In 1999, the Institute of Medicine (now called the National Academy of Medicine) dropped a bombshell on the healthcare industry.
The academy published the results of its study on patient safety, To Err is Human, which reported that 40,000 patients die each year in America’s hospitals because of preventable medical errors.
The publication defined a preventable error as “ ... the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”
One basic conclusion also reported was that preventable medical errors were normally the product of faulty systems, processes, and conditions. These factors tend to facilitate the making of these errors or failing to prevent them.
The results of this study provided the impetus for the Business Roundtable and several other organizations to form the Leapfrog Group. The name designates a hospital taking great leaps forward in promoting patient safety. One “giant leap forward” was reducing the rate of early elective deliveries. In just five years, Leapfrog reduced these early deliveries from a national rate of 17% to 2.8%.
The basic thrust of Leapfrog is to promote quality and safety in healthcare by setting standards and having hospitals report to these standards voluntarily.
The survey is constructed in several parts: (1) Profile and demographics of the hospital (2) Basic hospital information, such as a hospital’s bed size, admissions, teaching status, and ICUs operated (3) Medication safety, the hospital’s use of Computerized Physician Order Entry to prevent medication ordering errors and adverse drug events as well as processes the hospital has in place to prevent medication errors, including barcode medication administration and medication reconciliation (4) Inpatient surgery; the hospital and surgeon volume for eight high-risk procedures and surgical appropriateness criteria to prevent unnecessary procedures (5) Maternity care; questions about elective delivery, cesarean birth, or high-risk deliveries (6) Physician staffing; questions about the staffing structure of the hospital’s pediatric and adult general medical and/or surgical ICUs and neuro ICUs (7) Managing serious events, questions about the hospital’s response to “Never Events” (8) Pediatric care, questions about patient experience.
The results of the survey are published twice a year, once in the fall and once in the spring. Letter grades, A, B, C, D and F, are assigned to each reporting acute care hospital. This survey is the country’s only report focused entirely on patient safety — preventable errors, accidents, injuries, and infections.
The 2019 fall survey results on a national basis indicated:
• More than 2,600 hospitals were graded with the breakdown: 33% earned an A; 25% earned a B; 34% earned a C; 8% a D and just under 1% an F” The five states with the highest percentages of “A” hospitals were: Maine (59%), Utah (56%), Virginia (56%), Oregon (48%) and North Carolina (47%)
• There were no “A” hospitals in three states: Wyoming, Alaska and North Dakota • Notably, 36 hospitals nationwide have achieved an “A” in every grading update since the launch of the Safety Grade in spring 2012.
The fall results in Arizona ranged from A to D with no hospital being rated a F. Only one hospital received a D rating , Flagstaff Medical Center; all others were A, B, or C. This Fall, Arizona ranked 32nd in terms of the percentage of A ratings received, 26.09% of Arizona’s hospitals. This was an improvement over the Spring’s results, where Arizona ranked 34th, with only 20% of Arizona’s hospitals receiving an A rating.
Tucson hospitals basically received satisfactory safety ratings. A-rated hospitals were Banner University Medical Center South and Northwest Medical Center; B rated hospitals were Carondelet St Josephs and St Mary’s as well as Tucson Medical Center; Banner University Medical Center received a C rating.
And what about Sierra Vista and Canyon Vista Medical Center?...Stay tuned...that information will be in my next column!