THE BLOG
09/28/2016 12:58 pm ET

Pennsylvania Takes on Medical Errors, the Third-Leading Cause of U.S. Deaths

Written by Trent Smith, communications professional focusing on government

A May 2016 Johns Hopkins study indicates that 10 percent of all U.S. deaths are due to medical error, making it the third leading cause of death, behind only heart disease and cancer.

The Pennsylvania Patient Safety Authority (PSA) is combatting this problem by learning more about the causes and trends associated with medical errors. Pennsylvania's Medical Care Availability and Reduction of Error Act of 2002 tasked PSA with eliminating medical errors by identifying problems and implementing solutions that promote patient safety.

It's a tall order, particularly when you consider the sheer amount of information the PSA must wade through.

The PSA database contains more than 2.5 million medical error reports, each with over 200 data and text fields detailing both serious events and near-miss errors. "Serious events" result in actual physical harm to the patient. A "near miss" records an event that did not reach or harm the patient. Overall, it adds up to more than 500 million data fields and billions of text field characters.

A new weapon in their arsenal is data visualization, which can quickly spot trends and anomalies in massive amounts of data.

"It is one thing to develop one of the nation's largest and best-known statewide patient safety databases. It's quite another to turn that data into lifesaving information," said Howard Newstadt, PSA Finance Director and Chief Information Officer.

Analysis validates PSA's efforts

One of the first reports produced through the system revealed PSA has been exceptionally effective in protecting commonwealth citizens. The data showed a 45 percent decline in "high harm" events over 10 years, from 2005 through 2014.

"This outcome supports the work of PSA and the intent of the MCARE Act," said Newstadt. "It also suggests a positive effect on people's lives, alleviating suffering and in fact preventing death. The monetary savings alone associated with this decline are measured in tens of millions of dollars, if not more."

Immediate results reveal new data relationships
An early analysis of medical error reports identified previously unrecognized data relationships. One initial test led researchers to further explore how gender may influence specific types of medical errors.

First, PSA Visual Analytics filtered factors that could skew reported data, such as age range (women live longer) and gender-specific language or care areas. It quickly became clear that certain serious events involving adverse drug reactions were more likely among women, while skin integrity errors (cuts and abrasions) were more likely among men.

A better understanding of factors influencing patient safety events can inform changes to procedures, policies or cultures, affecting clinical risk assessments for certain types of patients, reducing medical errors and patient harm in Pennsylvania and nationally.

"The effect of this project has been transformational," said Newstadt.

Bringing clarity to a complex issue earns PSA national honors
Using SAS Visual Analytics, the Patient Safety Visual Analytics Reporting System the Patient Safety Visual Analytics Reporting System, is a finalist in the National Association of State Chief Information Officers (NASCIO) State IT Recognition Awards in the Emerging and Innovative Technologies category. Check out their nomination here.

The Johns Hopkins researchers were careful to caution, and I'd like to reiterate here, that "most medical errors aren't due to inherently bad doctors, and that reporting these errors shouldn't be addressed by punishment or legal action. Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability."

Clearly, this is a complex issue that requires further study of the data. Fortunately, Pennsylvania Patient Safety Authority is creating a blueprint for other states to follow to better protect patients around the country.

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