More Lethal Goofs
By Tom Hilliard
photos by john whipple
hospitals jump on board a campaign to accidentally kill fewer
here’s what I think we should do,” declared Donald Berwick,
M.D., surveying the hundreds of health-care executives and
physicians who had packed into a hotel ballroom in Orlando,
Fla. “I think we should save 100,000 lives. I think we should
do that by June 14, 2006.” A short pause. “9 AM.”
what? Did this guy you’ve never heard of just order the most
important people in American health care to save a large number
of lives by a fixed date? He did. And the leaders of American
health care took him very seriously.
Berwick launched his 100,000 Lives Campaign on a pleasant
(at least in Orlando) day last December. The challenge: Get
at least 1,600 hospitals—one-third of all hospitals nationwide—to
commit to using six “interventions” prepared by Berwick’s
organization, the Institute for Healthcare Improvement. Each
intervention has been shown in peer-reviewed literature to
save lives and improve care.
Six months later, more than 2,200 hospitals nationwide have
joined Berwick’s campaign, 40 percent of all hospitals nationwide.
About three- quarters of New York state’s hospitals are participating,
including every hospital in the Capital Region. Berwick’s
partners include a few organizations you might have heard
of, like the American Medical Association, the Centers for
Disease Control, the Centers for Medicare and Medicaid Service
(the government agency that runs Medicare and Medicaid), the
Veterans Health Administration, the American Heart Association,
the American College of Physicians, and a mind-numbing roster
of state hospital and physician associations.
The 100,000 Lives Campaign—usually shorthanded as 100K Lives—has
snowballed into the most ambitious collaborative campaign
among hospitals since the Salk penicillin trials 50 years
ago. If it succeeds, 100K Lives will be the greatest triumph
for organized medicine in years—and a hundred thousand people
will be alive who would otherwise be dead.
Health-care industry leaders seem thrilled without reservation
to be launching such a promising initiative, and, not unreasonably,
they want the public to give them a little credit. Says Kathy
Ciccone of the Healthcare Association of New York State, the
state hospital trade association: “I hope this campaign helps
consumers develop an awareness of all the efforts that hospitals
and providers undertake to improve quality of care.”
But the reality is a little more complicated. In fact, it’s
rather embarrassing. Because Berwick was not exactly playing
civic booster in that Orlando ballroom. “I’m losing patience,”
he declared. Berwick’s patience was fraying over lack of progress
in making the health-care system safe and effective. He acidly
suggested that his beloved Red Sox might win another World
Series before that happened—even if they had to wait another
Donald Berwick is best known as the president and cofounder
of the Institute for Healthcare Improvement, an organization
devoted to finding the best innovations in all aspects of
healthcare and spreading them throughout the industry. IHI
runs dozens of workshops and conferences each year, including
the conference in Orlando.
articles flow from Berwick’s pen each year, some careful studies
appearing in the most respected medical journals, some passionate
indictments of the status quo. Berwick is a graduate of Harvard
University and Harvard Medical School, as well as a member
of the faculty of Boston Children’s Hospital. Yet mere biography
does not get at Berwick’s unique status in healthcare. Berwick
has become the ultimate outside critic to healthcare while
remaining an admired—even revered—insider. As an outsider,
Berwick mercilessly criticizes the waste and negligence of
today’s health-care delivery system and calls out the culprits,
most often health-care managers. Yet he is anything but a
gadfly. Berwick is perceived as a leader within health care,
not an outside irritant. “He should get the Nobel Prize in
Medicine,” suggested one doctor interviewed for this story.
The roll-out of 100K Lives in December 2004 marked the 10th
anniversary of a death that launched the modern patient-safety
movement. On Nov. 26, 1994, Betsy Lehman, a health-care columnist
for The Boston Globe, checked into Dana Farber Cancer
Institute for chemotherapy to stop the progression of breast
cancer. She was the most informed and engaged patient imaginable,
and Dana Farber one of the nation’s top cancer centers. Yet
Lehman died of an overdose of a potent cancer drug. Worse,
she received the overdose for four straight days, even though
another woman in the same ward had collapsed of a drug overdose
less than a week before.
Lehman’s death made national news. But reporters, lacking
an incompetent doctor or goof-off nurse to blame, had trouble
explaining what had happened at Dana Farber.
They got the explanation, and much more, from an article published
two weeks later, in the Journal of the American Medical
Association by Dr. Lucian Leape, a pediatric surgeon and
Leape’s article focused on a touchy subject among doctors—medical
errors. Leape and his team had churned through 30,000 medical
records at 51 New York state hospitals, looking for possible
gaps in care. They found more than anyone could have imagined.
