COMMENTARY

Being a Patient Is Still Hazardous to Your Health

How safe is it to be a patient in the United States today? Compared with what? Being a patient in another country? It depends on the country. Compared with not being a patient? Not very safe at all.

Being a patient can be hazardous to your health. I first recognized that fact at the autopsy table even before medical school. A young child in Tuscaloosa, Alabama, dead after a tonsillectomy/adenoidectomy in 1953, asphyxiated on her own blood. As a pathology resident in San Antonio from 1958 to 1962, I autopsied many patients with cancer who were killed by their chemotherapy treatment, not by their cancer.

In 1976, when my friend and colleague Don Harper Mills, MD, JD, learned from me that I was moving to Sacramento to become professor and chair of pathology at UC Davis, he cautioned me that the Sacramento Medical Center (SMC, a county hospital) was a dangerous hospital. An expert in medical malpractice prevention and defense, Don had just completed a large review study of hospital records commissioned by the California Medical Association about "potentially compensable events" — medical injuries for which a jury might award malpractice money compensation. His examination of more than 20,000 patient charts from 23 California hospitals in 1974 found that nearly 5% of patients had suffered compensable injuries during their hospitalizations. I thanked him and said that the ongoing transition of the SMC to a University of California Medical Center had identified the improvement of quality of care as a key goal.

In 1994, Professor Lucian Leape approached me in the hallway of the Harvard School of Public Health about a paper he had written called "Error in Medicine" that had been rejected by The New England Journal of Medicine without outside review. He thought it was important and hoped to get it published in a good journal. With my background, I expressed immediate interest, read the manuscript, and invited submission to the Journal of the American Medical Association (JAMA).

After formal review, revision, and acceptance at JAMA, I tried to make sure the medical profession would see the paper and take it seriously. However, I also hoped that the public media and general public would not see it — at least not until efforts were made to better identify the safety problems and initiate solutions. Frankly, I was afraid of the splash and the backlash. So I tried to bury the study in a media dead spot, Christmas week. Alas, David Baron of NPR in Boston recognized its importance and reported on it, followed by The Washington Post and many others. The proverbial s#$% hit the fan and many AMA members called for my scalp (once again).

To its enormous credit, the AMA turned this problem into an opportunity and in 1997 created the National Patient Safety Foundation, which merged with the Institute for Healthcare Improvement in 2017.

Lucian Leape must be considered one of — if not the — founder of the patient safety movement. He tells the story in substantial depth and with much flavor in his brand-new, 450-page book, Making Healthcare Safe: The Story of the Patient Safety Movement. It is richly referenced, carefully documented, nicely illustrated, and published by Springer, but available open access via Creative Commons. Many early supporters of the patient safety movement are deservedly credited, none more so than the Institute of Medicine (now the National Academy of Medicine) which, under Ken Shine's leadership, published landmark safety reports beginning with To Err is Human in 1999. Dr Don Berwick, former administrator of the Centers for Medicare & Medicaid Services and CEO of the Institute for Healthcare Improvement, wrote the insightful foreword to Leape's book in which he cautions, "The work of safety improvement, indeed, is hardly begun."

So, are we more safe? I don't know. Have we created the necessary "culture of safety"? I would have to answer with a resounding NO.

As long as the medical (meaning, non-forensic) autopsy remains vanishingly rare in most American hospitals, not only will we not know, but worse, the culture does not want to know. My question to the hospital industry has always been, "How do you evaluate the quality of care given to your sickest patients, the ones who die?" Until the instant answer is autopsy and medical mortality review, there will be no culture of safety.

And for the non-dead, imagine consulting an American physician today with the principal complaint of pain, and almost always walking out of the doctor's office without a prescription for some opioid. Any exposure to an opioid begins an upward linear likelihood of addiction. While we have made major progress since its catastrophic peak in 2012, in 2019 there were still 46 opioid prescriptions per 100 Americans, with huge geographic variance. Far too many. Unsafe at any dose.

We are a long way from a medical culture of safety. But thankfully it remains a work in active progress. Thank you, Lucian.

That's my opinion. I'm Dr George Lundberg, at large for Medscape.

George Lundberg, MD, is contributing editor at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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