Refocusing on patient safety 

  • Mary Chris Jaklevic, independent journalist, AHCJ core topic leader/patient safety
  • Tejal Gandhi, chief safety and transformation officer at Press Ganey Associates, LLC
  • Ruth Ann Dorrill, office of Inspector General at the U.S. Department of Health and Human Services
  • Martin J. Hatlie, founding member of Patients for Patient Safety US

By  Adrianna Rodriguez

More than 250,000 patients are harmed in U.S. hospital events despite more than a decade of research raising the alarm, according to panelists during a Thursday morning session, 

Tejal Gandhi, M.D., Chief Safety and Transformation Officer at Press Ganey Associates, argued some progress was made in patient safety but more must be done to achieve the aspiration “zero harm” goal. One way to do this would be to broaden the definition of “harm” to include both patient and hospital providers physical, mental, and emotional health. As hospital leaders work towards this goal, Gandhi also argued they should also be addressing inequities along the way because “we won’t address all the harms unless we address the inequities that are occurring.” 

“If you chase perfection, you can catch excellence,” she said. “What can hospital leaders be doing despite all the pressures… they’re going to be the ones that are going to be leading the way to an aspirational zero harm goal.” 

Ruth Ann Dorrill from the Office of Inspector General at the U.S. Department of Health and Human Services, showed journalists how adverse events in hospitals has gone through little change in the past ten years. In October 2008 alone, HHS estimated about 267,000 patients were harmed in hospital adverse events where 44% were preventable, according to a study published in November 2010. Another HHS study ten years later found more than 258,000 patients were harmed in October 2018 where 46% were considered preventable. 

Most events were caused by medications followed by patient care and surgery. Nearly three-quarters of events led of prolonged care that resulted in a longer hospital stay, more care, transfer to another facility or subsequent hospital admission. 

The report also found only 5% of the events were captured by the Centers for Medicare & Medicaid Services. 

“Most of the time, there was no accountability for the harm that was occurring,” she said. “Our key takeaway here is that high rates of harm still persist.” 

Martin J. Hatlie, founding member of Patients for Patient Safety U.S., pushed back against the idea that progress has been made to reduce patient safety. 

“We’ve not embedded this as a priority in the health care system and were very, very frustrated with this,” he said. 

He argued the federal government must take more of an active role on patient safety and create an agency that will manage oversight and enforcement, and ultimately hold accountability. 

Hatlie also highlighted transparency a public reporting, arguing organizations should be sharing patient safety data. He also called on more patient and family engagement to create a sense of urgency. 

“There’s nothing like the lived experience of having someone harmed in a way that’s preventable,” he said. 

Adrianna Rodriguez is a health reporter for USA Today based out of the Washington, D.C. area.