Some 3.7 percent of hospital patients had been the victim
of an injury caused by the hospital itself, and six in 10
of those cases resulted from mistakes. One in seven victims
of an adverse event died. Multiplied nationwide, that would
mean 98,000 people dying annually of preventable medical errors—the
equivalent of a 747 airliner going down every day for a year.
Where Leape jumped most sharply from existing discussion was
in focusing on systems of care rather than the traditional
culprit, careless or negligent doctors. It was useless to
blame bad doctors when mistakes were taking place every day
at every hospital in America. Rather, gaps in the system of
care were allowing patients to be harmed.
Reporters jumped on Leape’s study, which offered the most
plausible explanation of what happened to Betsy Lehman: She
was killed by a system that failed to make providers check
medication dosage before administering it. In the process,
they also publicized the Leape study’s startling findings
on the wide prevalence of death by medical error.
Five years later, Leape and Berwick led a panel of the National
Institute of Medicine that drafted a new study, To Err
Is Human: Building a Safer Health Care System. The IOM
study added new findings and a tone of urgency. For example,
the study found that annual costs to the American economy
ranged between $17 and $29 billion, and that more people died
each year of medication errors alone (7,000) than workplace
injuries (6,000). To Err Is Human sparked a media frenzy
which made “medical error” a household word and forced the
health-care industry to admit the existence of a serious problem.
Err Is Human set a goal of reducing medical errors by
50 percent over five years, but it soon became evident that
little was changing in the health-care industry. “The pace
is astoundingly slow,” charges Michael Millenson, author of
Demanding Medical Excellence and a leading critic of
hospital quality standards. A recent survey of physicians
by the Commonwealth Fund found, for example, that rates of
several preventable adverse events and complications of hospital
care actually went up from 1995 to 2002 among Medicare recipients.
Commonwealth Fund researchers also found that only one-third
of all physicians had been involved in efforts to “better
manage patients’ clinical care.”
In the Capital Region, complaints of medical errors from former
patients and family members are regularly reported. Yet there’s
no way to estimate how common these errors really are. The
state maintains a medical error reporting system called NYPORTS,
but the system is not considered reliable due to chronic hospital
So it’s not surprising that Berwick has lost patience with
the healthcare status quo. Amazingly, however, he has succeeded
in getting key actors to share his impatience and buy into
his plan. How? By mimicking the structure of a political campaign.
Berwick argues that political campaigns operate more efficiently
because they’re always racing against a deadline, which is
to say, Election Day. So he made up an arbitrary deadline
and 2,200 hospital CEOs said OK. The six interventions are
the platform, the slogan is a suitably cutting campaign proverb:
“Some is not a number, soon is not a time.” The campaign even
has a candidate. “We’re going to elect quality,” says Berwick,
The other reason 100K Lives has launched so strongly is that
the interventions just plain make sense. “The IHI campaign
stands apart,” says Ciccone, “because it offers solutions.
It says, this is the best care as we know it right now that
we can deliver and here’s how to do it. It’s just a better
of Berwick’s interventions consists of a bundle of smaller
reforms, such as “maintain perioperative glucose control”
and “discontinue antibiotics within 24 hours of surgery end
time.” Each item in the bundle must be carried out for a patient
to count as having received “perfect care.” If a 500-bed hospital
fully implemented all six interventions, says Berwick, it
could save 230 lives each year. Participating hospitals turn
over data to the Institute for Healthcare Improvement that
document trends in patient mortality. If enough hospitals
sign on to 100K Lives and apply the six interventions their
collective drop in mortality rates should surpass 100,000
lives. Goal achieved! At least that’s the theory.
Dr. Robert Benton is testing the theory. Benton, a cardiologist
affiliated with Northeast Health in Troy, is piloting an intervention
to prevent acute myocardial infarctions. He chairs a multidisciplinary
team that takes quality of care standards like “early administration
of aspirin,” or “timely initiation of reperfusion,” and figures
out how to incorporate them into providers’ work flow. His
group spends a lot of time gathering and analyzing data and
flow charts. Then they have to talk to doctors and other staff
about pulling apart their daily routines and rebuilding them
in a new model.
Breaking through with a difficult program like this one requires
a zeal for numbers and a merciless look in the mirror. “I
went through the denial phase myself. I said, how can I not
be giving ACE-inhibitors to 100 percent of my patients?” recounts
Benton. ACE-inhibitors are a class of medication that should
be given to all chronic-heart- failure patients when they
leave the hospital unless otherwise indicated. Studies show
that patients who fail to get one are more likely to suffer
a traumatic heart problem. “When we measured it, I was at
about 80 to 85 percent. That’s not great. Some of these cases
are just documentation, but that’s important too. And then
there’s patients where I just don’t have them on ACE-inhibitors,
and I say, what kind of a doctor am I?”
