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HRG. 113–787 MORE THAN 1,000 PREVENTABLE DEATHS A DAY IS TOO MANY: THE NEED TO IMPROVE PATIENT SAFETY HEARING BEFORE THE SUBCOMMITTEE ON PRIMARY HEALTH AND AGING OF THE COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS UNITED STATES SENATE ONE HUNDRED THIRTEENTH CONGRESS SECOND SESSION ON EXAMINING THE NEED TO IMPROVE PATIENT SAFETY AND REDUCE PREVENTABLE DEATHS JULY 17, 2014 Printed for the use of the Committee on Health, Education, Labor, and Pensions ( Available via the World Wide Web: http://www.gpo.gov/fdsys/ U.S. GOVERNMENT PUBLISHING OFFICE 88–894 PDF WASHINGTON : 2016 For sale by the Superintendent of Documents, U.S. Government Publishing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800 Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001 VerDate Nov 24 2008 14:26 Apr 07, 2016 Jkt 000000 PO 00000 Frm 00001 Fmt 5011 Sfmt 5011 S:\DOCS\88894.TXT DENISE COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS TOM HARKIN, Iowa, Chairman BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee PATTY MURRAY, Washington MICHAEL B. ENZI, Wyoming BERNARD SANDERS (I), Vermont RICHARD BURR, North Carolina ROBERT P. CASEY, JR., Pennsylvania JOHNNY ISAKSON, Georgia KAY R. HAGAN, North Carolina RAND PAUL, Kentucky AL FRANKEN, Minnesota ORRIN G. HATCH, Utah MICHAEL F. BENNET, Colorado PAT ROBERTS, Kansas SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska TAMMY BALDWIN, Wisconsin MARK KIRK, Illinois CHRISTOPHER S. MURPHY, Connecticut TIM SCOTT, South Carolina ELIZABETH WARREN, Massachusetts DEREK MILLER, Staff Director LAUREN MCFERRAN, Deputy Staff Director and Chief Counsel DAVID P. CLEARY, Republican Staff Director SUBCOMMITTEE ON PRIMARY HEALTH AND AGING BERNARD SANDERS (I), Vermont, Chairman BARBARA A. MIKULSKI, Maryland RICHARD BURR, North Carolina KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska TAMMY BALDWIN, Wisconsin MICHAEL B. ENZI, Wyoming CHRISTOPHER S. MURPHY, Connecticut MARK KIRK, Illinois ELIZABETH WARREN, Massachusetts LAMAR ALEXANDER, Tennessee (ex officio) TOM HARKIN (Iowa (ex officio) SOPHIE KASIMOW, Staff Director KRISTEN CHAPMAN, Republican Staff Director (II) VerDate Nov 24 2008 14:26 Apr 07, 2016 Jkt 000000 PO 00000 Frm 00002 Fmt 0486 Sfmt 0486 S:\DOCS\88894.TXT DENISE CONTENTS STATEMENTS THURSDAY, JULY 17, 2014 Page COMMITTEE MEMBERS Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health and Aging, opening statement .................................................................................... 1 Warren, Hon. Elizabeth, a U.S. Senator from the State of Massachusetts ........ 2 Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode Island ...... 2 WITNESSES James, John T., Ph.D., Founder, Patient Safety America, Houston, TX ............ 3 Prepared statement .......................................................................................... 5 Jha, Ashish K., M.D., MPH, Professor of Health Policy and Management, Harvard school of Public Health, Boston, MA ................................................... 7 Prepared statement .......................................................................................... 9 Gandhi, Tejal K., M.D., MPH, CPPS, President, National Patient Safety Foundation; Associate Professor of Medicine, Harvard Medical School, Bos- ton, MA ................................................................................................................. 15 Prepared statement .......................................................................................... 17 Pronovost, Peter, M.D., Ph.D., FCCM, Senior Vice President for Patient Safe- ty and Quality and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD .................................... 19 Prepared statement .......................................................................................... 21 Disch, Joanne, Ph.D., RN, FAAN, Professor ad Honorem, University of Min- nesota School of Nursing, Minneapolis, MN ...................................................... 25 Prepared statement .......................................................................................... 27 McGiffert, Lisa, Director, Safe Patient Project, Consumers Union, Austin, TX .......................................................................................................................... 34 Prepared statement .......................................................................................... 36 ADDITIONAL MATERIAL Statements, articles, publications, letters, etc.: Senator Barbara Boxer, Report on Medical Errors ....................................... 57 Response to questions of Senator Warren by Peter Pronovost, M.D., Ph.D., FCCM ................................................................................................. 