Patient Safety Initiatives Get Mixed Report

In the first long-term study of its kind, RWJF Scholar finds that hospital patient safety initiatives are making childbirth safer, but not all surgeries.

    • February 5, 2012

In recent decades, hospitals have put a new emphasis on improving patient safety to reduce preventable complications. But have these efforts actually worked?

The answer, according to a groundbreaking new study, is ‘Yes and No.’

So says John Morton, MD, MPH, an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1995-1997) and the senior author of the first longitudinal study to examine national trends in patient safety. In the study, he and his colleagues found significant improvements in patient safety as a result of initiatives in some areas—but worrisome declines in others.

“For the majority of patients, safety is improving,” he said. “But there are still some areas where things are not getting better. Is the glass half-full or half-empty? It depends on your perspective. Certainly from a patient perspective, we want to make sure our glass is full.”

Hospitals have come under increasing pressure to improve patient safety and reduce costs in the wake of reports documenting tens of thousands of preventable medical errors that take a terrible human and financial toll. Preventable medical errors, in fact, exceed deaths attributable to motor-vehicle accidents, breast cancer and AIDS, according to a 1999 report released by the Institute of Medicine.

These errors contribute to worse outcomes and higher costs. In 2008, the Centers for Medicare and Medicaid Services restricted reimbursements for hospital-induced complications.

Hospitals have implemented major initiatives designed to improve patient safety to save lives and money in recent decades. These included hiring more providers to work in Intensive Care Units, lessening demands on medical residents and implementing computerized order entry systems.

Morton and his colleagues conducted the study to better understand if these kinds of initiatives have been effective in improving patient safety. It is part of a special issue of Health Services Research on "Bridging the Gap Between Research and Health Policy" that features research articles from current and former RWJF Clinical Scholars. The print edition was published in February.

For the study, Morton and his colleagues tracked 15 patient safety indicators at more than 1,000 hospitals across the country from 1998 to 2007. They found that safety improved significantly in seven of those indicators, mainly in the field of obstetrics, but declined in other areas, particularly in surgery.

Childbirth is Safer

“The big success story is in obstetrics,” Morton said. “Childbirth became much safer over the last decade.”

Indeed, Morton and his colleagues found improved safety in the areas of birth and obstetric trauma injuries to newborns and mothers.

Possible reasons for the improvements include efforts to employ more obstetricians who specialize in high-risk pregnancies; better surveillance of high-risk patients; more vaginal deliveries after previous C-section births; fewer deliveries assisted by instruments such as vacuums and forceps; and technological advances, Morton said.

“You take it all in combination and they’re obviously doing something right,” Morton said.

There was good news for other non-obstetric patients as well; the scholars found fewer deaths after complications (failure to rescue), fewer post-operative hip fractures, fewer collapsed lungs, and lower rates of postoperative wound dehiscence (when a wound falls apart). Possible factors contributing to the improvement include better-rested physicians, better training of code-teams, implementation of rapid response teams and increasing utilization of new technology like laparoscopy, which avoids large incisions.

Surgeries, on the other hand, have considerable room for improvement. The study found declines in patient safety after surgery in indicators such as blood clots in the lungs or deep veins; unanticipated body chemistry changes; toxic response to infection; and respiratory failure. The study also showed declines in patient safety in the areas of infections; bed sores; and accidental punctures or lacerations.

Possible reasons for declines in safety in these areas include the increasing prevalence of surgery and a population that is living longer with more chronic conditions, which may lead to sicker patients seeking surgery, Morton said. In addition, increasing rates of early patient discharge, higher patient volumes and decreased staffing could also be contributing factors, the study concluded.

Morton said, “There is no question that when it comes to surgical safety, we need to do better. This study gives us a blueprint for quality improvement prioritization.”

One way to do that is to standardize patient safety interventions that are proven to be effective and to refer high-risk patients needing complicated procedures to centers that specialize in high-risk surgeries, Morton said. Incentives to reward surgeons who practice high-quality care and more studies of patient safety practices could also help improve safety, he added.

“We’ve got to keep our eye on the prize,” he said. “We’re doing a lot of things to suggest we can improve quality, but we really have got to ensure what we’re doing is making a difference for our patients.”