Benton’s question is revealing. Once upon a time, doctors
reacted to every criticism of their profession as a personal
criticism: “What kind of doctor are you?” Doctors are taught
in medical school that they cannot ever afford to make a mistake,
because a mistake can cost a life. Paradoxically, what would
seem to be an admirable ethic of personal responsibility makes
it all the harder for physicians to admit the possibility
that mistakes happen. “Most doctors don’t believe that they
themselves are responsible for errors,” says Millenson, “and
it’s certainly not something they like to think about any
more than you or I would.”
shalt make no assumptions about what it will take to change
physician behavior,” declares Dr. John Collins, medical director
of Northeast Health, which operates Samaritan Hospital and
Albany Regional Hospital. He’s being modest. Collins, a genial
bearded man with a tone of cheerful idealism and a subtle
eye for human nature, actually has a pretty good idea of what
it takes to change physician behavior.
have some credibility,” says Collins, “but it’s not the same
as your partner sitting down with you and saying your data
doesn’t quite look like it should.” He’s talking about people
like Robert Benton, who can talk to other cardiologists heart
to heart, as it were. Just as important, Collins sticks close
to the data and talks about fixing systems, not doctors.
minds are not closed about these issues,” Collins insists
about his doctors, but his war stories are not totally reassuring
on this count. Take the practice of shaving patients before
surgery. IHI’s how-to guide on preventing surgical infections—the
second most common mistake after medication errors—reports
that “the use of razors (shaving) prior to surgery increases
the incidence of wound infection when compared to clipping.”
This research finding dates back to 1971, preceding the IOM
study, not to mention Watergate and the fall of Saigon. It’s
that old. But still, plenty of surgeons allegedly continue
to shave their patients before surgery. “There’s a subset
of surgical colleagues who feel as though shaving is the right
way to go,” says Collins. “They’ve always shaved, they don’t
perceive it as a problem. There’s another group that says,
‘I’ll clip, but get me the best clippers, and the first time
they don’t work I’m going back to shaving.’” From one facility
to another, says the IHI guide, the use of shaving “can range
from zero to nearly one hundred percent.”
Physicians may be coming around after all these years, but
there are plenty of other obstacles to eliminating mistakes
Antiquated payment structures: The straight payment-for-treatment
system used by public and private insurers makes error reduction
a sucker’s game. “If you have zero infections in the intensive
care unit, you lose money,” complains John Morley, medical
director of Albany Medical Center. For example, if an elderly
patient gets an infection after surgery due to poor hand washing
hygiene, Medicare pays the full cost of care. Fewer infections
equal less money.
Lack of information technology: Many dangerous mistakes have
resulted from illegible handwritten prescriptions. But what
if doctors could print out prescriptions from their computers?
What if doctors could pull up all the information on a patient
at their computer instead of flipping through a bulky medical
record that might or might not even be available? Fewer than
10 percent of hospitals in America have such systems. The
hold-up is the vast expense of the information systems needed.
“We need technology, and technology costs dollars,” says Morley.
Short staffing: Some causes of medical errors have been known
for years, like inadequate hand washing by surgeons and other
providers. Nancy Webber, a spokesperson for the New York State
Nurses Association, says that nurses could improve hygiene
standards—if only they weren’t so understaffed. A 2002 study
in the New England Journal of Medicine found a parade
of horrible outcomes, such as urinary tract infections, upper
gastrointestinal bleeding, shock and longer hospital stays
to be tied to inadequate nurse staffing levels.
The obstacles may seem overwhelming. But Berwick isn’t taking
excuses, and no one wants to disappoint him. Collins, Benton
and others from Northeast Health were in the audience for
Berwick’s Orlando speech. For a few minutes they glimpsed
the promised land of Safe and Effective Healthcare. When they
returned home, Collins began organizing Northeast Health to
implement all six interventions. Other hospitals in the Capital
Region are starting more cautiously, rolling out one or two
As their spokespeople explain why they picked this or that
intervention, it all sounds reasonable, thoughtful, mature.
On the other hand, patients are dying every day who don’t
After Berwick had finished speaking, he turned the microphone
over to Sorell King, the mother of a little girl named Josie
who died at Johns Hopkins Medical Center in 2001 of dehydration
due to a remarkable series of mix-ups. She controlled a sob,
and then told the audience: “If this campaign had been in
place four or five years ago, that rapid-response team would
have come when the nurse wanted or when I wanted and Josie
would be alive.”
