Patient safety is not improving: studies

Well, this is discouraging. Two recent studies indicate that, after a decade-long, nationwide campaign to make hospitals safer for patients, essentially no progress has been made.

A patient checking into a hospital today appears to face at least a one-in-four chance of coming to some degree of harm there.

A study published this week in the New England Journal of Medicine looked at the records of 2,341 patients discharged from 10 randomly selected hospitals in North Carolina, which was chosen because of that state's "high level of engagement in efforts to improve patient safety."

The study took place between January 2002 and December 2007. What it found was, in short, that "harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care," the report stated.

A total of 588 patients were injured — 25.1 percent of study subjects. Harm was caused by, in declining numbers, procedures, drugs, hospital-based infections, other therapies, tests, falls and other causes, the study found. Sixty-three percent of these injuries were deemed to have been preventable. Nine preventable errors resulted in death, and 13 in permanent damage.

In addition, a report from the U.S. Dept. of Health and Human Services released earlier this month documented the experiences of 780 randomly selected Medicare patients discharged from various hospitals in October of 2008.

About one in seven of these patients experienced "adverse events" — serious harm that comes to a patient as a result of medical care.

A second group of about the same size in the HHS study suffered "temporary harm," a transient injury like bedsores (here called "pressure ulcers") for example, or hypoglycemia. Twenty-seven percent of temporary harm events were caused by drugs.

Twenty-eight percent of patients who experienced more serious "adverse events" also suffered some temporary harm during the same hospital stay.

About 44 percent of all these events — adverse events and temporary harm — in the HHS study were deemed preventable — the result of errors, substandard care, or insufficient monitoring.

In 1999, the independent, not-for-profit Institute of Medicine published a report on hospital safety, "To Err is Human," which caused a sensation and produced a massive effort to improve protocols at hospitals across the country. The goal was to decrease errors by 50 percent over a five-year period.

"To Err is Human" asserted that as many as 98,000 patients die in hospitals each year because of medical error.

Commenting on the two discouraging new studies, the authors of the NEJM report on patient safety in North Carolina write, "All the findings about extent of harm should increase our commitment to prevent it."

How hospitals can promote breast-feeding

The Baby Friendly Hospital Initiative, an international program, has created a list of things birth facilities in the United States can do to optimize the chances that mothers will choose to breast-feed their babies.

Here are "The Ten Steps To Successful Breast-feeding," from BFHI USA:

    1. Have a written breast-feeding policy that is routinely communicated to all health-care staff.
    2. Train all health-care staff in skills necessary to implement this policy.
    3. Inform all pregnant women about the benefits and management of breast-feeding.
    4. Help mothers initiate breast-feeding within one hour of birth.
    5. Show mothers how to breast-feed and how to maintain lactation, even if they are separated from their infants.
    6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
    7. Practice “rooming in” — allow mothers and infants to remain together 24 hours a day.
    8. Encourage breast-feeding on demand.
    9. Give no pacifiers or artificial nipples to breast-feeding infants.
    10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.

The BFHI is underwritten by the World Health Organization and the United Nations Children's Fund (UNICEF).

Calvin Trillin’s rule of thumb

The writer-humorist Calvin Trillin has said that his idea of alternative medicine is a doctor who was not trained at Johns Hopkins School of Medicine in Baltimore, Md. To the extent that Johns Hopkins is considered the gold standard of medical care, the institution's excellence owes much to its beginnings.

Johns Hopkins

Johns Hopkins

Johns Hopkins, the son of prosperous Maryland Quakers (his first name was his great-grandmother's maiden name), made a fortune investing in America's first important railroad, the Baltimore and Ohio.

In 1867, he established funds for a university and hospital to bear his name, and when he died in 1873, he left $7 million for the two institutions, the largest gift ever bequeathed in America up to that point.

John Shaw Billings, a major in the U.S. army who had distinguished himself as a surgeon in the Civil War, and for his writings on, and criticism of, the care of sick and injured soldiers, created a plan for the hospital that reflected his keen interest in infrastructure, and his assiduous research into the best hospital designs in Europe.

John Shaw Billings

John Shaw Billings

For example, he had the hospital wired for electricity years before it was on the grid. Johns Hopkins was also the first hospital in the country with central heating.

The measures Billings took to prevent the spread of disease throughout the hospital ranged from the horizonal layout of the wards, to the decision not to include elevators, to the elaborate ventilation system that prevented patients from breathing each other's air.

Billings also came up with the idea of a four-year medical school and favored a tough curriculum to weed out all but the best candidates. According the John Hopkins Medicine website, history has not given this remarkable man his due.

Getting the hospital up and running took 12 years. Even though many of the revolutionary ideas the institution embodied were his, Billings decided it was time to move on. He ended his career as director of the New York Public Library.

Johns Hopkins Hospital

An early view of the hospital

Opened in 1889, Johns Hopkins Hospital had 17 buildings (three of which remain today, part of a 22-acre campus) and cost $2 million.

Johns Hopkins Hospital had no religious affiliation, which made some people nervous. In 1896, William Wallace Spence, a wealthy Baltimore businessmen, donated a large statue of Jesus Christ that still stands in the rotunda of the Billings Administration Building.

Can the VBAC make a comeback?

Let's interrupt our Women's History Month programming to consider the news. The National Institutes of Health today begins a three-day session on vaginal birth after Caesarean, a hot topic, given that this practice, which was commonplace 15 years ago, has become scarce in the United States, at the same time that the Caesarean section accounts for nearly one-third of American births.

The VBAC has some passionate champions. While it isn't for everyone, it can work for many mothers, enabling them to avoid major surgery, and perhaps also to enjoy birth as they have always imagined it. The VBAC's decline has attended a steady rise in reliance on the Caesarean section, in part because the VBAC does carry a risk of rupture to the uterus, which can be life-threatening.

So it will be exciting to see what comes out of this conference, which aims to bring the best research available to bear on determining the safety and efficacy of the practice.

The VBAC is also one subject of an article by Denise Grady in the New York Times on Sunday, about a hospital in Tuba City, Ariz., where 32 percent of women who previously had Caesarean sections delivered vaginally, compared with a national average of less than 10 percent.

The rate of Caesarean births at the Tuba City Regional Health Care Corp., where about 500 babies are born a year, is 13.5 percent, less than half the national rate of 31.8 percent. The hospital is run by the Navajo Nation and is partially funded by the Indian Health Service, and it largely serves a Native American population.

What I love about Grady's account is how well this small, poor hospital appears to be doing in addressing one of the major tensions in the modern birth story -- how to keep the blissful experience of childbirth from being swamped by the technology that has been developed to keep it safe.