Detecting Clinical Risk to Improve Patient Safety.

September 19, 2023

When it comes to patient safety, good intentions aren’t enough.

Three ways to predict and prevent medical errors.

As the ASHRM Annual Conference draws near, patient safety takes center stage in our endeavors at Preverity. Medical error rates remain alarmingly high despite advancements in procedures and the unwavering dedication of healthcare providers and systems. Tragically, preventable medical errors often result in devastating outcomes, significantly burdening healthcare costs. Our commitment to addressing these challenges is unwavering as we strive for a safer, more efficient healthcare system.

I look at common conditions in today’s blog that can lead to avoidable errors. Then, I walk through three examples that show how robust data and advanced analytics provide insights to help risk managers predict and prevent medical errors.

The extent of the challenge.

Medical errors are a common and preventable issue in the healthcare industry. They come in multiple forms, including diagnostic, surgical, medication, devices and equipment, systems failures, infections, falls and healthcare technology. Despite many years in healthcare, the number and impact of medical errors still surprises me. 

• According to the NIH, approximately 400,000 hospitalized patients are affected by medical errors yearly, resulting in around 100,000 deaths.
• Financial costs associated with medical errors can range from $4 billion to $20 billion annually.
• Further research has revealed that 13% of hospitalized Medicare patients experience preventable harm during their hospital stay.

According to recent reviews of medical records, many patients continue to get hurt. The Department of Health and Human Services found that 13% of hospitalized Medicare patients experienced preventable harm during a hospital stay.

Why are medical errors so persistent?

Two key issues stand out to me. Firstly, healthcare systems have faced challenges in sharing information as well as establishing benchmarks and measuring results for procedures and outcomes. Safety experts at Johns Hopkins highlight that advancements in surgical procedures haven’t always been effectively disseminated across institutions. “There hasn’t been enough effort to be more systematic.”

Additionally, medicine encounters distinct obstacles when addressing “failure.” The National Institutes of Health (NIH) identifies fear, shame, and secrecy as prevalent factors. Addressing these challenges and fostering a culture of openness and learning within the medical community is crucial.

“Clinicians equate errors with failure, a breach of public trust, and harming patients despite their mandate to ‘first do no harm.’ Despite concern for safety, fear of punishment makes healthcare professionals reluctant to report errors. Unfortunately, failing to report increases the likelihood of serious patient harm. Rigid policies create an adversarial environment where staff hesitate to document and report an error, feeding an evolving cycle of medical errors.  When these errors do come to light, they can tarnish the reputation of the healthcare institution and the workers.”

How data can predict and prevent medical errors.

Well-intentioned professionals can and do make mistakes. Unfortunately, fear of punishment can discourage healthcare professionals from reporting errors. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident.

That’s where Preverity can make the difference. We help you identify clinical practices you can encourage, modify or limit to enhance patient safety. We empower risk managers to have conversations about preventable risks before errors occur. By analyzing the US’s largest clinical data repository focused on risk, Preverity shows healthcare leaders how their systems, physicians, and clinical practices compare nationwide. As a neutral third party, we offer guidelines based on peer activities at regional and national levels. We draw back the curtain to show why falling above or below the average for a given practice or procedure may increase the risk of a malpractice event.

Prevention is better than cure.

Change is hard. However, we have observed that doctors armed with accurate information can effectively modify their behavior. Applying data-driven feedback on specific clinical activities helps physicians to see how their decisions compare to their peers, ultimately enhancing patient safety.

Let’s explore three examples where data plays a crucial role in preventing medical errors in the emergency department, the delivery room, and upon patient discharge.

Detecting missed diagnoses in the emergency department.

A hospital admission within a few days of an emergency room visit suggests a potential missed diagnosis in the ED. These events can easily go unnoticed, particularly if the patient seeks care at a different facility. Identifying these patterns can initiate discussions that enhance patient safety and improve outcomes.

Addressing obstetrical adverse events by identifying riskier procedures.

Deliveries with complications are a leading cause of malpractice litigation. One potentially risky procedure is vaginal birth after cesarean (VBAC). Because VBACs can be riskier, understanding when and how they are performed can improve patient safety.

Preventing potential opiate abuse by monitoring discharge prescriptions.

Opiate abuse receives considerable attention, and most health systems have policies in place for prescribing opiates, particularly around Emergency Department visits. ED physicians who have consulted with Preverity recommend that patients need to be directed back to their primary care physicians if they require more than the minimum number of opiates to manage pain.   Prescribing too much without the clinical infrastructure in place to manage the patient creates the risk of abuse and addiction.

Preverity’s patient safety monitoring system utilizes clinical data from 80% of the US market, enabling the identification of behaviors and standards that correlate with improved safety and patient outcomes. These insights empower financial executives, chief medical officers, and risk managers to benchmark practices and pinpoint strategies that enhance patient safety.

If you’d like to hear more about detecting clinical risk to improve patient safety, contact me directly or stop by our booth [806] at ASHRM (Oct. 1 – 4).

Kind Regards,

Gene Boerger, President and Chief Operating Officer

615-982-7076 | info@preverity.com