Opinion: U.S. Medicine Should Step Up Error Prevention
The U.S. could "substantially improve the safety of medicine" and reduce expenses related to medical error by billions of dollars annually by creating "an independent agency charged with identifying and eliminating the causes of medical error" similar to the National Transportation Safety Board, argues Jim Hall, former NTSB chair and managing partner of a health care and safety consulting firm.
July 29, 2009
First, Make No Mistakes
By JIM HALL
IN the health care debate, there is one thing we can all agree on: the importance of reducing unnecessary deaths in medicine. Medical error causes tens of thousands of deaths each year that could be prevented by known techniques and technologies. And all errors, even those that are not fatal, are costly: 10 years ago, the Institute of Medicine estimated that the effects of medical error accounted for $17 billion to $29 billion in domestic health care spending, and the error rate has not declined since then.
What makes the problem all the more frustrating is that we could address it with little cost to the American taxpayer. Because American medicine accepts error as an inevitable consequence of treatment, our hospitals, insurers and government do little to respond to unnecessary deaths. If we are to address the problem in a serious manner, we must first change this culture.
As a former chairman of the National Transportation Safety Board, I am familiar with the deadly consequences of human error. However, because that agency views every transportation death as a preventable occurrence, our roads, rails and skies enjoy an unparalleled level of safety. After any significant accident, the board undertakes an extensive investigation, and makes recommendations to the parties involved to ensure that such an accident never recurs. While the transportation safety board has no regulatory authority, its recommendations are viewed by the industry and the public as unbiased and therefore credible, and federal regulators usually act with haste to address them.
Such an investigative body could substantially improve the safety of medicine in the United States. While it surely could not investigate every individual instance of error, it could address many well-known maladies. Hospital-acquired infections, for instance, affect millions of Americans each year. A National Medical Safety Board would collect regional data on the problem, paying particular attention to hospitals with high incidences of infection. It would then determine preventive measures and make recommendations to state and federal regulators, hospitals and health care officials.
When such a board discovered new solutions to old problems, their advice would have the credibility that comes with independent investigation. In some cases, the board might recommend practices that doctors are already aware of, but for some reason do not employ; the public awareness that would follow would pressure hospitals to do better.
These benefits could come at a minuscule cost to taxpayers. The National Transportation Safety Board costs each citizen approximately 25 cents per year. This is a small price for an agency that has eliminated midair plane collisions, persuaded Americans to put children in the back seats of cars instead of the front and prevented deaths in every category of transportation. Given health care’s notorious struggles with rising prices, this is a cost-saving opportunity the industry cannot afford to overlook.
An overhaul of our national health care system is at hand and with it a crucial opportunity to improve medical safety. The Obama administration should take a lesson from the transportation safety board’s successes and establish an independent agency charged with identifying and eliminating the causes of medical error. Such a move would save money by saving lives and would ensure that our nation’s health care system is equipped to provide the safest medical care possible.
Jim Hall, the chairman of the National Transportation Safety Board from 1994 to 2001, is the managing partner of a health care and safety consulting firm.