The numbers were startling. The health care community sat up and noticed when the Institute of Medicine, the health arm of the National Academy of Sciences, released the report “To Err is Human” 15 years ago.
We learned from that report that medical errors are one of the leading causes of death and disability in the United States. In 1999, the IOM estimated nearly 100,000 annual deaths from health care-related error – the equivalent of a jumbo jet crash with no survivors every single day of the year! Non-fatal medical errors that result in serious harm are estimated to be 10 to 20 times higher. Stunning, isn’t it?
Since that initial report, a patient safety movement has led to innovative strategies, technology and training to try to turn these staggering numbers around. Health care providers and patient safety experts pitched in to design new processes and tools such as surgical checklists, computerized order entry and barcoding of medications, electronic medical records, treatment protocols, teamwork training and incident reporting systems.
But the news has not improved as much as anyone had hoped. Using an updated methodology, recent figures suggest that the number of premature deaths from patient harm associated with hospital care may actually be as high as 400,000 per year. Of course, health care occurs in many other settings, and estimates of patient safety error in medical offices, surgery centers, nursing facilities and other sites are no less alarming.
Medical harm includes surgical and medication error, health care-associated infection and errors that occur during times of transition or handoffs, as well as teamwork, documentation and communication error.
Diagnostic error is a hot topic right now in patient safety circles. One piece of the puzzle related to diagnostic error concerns failure to act on clinically significant test results.
Communication failures related to test results are frequent and potentially devastating. Systemic solutions such as information management systems look to improve testing, lab and results management workflow. This is no small task: One commonly cited study reports that physicians spend more than 70 minutes each day managing test results and review more than 1,000 diagnostic test results each week.
Lack of follow-up to abnormal test results is responsible for nearly a quarter of all medical errors that happen in the outpatient setting. These common and avoidable errors can be reduced by encouraging the health care consumer to participate in the communication of test results.
Over your lifetime, you have probably heard more than once, if you don’t hear back from your health care provider, you should assume that all is well, or “no news is good news.” It is time to bury that saying. A much safer approach is to encourage you, the patient, to take charge of your test results and know that no news is really only no news.
On Sept. 5, a highly energized group of interdisciplinary health care professionals and patient safety advocates met at the University of Southern Maine for the fifth annual Patient Safety Academy. We shared our knowledge, strategies and concerns. We agreed to promote a “No News is No News” campaign here in Maine. Representing organizations across the state, it is possible to promote or “crowdsource” an inherently simple patient safety improvement idea.
Maine Patient Safety Academy attendees will be encouraging their organizations to provide follow-up instructions to patients at the time of medical tests.
For example, a small “No News is No News” card could encourage consumers to call for test results by a specific date if they have not heard from their provider. As consumers, we should also make sure that we know specifically what tests have been performed. This information will help us participate in the follow-up process if needed.
It is time to put some patient power behind these test miscommunication errors. Whether you receive a “No News is No News” card or some other document with similar information, know that you can help protect yourself from unintentional harm by calling for your results if you have not received them by the projected date.
This simple step can help stem the tide of preventable error. After all, no news is just no news.
— Special to the Press Herald
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