Opioid Safety, Respiratory Compromise

Improving Patient Safety in Hospitals: Can Hospitals Afford to Give Away Money? So Why Do Preventable Adverse Events Still Occur in Hospitals?

by Michael Wong

This is the question that I posed to lawyers, insurers, and healthcare professionals attending a major healthcare conference, the Crittenden Medical Conference.








Pointing to the tragedies of Amanda Abbiehl, Leah Coufal, Justin Micalizzi, and Louise Batz, I underscored the commonality of these unfortunate patient tragedies — healthy patients who were put on PCA without monitoring shared a common result — sadly, none of them came out of the hospital alive.


  • Pennsylvania Patient Safety Authority:
    • about 4,500 reports associated with PCA pumps
    • 6-yr period (June 2004 to May 2010)
  • Medmarx (national voluntary medication error-reporting database):
  • Veterans Health Administration (root cause analyses since 1999):
    • 13% involved two types of pumps

I provided the solutions of the Veterans Affairs Administration. Bryanne Patail (biomedical engineer at the US Department of Veterans Affairs, National Center for Patient Safety). As he told me in our recent discussion:






  • prevented estimated potential expenses of almost $4 million
  • 5 year ROI of $2.5 million

Next week, I will post my interview with Carolyn Williams from St. Joseph/Candler, which describes in detail the St Joseph/Candler story (click here to read that post). In the meantime, for a pdf of my conference presentation, please click here.



What do you think?

4 thoughts on “Improving Patient Safety in Hospitals: Can Hospitals Afford to Give Away Money? So Why Do Preventable Adverse Events Still Occur in Hospitals?

  1. Dr. Emanuel Kanal and I looked at two years of MRI accident data from the FDA. Much to our horror, more than 92% of the reviewed accidents fell into only three categories of preventable errors! Our analysis suggested that there are thousands of these types of accidents every year, and yet these accidents that jeopardize the safety of patients *and* providers continue, and have grown year-over-year for most of the last decade at alarming rates.

    If there are existing best-practice standards that can reduce injury, improve efficiency, and save a facility money, why aren’t they put into practice? For relatively low-frequency events, there’s always the thought that ‘it won’t happen to me’, a condition made worse by the low reporting rates (thought to be due largely to embarrassment of reporting an error that a provider could have readily prevented).

    We hope that license authorities, accreditation organizations, and regulatory bodies help providers conform with best practices. Not only would it be good for patients, but these efforts would also reduce the alarming costs associated with accidents in what is a very expensive service to operate.

  2. Great points Toby.

    As an expert in Root Cause Analysis (RCA) who has investigated hundreds of undesirable outcomes across most every industry over the past 27 years, I have found the healthcare industry to be the most resistant to accept what ‘true’ RCA is all about. Much of this is NOT due to mal-intent by any stretch, but driven by regulations that 1) encourage reaction and 2) lack comprehensiveness and depth in order to be compliant.

    First of all RCA is ill-defined in the industry as a whole and people can find or create a definition that matches their need. Whatever they are doing to solve problems, they will call it RCA. This is a big part of the problem, lack of a universal standard for what RCA is, versus should be.

    There are over 6000 hospitals in the U.S. and most all are accredited. If all are accredited and meeting regulatory RCA minimum standards, why aren’t patient safety numbers improving (especially since the 1999 IOM report) nationally? It doesn’t make sense on the surface.

    Let’s get back to your question, “So Why Do Preventable Adverse Events Still Occur in Hospitals?”

    It has been my experience the primary goal of healthcare (in general) related to RCA, is to pass their regulatory audits to ensure they continue to receive their CMS funds. The problem here is there is no direct, bottom-line correlation to an improvement in patient safety. This demonstrates a direct disconnect between compliance and patient safety. RCA should be focused on patient safety metrics first and then compliance would be a by-product. I see it the other way around today.

    How can this happen with such well-intended people involved? RCA regulations need to be more comprehensive and prevent ‘shallow cause analysis’ from being compliant. Secondly, regulations should use risk assessment technologies to focus on preventing sentinel/never events instead of reacting to them.

    Part of the image problem with RCA is it is seen only as a reactive tool. Something really bad has to happen before a hospital will commission a full blown RCA. What if….we used RCA proactively? What if…we conducted more FMEA’s and applied RCA to the identified unacceptable risks? Why shouldn’t we first focus on reducing the risks instead of becoming better responders after-the-fact?

    Preventable adverse events are permitted because we don’t analyze them deep enough and uncover all the systemic root causes that impact decision making, and because we can get away with a shallow cause analysis to be compliant. Think about it, RCA is seen as another task on my already full plate. I did not go to school to learn how to be a professional RCA analyst, yet I am expected to be proficient at it in my job responsibilities. This is a paradox for sure.

    When we start measuring the effectiveness of our RCA efforts by direct improvements in patient safety we will start to make greater strides in protecting our patients and lowering our costs of care. How many hospitals measure the effectiveness of their RCA efforts by how may times they analyze the same event over and over again? RCA is about uncovering the truth and the sad fact is the truth is hard to accept. However, denying the truth only opens the door for a repeat of the undesirable outcome.


    Bob Latino
    Reliability Center, Inc.

  3. Two interesting comments posted on National Patient Safety Foundation in answer to question “Why do preventable adverse events still occur in hospitals?”:
    (1) Cost of Doing Business – “Presumably because the necessary costs for prevention procedures/systems will be more expensive than the costs of the few litigation cases in each hospital that go to trial.”
    (2) Lack of Training – “In part due to our lack of specialty training after graduation with performance as an end point vs. X number of weeks. Our students have limited experience due to too many schools of nursing who need clinical sites.”

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