Medical errors are not new news. The high number of deaths due to preventable medical errors made the headlines in 1999 with the publication of the Institute of Medicine’s To Err is Human report. Since then, there have been numerous other studies on the same topic, nearly all saying that the 1999 report underestimated the magnitude of the problem. Most recently, a 2016 study published in BMJ1 estimated that medical errors may be the third leading cause of death in the United States, second only to cancer and heart disease. Medical errors are not just an American tragedy. That same study also noted that the number of preventable deaths are likely underestimated in Canada, the United Kingdom and possibly many other countries due to a lack of information as to whether a medical error contributed to a patient’s death.
What’s even more alarming is that despite numerous initiatives to increase the safety of hospitals, there has been relatively little improvement beyond a reduction in the number of hospital acquired infections. Why is that the case? One answer is that medical errors are a systemic issue, resulting from care being delivered in what is essentially an unsafe environment. Isolated interventions alone are not enough. They need to be part of an overall effort to transform the healthcare delivery environment in a manner that reduces the likelihood that an adverse event could occur in the first place. The supply chain can play an important role in this regard, which was the message delivered by Anne Snowdon, RN, PhD, to those attending the HIMSS Supply Chain Special Interest group meeting at the annual HIMSS conference in Orlando in February.
In her speech, Dr. Snowdon shared some real-life examples of issues that could have been avoided with a supply chain infrastructure that supports better visibility into the products, people and processes involved in patient care. The examples included:
- A spine surgeon who used off-label screws on thousands of patients, only to have the screws rust after implantation.
- A Michigan hospital that was unable to identify the multitude of patients who may have been treated with syringes that were recalled because the supplier could not guarantee sterility.
- The physician who was unable to determine if a stent implanted in a patient’s bile duct contained metal, which would preclude the patient having an MRI, even though the stent was implanted at the same hospital where the patient was being treated.
In each of these cases, the problems could have been avoided had the products been labeled with GS1 standard identifiers and had the hospitals captured the data about the products used in patient care in the patients’ medical records.
Dr. Snowdon is a professor of entrepreneurship and strategy at the Odette School of Business at the University of Windsor and the chair of the World Health Innovation Network (WIN), which seeks to accelerate health system transformation to improve economic and clinical performance. In 2016, WIN published a report on the value proposition of greater visibility for healthcare systems. 2 The paper references a report3 by the Canadian Institute of Health Policy, Management and Evaluation that sought to understand why so little progress has been made in improving patient safety, not only in Canada but around the world. One of the more alarming factors noted in the report was both leadership and staff acceptance of less than optimum environments for delivering patient care. One referenced study found that equipment was either missing or faulty in one out of three operations, representing a threat to patient safety and adding work for clinical staff.
Patient safety interventions also add work for nurses and other clinicians. That same report referenced a study that found nurses had to spend an extra 115 minutes per patient per day on activities associated with preventing ventilator-associated pneumonia. But the likelihood of these steps being taken is directly related to whether the work can be integrated into daily practice and if those required to do the work believe it will really make a difference.
This is one of the challenges being addressed in healthcare systems in the U.S. as they prepare for upcoming regulations requiring capture of unique device identifiers (UDIs) for implantable devices in electronic health records. Members of the AHRMM Learning UDI Community work group focused on device capture are looking at how to make it easier for nurses to scan UDI-compliant barcodes at the point of use. Research I recently completed for graduate school uncovered a disconnect between hospital supply chain professionals recommending the use of stacked barcodes (due to the lack of scanners that could read concatenated or 2D barcodes) and resulting confusion for nurses who did not know which barcode to scan. This speaks to the importance of supply chain and clinical staff discussing why barcode scanning is needed and then working together to find a solution that achieves the goal with as little disruption as possible. Even better, if supply chain can help automate processes to minimize how much time clinicians have to spend on supply-related tasks, caregivers will have more time to spend with patients in an optimum environment for all involved.
1. Makary MA, Daniel M. Medical Error- the third leading cause of death in the US. BMJ. 2016; 353: i2139.
2. Snowdon A, Alessi C. Visibility: The New Value Proposition for Health Systems. 2016.
3. Baker GR, Black G. Beyond the Quick Fix: Strategies for Improving Patient Safety. 2015. Available at http://ihpme.utoronto.ca/wp-content/uploads/2015/11/Beyond-the-Quick-Fix-Baker-2015.pdf.