comply with 2015 requirements.
“Purple Button” Technology
Ensuring compliance with federal mandates requires a protective environment and an easy method of sharing patient safety information. One of technology’s most important roles in the healthcare industry is outcomes assessment, which has been expensive and complicated to perform without computerized data. However, with the high levels of adoption of electronic medical records (EMRs), utilizing and analyzing the data that already exists can enable a much better understanding of patient care and areas of improvement.
If the technology to do so exists, why aren’t more physicians disclosing vital information that could improve patient outcomes and even save lives and prevent harm? Some physicians are hesitant to take time to document patient safety events, as they deem it disruptive to their daily workflow. Despite the implications of the PSQIA, the fear of disciplinary action, litigation and impact on reputation all influence physicians’ decisions in choosing to share their patient safety concerns. Therefore, many physicians and hospital personnel chose to deal with patient safety information on an individual, case-by-case basis, meaning the data is siloed, not shared.
Enter the “Purple Button” technology. The concept of Purple Button technology focuses on information sharing, from the patient bedside to the boardroom, to help hospitals and healthcare organizations improve quality and patient safety and prevent harm from the occurrence of medical errors. If reported, these events could provide critical raw data for healthcare providers, researchers, developers and policymakers to improve patient safety and increase the value of healthcare IT.
With Purple Button technology, hospitals and healthcare organizations can accurately, securely and automatically generate and analyze patient safety events – with just one simple click. In short, the Purple Button enables clinicians to record and submit patient safety events or unsafe conditions using Direct Project secure messaging directly from an EMR or the Internet.
The Purple Button streamlines the process for healthcare providers to send patient safety information from existing databases, which are already in place in many healthcare organizations. The hospital’s Patient Safety Officer and other organizational stakeholders receive the relevant information in the AHRQ Common Formats for analysis and quality improvement in their Patient Safety Evaluation System.
As a result of information sharing, healthcare organizations can analyze all contributing factors in any medical outcome and recognize best practice interventions. Integrated processes, systems and thinking contribute to improved environments for both patients and providers. If healthcare managers know what to fix and how to fix it before it breaks, they can develop and enact plans to increase their staff’s effectiveness, produce positive results, and render, timely, patient-centered care productively, efficiently, and correctly to keep patients safe and healthy.
Without a doubt, today’s rising healthcare costs are of concern to patients, healthcare providers, the federal government and insurance companies. The costs, both monetary and in patients’ well being, associated with preventable patient safety events can be dramatically reduced by implementing technology that enables a secure means of capturing and recording these occurrences. With the looming deadlines imposed with the ACA, there is no time like the present to implement Purple Button technology in every hospital and EMR to help improve patient care and save lives.
About the Author
Douglas Dotan is president and CEO of CRG Medical, developer of the KBCore patient safety knowledge builder software platform http://kbco.re/ .
