Dear Citizens of the Great Lakes Bay Region, In 2016, Johns Hopkins released the findings from a large study which reviewed years of medical death data. The results estimated that 250,000 deaths per year occur in the United States due to medical error. Those estimates place medical error as the third leading cause of death in our country, right behind heart disease and cancer. For decades, our regional healthcare systems have been working to eliminate medical error, but as the Johns Hopkins study revealed, we have more work to do. Two years ago, the healthcare systems of our region aligned to create the THRIVE Patient Safety Taskforce. Our main focus became the elimination of preventable medical harm, with a timeline of achieving this outcome by 2025. As part of this goal, the THRIVE Patient Safety Taskforce committed to not only share publicly the existing level of healthcare harm in our region, but also the efforts already underway to achieve and ultimately sustain Zero Harm. Our regional data is as follows:
Total Harm Events in Calendar Year 2019: 484 (with breakdown as follows):
Mild or Minimum Temporary Harm: 401
Moderate Temporary or Permanent Harm: 52
Severe Temporary or Permanent Harm: 26
The Johns Hopkins data, when applied to our region, would suggest that somewhere between 300-700 deaths occur annually due to medical error. While our regional numbers might seem small, it is important to remember that the Johns Hopkins data includes all deaths attributable to medical error, not merely those deaths which occur in hospital settings and are identified using these standard tracking processes. Many additional causes of harm and death exist, such as those relating to inaccurate diagnoses or others caused by medication overload. We are working to eliminate all preventable harm both inside and outside our hospitals, but right now the most complete harm data which we have to share with the public comes exclusively from the inpatient setting. The regional inpatient hospitals (Ascension, Covenant, McLaren, and MidMichigan) are pursuing standards of excellence in their delivery of inpatient care. They employ robust patient safety processes to optimize the safety of all hospitalized patients, including daily safety huddles, dual patient authentication when administering medications, systematic assessment for breakdowns in safety protocols with subsequent protocol review and correction, peri-operative and operative improvements aimed at eliminating surgical errors, and physician-led case reviews where adverse outcomes are identified and addressed. These efforts are ongoing and ever evolving, and include many new and innovative approaches. Despite these efforts, we can do better. By creating the THRIVE Patient Safety Taskforce, we have built the sharing platform that will allow us to examine best practices and apply the newest safety science. In our commitment to accelerating the implementation of Zero Harm care, we also commit to building greater partnership with you, the wonderful people of our region. We look forward to listening to your ideas and partnering with you to discover new, innovative solutions for safety. Please know that we value your feedback, and that our sharing of the regional harm data is designed to stimulate and encourage important conversation on this topic. We know it is only together that we will usher in the day of true Zero Harm care for every citizen of the Great Lakes Bay Region. Respectfully,
Sasha P. Savage, M.D., Chair THRIVE Patient Safety Taskforce
Cathy Baase, M.D., THRIVE Senior Fellow
Barbara Bates, M.D., MBA, Medical Center Director, Aleda E. Lutz VA Medical Center
Jim Borin, Community Member
Norm Chapin, M.D., Chief Medical Officer – McLaren Health Care’s Bay and Thumb Regions
Sue Graham, MSA, BSN, RN, Nurse Executive – HealthSource Saginaw
Lee Gordon, Vice President Operations – Great Lakes Bay Health Centers
Clark Headrick, D.O., Chief Medical Officer – Ascension St. Mary’s Hospital, Standish and St. Joseph
Michael Sullivan, M.D., VP/Chief Medical Officer – Covenant HealthCare
Ellen Talbott, RN, MSN, CPHQ, President and CEO – McLaren Bay Special Care
Lydia Watson, M.D., Chief Medical Officer – MidMichigan Health
Thomas Veverka, M.D., MidMichigan Health
Great Lakes Bay Region Safety Data Q&A
What is included in the data of healthcare harm noted here?
This data is from the four acute care health systems (Ascension St. Mary’s, Covenant, McLaren Bay Region, MidMichigan Midland) only and it only represents harm within the context of hospitalization. This data does not include all of the healthcare delivery system sources.
Does this data include all the types of healthcare harm that could be happening?
No, these numbers are only the results of standard tracking systems for hospital-based errors that lead to harm. They do not include harm which may have occurred but would not be captured by these reporting systems. For example, this data does not include diagnostic errors which can be up to 40% of healthcare harm cases by some estimates. As noted in question 1, it also does not include healthcare harm that might occur in ambulatory care or in extended care facilities.
Is this data consistent with the research showing healthcare harm to be the third leading cause of death?
This data is a piece of the story for our region. It is an honest and accurate summary of the healthcare harm tracked with standard hospital-based tracking systems and processes. There are other sources of harm as noted in questions 1 and 2 which will not be in this summary. Studies which have demonstrated healthcare harm as the third leading cause of death collect that data from tracking systems and exhaustive examination of medical records which cover the entire healthcare delivery ecosystem.
How will we know if there is progress in reducing healthcare harm in our region given the pledge for zero harm?
First of all, we will continue to track and report the hospital-based harm and the trend will be clear. Second, we are taking on major areas which contribute to healthcare harm. In addition, we are tackling medication safety for seniors. We will be tracking the baseline and improvements on this project in medication safety and harm. This and other projects will give specific data and will allow tracking of improvement.
What can patients and families do to help reduce their chances of experiencing healthcare harm?
Patients and their families have a major role in reducing harm. Their input into their care is very important. Their information shared with healthcare providers helps get accurate diagnosis and manage treatment plans. Patients and families need to ask questions and pay attention since they will be able to catch things that could lead to harm through their involvement in the care. The general advice for patients is that Questions are the Answer!
What is the difference between the different levels of harmful events?
A full description and definition of harm levels with examples can be found here.