MedicalResearch.com Interview wth:
Kevin Kavanagh, MD, MS
Board Chairman of Health Watch USA
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The genesis of our study was a desire to respond to a keynote speech at a major national patient safety conference which seemed to mitigate the problem of preventable hospital mortality in the United States.
Our main finding is that there is credible evidence indicating that the preventable hospital mortality rate is more than 160,000 per year. When one considers the events which were not captured, and that we did not count diagnostic errors or post-discharge presentation of events, this number can be projected to approximate or exceed 200,000.
MedicalResearch.com: What should readers take away from your report?
Response: The most important message is that there needs to be a change in the culture of health care. The patient context needs to be dissociated from preventable medical errors and preventable hospital mortality. The commission of an error should not be mitigated because of the patient’s age, sickness or life choices. If an airline crashes with 380 souls on board, does the airline industry report 380 deaths or only 370 because 10 passengers were elderly and were going to die soon anyway?
Another issue with those who mitigate the problem of preventable mortality is that they often use studies from foreign nations to bolster their arguments. One cannot extrapolate the performance of integrated nationalized healthcare systems found in Canada and Europe to the disjointed non-centralized system in the United States which is composed of a conglomeration of non-profit, for-profit and government facilities.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: Many try to make the argument that current estimates of preventable hospital mortality are too high because they are based on flawed data. However, the data overall tends to underestimate events, so if anything, the current estimates of hospital mortality are too low. Better data and more complete reporting are definitely needed. This will help drive change. I am a firm believer that what is measured is managed. In addition, clear standards need to be set, and perhaps regulations to assure proper staffing and patient safety.
MedicalResearch.com: Is there anything else you would like to add? Any disclosures?
Response: Patient advocates are not asking for the prevention of adverse events for which solutions are not known, but for the implementation of known interventions to prevent adverse events. A firm commitment to foster a culture of safety and to invest in adequate staffing is needed. We would not tolerate a single preventable airline crash as an accepted status quo. The same should be true for preventable hospital mortality.
Disclosure: Kevin Kavanagh, MD, MS is Board Chairman of Health Watch USA, a non-profit 501C3 organization. Dr. Kevin Kavanagh has received partial conference attendance and meeting support from the U.S. Dept. of Health and Human Services, National Quality Forum, National Patient Safety Foundation (NPSF), The Leapfrog Group, National Center for Health Research (PCORI supported) and Consumer Union. He has served on the Centers for Medicare and Medicaid Services’ Technical Expert Panel for Hospital Acquired Conditions, and most recently on the Strategic Working Group for AHRQ for quality indicators and is an Associate Editor for the Journal of Patient Safety. |
Citation: Kavanagh KT, Saman DM, Bartel R, Westerman K. Estimating hospital-related deaths due to medical error: A perspective from patient advocates. Journal of Patient Safety. Published online February 9, 2017. doi: 10.1097/PTS.0000000000000364
YouTube video on preventable hospital mortality: https://youtu.be/ktjh8EmO9QU
Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.
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