Expert Testimony about # of Deaths, Medical Errors & Patient Safety in U.S.-Excerpt: Tejal Gandhi, MD, MPH, President National Patient Safety Foundation

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On July 17th, 2014 the Senate Subcommittee on Primary Health and Aging held an important hearing on “Over 1000 Deaths Per Day is Too Many:  The Need to Improve Patient Safety“. Six experts testified and shared pdf. files of their reports including citations.

To download all of the experts’ complete testimonies  or listen to the hearing go here.

To get links to all expert excerpts published in Confident Voices in Healthcare Blog go here.

Excerpt from:  Tejal K. Gandhi, MD MPH CPPS
President, National Patient Safety Foundation/Lucian Leape Institute
Associate Professor of Medicine, Harvard Medical School
Boston, MA

I would like to talk to you today about ambulatory patient safety and the priorities and challenges that we currently face. Much of the effort of the patient safety movement over the past 15 years, since the Institute of Medicine report To Err is Human (http://www.nap.edu/catalog.php?record_id=9728),  has
focused on improving patient safety in the hospital setting. However, it is important to remember that most care is given outside of hospitals, and there are numerous safety issues that exist in other health settings that are quite different from those we face in hospitals (http://www.nejm.org/doi/full/10.1056/NEJMp1003294). 

The setting that we know the most about, in terms of ambulatory safety issues, is primary care. I will touch on 3 areas in particular‐‐medication safety, missed and delayed diagnoses, and transitions of care…

…Studies have shown that medication errors are common in primary care, and that adverse drug events, or injuries due to drugs, occur in up to 25% of patients within 30 days of being prescribed a drug (http://www.ncbi.nlm.nih.gov/pubmed/12700376)…

…Patients do not fill one out of 4 prescriptions ‐‐and these include prescriptions for important, highly prevalent chronic conditions such as high blood pressure and diabetes (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842539/)…

…Missed and delayed diagnosis is a key issue as well‐‐ this is the most common type of outpatient malpractice claim (usually missed and delayed diagnosis of cancer in primary care). Missed and delayed diagnosis is complex‐‐ in one study, a single malpractice case had on average 3 steps in the diagnostic process that broke down and led to the missed diagnosis
(http://www.ncbi.nlm.nih.gov/pubmed/17015866)…

…one study found that after hospital discharge, within 3 to 5 days, one‐third of patients were taking their medications differently than how they were prescribed at discharge (http://www.ncbi.nlm.nih.gov/pubmed/16534045)…

…Another study showed that 40% of patients are discharged with test results that are pending (the final result has not come back) and these results are often not seen by the patients’ primary care providers
(http://www.ncbi.nlm.nih.gov/pubmed/16027454).

To read my open letter to the Senate Subcommittee  in response to the hearing go here.

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