Chapter 3: Quality and Safety in Healthcare:  The Evidence So Far

THE BEST THE WORLD HAS EVER SEEN

Much of this chapter will focus on sobering statistics about quality and safety and healthcare, but we start simply with this: Healthcare today is the best the world has ever seen. Just two centuries ago, the average life expectancy was only about 25 years. Today, it is more than 70. Infant mortality has fallen dramatically, not only in the United States (Figure 3-1), but also worldwide. And improvements haven’t only been because of reduced infant mortality: life expectancy after the age of 65 has also risen. Diseases that used to be uniformly lethal have been converted to chronic, manageable conditions. Formerly experimental, esoteric treatments are now routine. For example, between 1990 and 2016, the use of bone marrow and stem cell transplantation more than tripled,¹ and today we use a patient’s own reengineered T cells to target their cancer—something that would have seemed like science fiction only a few years ago. Healthcare today is the best the world has ever seen.

THREE CRITICAL PAPERS TO KNOW

In spite of this, the overwhelming evidence is that healthcare today is neither safe nor high quality. There are a few landmark papers that every healthcare delivery scientist should know about because they help form the bedrock of the field. These studies, and ones that followed from them, helped launch the modern quality and safety movements.

The Harvard Medical Practice Study: Incidence of Adverse Events and Negligence in Hospitalized Patients (1991)

The Harvard Medical Practice Study² reported the results of an analysis of 51 randomly selected hospitals in New York State. In this seminal piece of research, the authors reviewed the medical records of 30,121 randomly selected patients from 1984. Each chart was screened by a nurse and a medical record analyst; those patients who screened positive had their records reviewed by two separate board-certified physicians. They assessed whether (1) adverse events were due to medical management and (2) if adverse events were related to “negligence,” which the study defined as substandard care.

The researchers found that 3.7% of hospitalizations included adverse events. Of these, 13.6% led to death. Just over a quarter of these adverse events were judged to be related to negligence, and both the number of adverse events and the rate of negligence rose with patient age. When this study was weighted to account for all of New York State, the authors estimated that there were 98,609 adverse events and 27,179 adverse events involving negligence in the 2.7 million hospitalizations in the state that year.