2 decades after landmark IOM report, this group is still fighting to convince hospitals to take safety steps

HUNTINGTON BEACH, Calif.—Standing beneath the bright lights on a stage in a California conference center, Joe Kiani told a crowd of hospital leaders he was frustrated.

Seven years ago, he’d founded the Patient Safety Movement Foundation. And Kiani, who’d made a name for himself founding medical technology company Masimo, had been able to convince thousands of hospital leaders from around the globe to agree to an audacious goal: Get to zero preventable patient deaths by 2020.

To do that, they've released a collection of free tools for patients and hospitals to improve safety and prevent avoidable patient deaths. They've called for commitments. They've gathered annually to talk about solutions that are working.

But one year out from the goal to reach zero, Kiani said, speaking at the 7th Annual World Patient Safety, Science & Technology Summit, he had to concede healthcare is nowhere close.

Twenty years since the landmark Institute of Medicine report “To err is human” reported in 1999 that as many as 98,000 people die in U.S. hospitals due to preventable errors every year, figures show that number is likely closer to 200,000 deaths in the U.S. and 4.8 million worldwide.

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“Then frustration hit me. I’ve been thinking about the people who haven’t joined despite numerous attempts. I’m so frustrated by the prevalence of apathy, pettiness and minimalistic effort when people’s lives are at stake,” Kiani told the crowd. "Are we not going to put these mortal plights aside for the sake of our sisters and brothers?”

The problem won't truly get better until hospitals are forced to do something, he said.

Building the conversation

In a way, it is awkward.

Listening to highly produced presentations and networking in the wide hallways overlooking the Pacific Ocean was a collection of health professionals talking about a decidedly ugly topic. How do they convince leaders across healthcare to have an open and candid conversation about the industry's problem with preventable harms to their own customers?

That is just the point, organizers say: More organizations are becoming courageous enough to acknowledge the problem openly and deal with the issue transparently over the last seven years. They are becoming more willing to invest in solutions to eliminate the hospital-acquired infections, the medication errors, the missed indications of more serious conditions rather than accepting them as the cost of running a high-risk organization.

Now, they are trying to get more organizations to really get serious about actually seeing zero preventable patients deaths not as a goal, but as an attainable priority.

"The people here—that’s the choir. The question is, how do you get everyone else who doesn’t come to church to buy in?" said Steven Scheinman, M.D., who is the president and dean of the Geisinger Commonwealth School of Medicine.

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By the Patient Safety Movement Foundation’s count, more than 90,000 lives were saved in 2018 alone due to the efforts by 4,710 hospitals worldwide that have made commitments to patient safety and 89 healthcare technology companies that signed an open data pledge.

In all, 273,077 lives have been saved since the summit began in 2013, they said.

But there are still too many stories like those of attendee Michele Monserratt-Ramos, who lost her fiancé Lloyd Monserratt to a medical error during surgery that resulted in an infection. Only after Lloyd’s death did she learn his surgeon had been arrested multiple times for a serious drug addiction and that concerns had been raised about his performance with other surgeries.

She was unable to get a formal investigation of his case.

Listening at the conference, Monserratt-Ramos was frustrated. One one hand, it was good to see so many people taking the problem of patient harm in healthcare so seriously.

“It’s difficult. It’s very difficult,” she said. “Thirteen years after losing Lloyd, I lost my mother to sepsis. And I’d done everything possible to help her. I did everything and the emergency doctor still refused to admit her.”

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There is still a long way to go at many organizations. But creating a goal around zero patient harms has helped move the needle, said Dave Mayer, who is the executive director of the MedStar Institute for Quality and Safety and was named CEO of the Patient Safety Movement Foundation.

"A lot of people said 'Is he crazy? We look at aviation, we look at other industries. And it can’t be solved that quickly,'" Mayer said. "But I think it created an urgency that’s been lacking in the patient safety side of quality and safety."

Kiani is convinced the path forward needs to include legislation to incentivize hospitals to take the right steps to engineer high-reliability systems into a high-risk industry—and force organizations to be more transparent when things go wrong.

The idea of additional regulations in an already highly regulated industry is, unsurprisingly, one plenty of organizations have pushed hard against.

”Maybe legislation is not the answer. But how are we going to get everyone else involved?” Kiani said. “We need to do anything and everything we can to get to zero. We owe it to ourselves, we owe it to our patients. How do we know legislation won’t work if we don’t try it?”