Embarrassing New GAO Report On Hospital Safety Has Two Surprising Bright Spots

Hospitals are flummoxed by the problem of patient safety, according to a report issued by the Government Accounting Office (GAO) just in time for this week’s Patient Safety Awareness Week. Issued at the request of ranking members of the Senate Committee on Finance and Senate Committee on Health, Education, Labor and Pensions, Sen. Ron Wyden (D-Ore.) and Sen. Patty Murray (D-Wash.), respectively, the report reveals three explanations on why hospitals find it so difficult to address patient safety. I am summarizing, but I am not exaggerating:

• Hospitals can’t find the problem. Hospitals cannot identify in their own records all their errors, accidents and infections, even though they are required to report many of them to the federal government.
• Hospitals can’t figure out how to solve the problem. Despite a large body of research about how to address most safety problems, hospital leaders can’t seem to find the time to read it. Some hospitals even admit to throwing a bunch of ideas at a problem at once–surprised when it becomes nearly impossible to tease out which ones worked, and which didn’t.
• Nobody does what they are told anyway. Even when hospitals identify a problem that is hurting patients, and commit to an evidence-based solution to stop the harm, they can’t get their staff on board.

In the hour it took me to study the report, at least 20 people died of a preventable error in American hospitals. Hundreds more suffered an avoidable injury or infection that will debilitate them and devastate their families. When tens of thousands of people are dying from preventable errors, is it too much to ask hospitals to read the latest research? It’s as if the house is burning down with people inside, and the fire department is confused about which room to attack first, and which hose to use. Worse, the chief isn’t sure the firefighters will do the job...