65 (III) VerDate Nov 24 2008 14:26 Apr 07, 2016 Jkt 000000 PO 00000 Frm 00003 Fmt 0486 Sfmt 0486 S:\DOCS\88894.TXT DENISE VerDate Nov 24 2008 14:26 Apr 07, 2016 Jkt 000000 PO 00000 Frm 00004 Fmt 0486 Sfmt 0486 S:\DOCS\88894.TXT DENISE MORE THAN 1,000 PREVENTABLE DEATHS A DAY IS TOO MANY: THE NEED TO IMPROVE PATIENT SAFETY THURSDAY, JULY 17, 2014 U.S. SENATE, SUBCOMMITTEE ON PRIMARY HEALTH AND AGING, COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS, Washington, DC. The subcommittee met, pursuant to notice, at 10:02 a.m., in room SD–430, Dirksen Senate Office Building, Hon. Bernard Sanders, chairman of the subcommittee, presiding. Present: Senators Sanders, Whitehouse, Murphy, and Warren. OPENING STATEMENT OF SENATOR SANDERS Senator SANDERS. Let me begin by thanking all of our distin- guished panelists for being with us this morning. In a sense, the discussion we’re going to have today is personal, I think, for people all over this country in the sense that many of us, myself included, have seen folks go into a hospital for one problem or another and end up coming out a lot sicker than when they went in and, in some cases, dying as a result. What is widely known is that the major cause of death in the United States today is heart disease, a serious problem. The second leading cause of death is cancer. According to the 2010 CDC report, more than 597,000 people died of heart disease and 574,000 died of cancer. But what is not widely known and, in fact, what this hearing is about—and I hope to do my best with the help of my fellow Sen- ators and members of this panel—is to start focusing attention on the third leading cause of death in the United States of America, and that will come as a great surprise to most people. The third leading cause of death in this country has to do with preventable medical errors in hospitals. A recent article published in the Journal of Patient Safety esti- mates that as many as 440,000 people a year may die from pre- ventable medical errors in hospitals—440,000 a year. That could be more than 1,000 a day. Tens of thousands also die from prevent- able mistakes outside the hospital, such as deaths from misdiagnoses or injuries from medications. Nearly 15 years ago, the Institute of Medicine published a re- port—it is a well-publicized report—entitled, ‘‘To Err is Human,’’ which found that as many as 98,000 people die in hospitals each year due to preventable medical errors. According to a 2010 report, (1) VerDate Nov 24 2008 14:26 Apr 07, 2016 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 S:\DOCS\88894.TXT DENISE 2 a more recent report, from the Department of Health and Human Services, 180,000 Medicare patients alone, just Medicare patients, die from preventable adverse events in hospitals. According to the CDC, 1 in 25 hospital patients gets an infection from being in the hospital. In 2011, these hospital-acquired infec- tions caused 700,000 people to get sick and 75,000 people to die. Clearly, these errors cause an immense amount of human suf- fering. But they are also—from a financial point of view—very, very expensive to the government and to individual families. Med- ical errors cost the U.S. healthcare system more than $17 billion in 2008, and when indirect costs are taken into account, such as lost productivity due to missed work days, medical errors may cost nearly $1 trillion each year. Now, in the midst of this situation, which we will be discussing today—and I think we agree, it’s not just an American issue. This is an issue that’s taking place all over the world. Countries’ healthcare systems all over the world are trying to combat it. The good news is that there has been progress made in recent years. We’re going to hear from our panelists about the kinds of progress that has been made and, more importantly, where we have to go. I think the horror here is that we all understand that tragedies occur. People die for all kinds of reasons. But the tragedy that we’re talking about here are deaths taking place that should not be taking place, and that’s what we are going to be focusing on. Some of the advances that we have seen—and we’ll be discussing these this morning—come from following practices, interestingly enough, that have been established in other high-stakes fields like aviation and nuclear safety by people who are obviously dealing with very dangerous situations. For example, through the imple- mentation of checklists, infection rates in our country have dropped dramatically. Advances in technology, such as electronic prescrib- ing, can catch medication errors, and robotic tools, which create smaller incisions during surgery, can reduce the risk of an infec-