Maryn McKenna

Journalist and Author

  • Contact
  • Blog
  • Speaking and Teaching
  • Audio & Video
    • Audio
    • Video
  • Journalism
    • Articles
    • Past Newspaper Work
  • Books
    • Big Chicken
    • SuperBug
    • Beating Back the Devil
  • Bio
  • Home

10 years but little progress on patient safety

June 8, 2009 By Maryn Leave a Comment

Constant readers, I’ve been away for a week — trying to get my breath back now that the chaos of the novel H1N1/swine flu is diminishing — and so I’ve missed a lot of news. Over this week, I’ll try to catch you up on it.

First up: Some of you know that, 10 years ago, the nonpartisan, Congressionally-chartered Institute of Medicine (IOM) published a groundbreaking report called To Err is Human (html here, pdf here) that jump-started examination of medical quality in the United States. That report said:

Health care in the United States is not as safe as it should be–and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented…
Preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. …
Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. (To Err is Human, executive summary)

The report prompted a huge groundswell of legislative interest and patient advocacy that led, years later, to the successful passage of state laws insisting on public reporting of hospital infections and more recently on disclosure of hospital-acquired MRSA.

And yet: Despite all that scrutiny and activism, we are nowhere near as far as we should be in reducing medical errors. Just in the area of hospital infections, which is our greatest interest here, there is not mandatory reporting in all states, and there is no nationwide reporting.

So says the Safe Patient Project of Consumers Union, which has produced an update to the IOM report called To Err is Human — To Delay is Deadly. They conclude:

Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.
Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year — a million lives over the past decade. This statistic by all logic is conservative. For example, the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired infections alone kill 99,000 people each year.

The project finds that many of the reforms recommended by the IOM in 1999 have not been created:

  • Few hospitals have adopted well-known systems to prevent medication errors and the FDA rarely intervenes.While the FDA reviews new drug names for potential confusion, it rarely requires name changes of existing drugs despite high levels of documented confusion among drugs, which can result in dangerous medication errors. Computerized prescribing and dispensing systems have not been widely adopted by hospitals or doctors, despite evidence that they make patients safer.
  • A national system of accountability through transparency as recommended by the IOM has not been created. While 26 states now require public reporting of some hospital-acquired infections, the medical error reporting currently in place fails to create external pressure for change. In most cases hospital-specific information is confidential and under-reporting of errors is not curbed by systematic validation of the reported data.
  • No national entity has been empowered to coordinate and track patient safety improvements.Ten years after To Err is Human, we have no national entity comprehensively tracking patient safety events or progress in reducing medical harm and we are unable to tell if we are any better off than we were a decade ago. While the federal Agency for Healthcare Research and Quality attempts to monitor progress on patient safety, its efforts fall short of what is needed.
  • Doctors and other health professionals are not expected to demonstrate competency.There has been some piecemeal action on patient safety by peers and purchasers, but there is no evidence that physicians, nurses, and other health care providers are any more competent in patient safety practices than they were ten years ago.

The entire report is well worth reading. Its lamentable but well-supported conclusion:

We give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.


Filed Under: activism, health policy, hospitals, mandatory reporting, medical errors, nosocomial

World MRSA Day, coming in October

May 6, 2009 By Maryn Leave a Comment

Folks, MRSA activist Jeanine Thomas, who helms the group MRSA Survivors Network and was substantially responsible for getting Illinois to pass its MRSA reporting legislation, is heading the movement to observe World MRSA Day on Oct. 2, 2009.

Jeanine has been tireless in pressing for reform despite her own MRSA injuries. Please consider visiting her site and checking out the network and the October observance.

Filed Under: activism, Chicago, legislation, MRSA, testimony

Good news from California

September 26, 2008 By Maryn Leave a Comment

Last night, California Gov. Arnold Schwarzenegger signed an extremely important bill, California SB 1058. The new law, formally called the Medical Facility Infection Control and Prevention Act, requires California hospitals to do MRSA screening on high-risk patients (such as in ICUs, admitted from long-term care facilities, or known to have a previous MRSA infection) and to report their rates for hospital-acquired infections including MRSA to a newly created body with the state Department of Public Health.

This new law puts California in the vanguard of states who are requiring healthcare institutions to count and track MRSA infections. (For a complete list, visit the database maintained by Consumers’ Union’s Stop Hospital Infections project.) This is vital not only for controlling MRSA, but also simply for helping us to understand how much MRSA is out there. Because MRSA has not been a reportable disease, and is not subject to any national surveillance, state counts like these are one of the best ways of assembling a fuller picture of the bug’s spread.

The most important reason to hail the passage of this law, though, is that it represents a memorial to a MRSA victim, and a determination by his survivors that no one else should meet the same fate. SB 1058 is also known as “Nile’s Law.” Nile is Nile Calvin Moss, who died in 2006. In response, his parents Carole and Ty Moss founded Nile’s Project and became tireless advocates for MRSA surveillance and screening. Among other efforts, Carole was appointed by Schwarzenegger to a state commission on hospital-acquired infections, where she is the sole voting member representing health-care consumers.

It is no small thing to step out of your grief and make your loss into a force for change. Carole and Ty Moss deserve congratulations.

Filed Under: activism, California, hospitals, infection control, legislation, MRSA

News round-up

August 22, 2008 By Maryn Leave a Comment

I’m deep into writing again and therefore slipping on posting; apologies to regular readers! But here are some items of importance from the past week:

  • Wednesday (Aug. 20) marked the first anniversary of Illinois‘ signing and immediately enacting the MRSA Screening & Reporting Act, the first state law to mandate that hospitals screen all ICU and other high-risk patients for MRSA colonization and to isolate and treat them until they are clear. This law would never have been passed without the extraordinary advocacy of MRSA survivor Jeanine Thomas, founder of the MRSA Survivors Network (site here and in the blogroll).
  • Also as of Wednesday, California came within one step of passing its own MRSA laws, SB 1058 and SB 158. They await the signature of Gov. Arnold Schwarzenegger — but with California’s budget in a $15.2 billion deficit freefall, new legislation there may be held hostage until a budget deal is agreed. Important addition: SB 1058 is also called “Nile’s Law,” after Nile Calvin Moss, who died of MRSA in April 2006. His parents Carole and Ty have pushed relentlessly for a MRSA law in his memory.
  • Plus, a great find thanks to Carole Moss: The Washington State Department of Health has put together an excellent pamphlet, Living with MRSA, that explains MRSA infection, colonization, decolonization and infection-control care at home in excellent everyday language.
  • And finally, another blog worth knowing about: GERMblog, written by Dr. Harley Rotbart, professor and vice-chair of pediatrics at University of Colorado School of Medicine and author of Germ Proof Your Kids: The Complete Guide to Protecting (Without Overprotecting) Your Family from Infections. I interviewed Dr. Rotbart recently for a magazine story and his advice was clear, science-based and sensible. His blog is now in the blogroll.

Filed Under: activism, California, colonization, Illinois, infection control, legislation, MRSA

Copyright © 2023 · Maryn McKenna on Genesis Framework · WordPress · Log in

© 2017 Maryn McKenna | Site by Sumy Designs, LLC

Facebook