Somewhere in America, an eight-year-old boy was referred to a hospital for an evaluation of masses in his neck. The ultrasound revealed a lesion, and the doctor performed a minor surgery to get a sample. The boy was placed under anesthesia. The procedure was uneventful and took three minutes.
Following the procedure, the boy was provided oxygen, but inexplicably, his oxygen saturation and heart rate plummeted. CPR was initiated. Intubation. Emergency drugs, steroids. The boy was unresponsive. It was not until the boy's oxygen was re-sourced from the wall to a cylinder that that his oxygen levels improved, but it was too late. He was transferred to the ICU on a ventilator, comatose, sustained multiple heart attacks, and died.
The hospital's root cause analysis found that the wall outlet marked for oxygen was instead connected to nitrous oxide. Process failures followed.
This real case study was published last month by Agency for Healthcare Research and Quality's Patient Safety Network.
In 2017, the Institute for Healthcare Improvement (IHI) found that one-in-five respondents in their national survey reported experiencing a medical error; nearly one-in-three reported being involved in the care of someone who experienced a medical error.
A 2023 study by David Bates of Mass General Brigham and other smart people reinforced the finding. In their examination of a sample of 2.8k admissions across 11 MA hospitals, "adverse events" were identified in "nearly one in four admissions, and approximately one fourth of the events were preventable," and included a death.
Estimates vary in what this amounts to nationally -from 44k to 250k deaths/yr- because we do not have reliable #healthdata systems to measure the whole. In response to a federal RFI on patient safety, the Patients for Patient Safety US noted that estimates "are piecemeal, based on narrow subsets of adverse events and sample studies in siloed delivery settings rather than systemic surveillance and reporting."
It's a tension in our nation's systems of health: confusing the desire to empower state + delivery system innovation with freedom from federal bureaucracy (amen); and the real need - for our national wellbeing - to ensure we have shared health information #interoperability, standards, and infrastructure to support national responses and insights. (See: public health reporting during the pandemic.)
In March, Reps. Barragan and Burgess introduced the bipartisan "National Patient Safety Board Act" to address these concerns, centralizing national patient safety oversight (like w aviation) and filling national reporting #datagaps. With support from the National Patient Safety Board Advocacy Coalition, NCQA, Families USA, AARP, The ERISA Industry Committee, and others, I hope it advances, because while it is sometimes easy to let cold stats roll off, the stories haunt me.
https://lnkd.in/eayuHBM3