The rapid-response team King referred to is an intervention
in which a provider team bypasses the chain of command to
respond directly to patients whose condition seems to be deteriorating:
chest pain, trouble breathing, altered mental state and so
on. What happens today is that bedside staff observe the symptoms
but often fail to call a doctor and the patient goes into
cardiac arrest. Rapid-response teams have been shown to cut
the rate of cardiac arrest and other traumatic events by as
much as half.
Yet only 40 percent of the New York hospitals participating
in 100K Lives are implementing the rapid-response team, including
only Saratoga Hospital and Northeast Health in the Capital
Region. Kathy Ciccone of the state hospital association points
out that the rapid-response team is a newer idea with a thinner
evidence base than the other five interventions, which is
true. Nonetheless, it’s hard not to feel a sense of impatience.
For all we know, another Josie King may be lying in a nearby
hospital at this very moment.
Still, it should be understood that hospitals are looking
for more from 100K Lives than saving lives. What really excites
doctors and hospital managers is the tantalizing opportunity
to transform their change-resistant, goof-prone cultures into
change-friendly, goof-free cultures. So much of what hospital
leaders gush about makes the eyes of regular people glaze
over: bundling, checklists, protocols, aligning improvement
indicators of various organizations, and so on. And yet, this
is the mundane stuff of transformation. Says Collins: “It’s
a great reordering in how we think about work.”
And on June 14, 2006, 9 AM, those of us on the outside will
get a glimpse of what’s really changing inside those necessary
but nerve-racking edifices called hospitals.
Institute for Healthcare Improvement Web site, www.ihi.org/IHI/Programs/
Campaign, contains a wealth of information on the 100,000
Lives Campaign, including a video of Don Berwick’s Orlando
speech and the full text of the how-to guides on each intervention.
These how-to guides are recommended for people about to check
into a hospital, especially surgery patients.
photocap:Embracing change: Dr. John Collins, medical director
of Northeast Health.
Six Interventions to Change Health Care
rapid response teams at the first sign of patient decline.
Deliver reliable, evidence-based care for acute myocardial
infarction [heart attack].
Prevent adverse drug events by implementing medication reconciliation.
Prevent central line infections by implementing a series of
interdependent, scientifically grounded steps.
Prevent surgical site infections by reliably delivering the
correct perioperative antibiotics at the proper time.
Prevent ventilator-associated pneumonia by implementing a
series of interdependent, scientifically grounded steps.
Prize from 100K Lives
an odd-couple coalition of hospital trade associations, employer
associations, consumer groups, healthcare unions and lawmakers
held a press conference to announce their support for a bill
to establish a system for public reporting of hospital-acquired
infections. The categories track IHI’s three infection-related
targets: surgical-site infections, central line infections,
and ventilator-associated pneumonia.
The bill mandates that each hospital maintain a program for
reporting each infection acquired by a patient at the hospital,
some resulting from errors and others considered unavoidable.
Hospitals will transmit the information to the State Department
of Health, which will compile it into comparative tables on
hospital infection rates. Patients about to choose a hospital
can check a Web site to find out which hospitals have the
highest and lowest rates of post-surgery infections.
If successfully implemented, a system for reporting hospital-acquired
infection systems would put New York state at the forefront
of the hospital-safety movement. It would also radically energize
hospitals to improve their infection-control systems. Consider
the success of the Cardiac Surgery Reporting System. In 1989,
New York became the first state to compile and release hospital-by-hospital
mortality rates for cardiac surgery. Under the bright spotlight
of publicity, hospitals around the state slashed their mortality
rate by 41 percent over four years. In 1989, St. Peter’s Hospital
in Albany was found to have an alarming 26 percent mortality
rate for emergency cases. By 1993, the hospital had cut its
mortality rate to 0 percent. That’s right, 0 percent.
But implementing hospital-acquired infection reporting won’t
be simple. Dr. Edward Hannan, Chair of the Department of Health
Policy, Management and Behavior at the University at Albany
School of Public Health, helped devise and manage the Cardiac
Surgery Reporting System. He warns of pitfalls ahead. For
example, publicly reporting hospital-specific data could create
incentives for hospitals to understate infection cases. “The
state will need to identify which of the millions of hospital
cases where no infections were reported should be audited,”
says Dr. Hannan. That could be difficult and expensive. “It
may not be rocket science, but it ain’t marbles either.”
One factor seems to herald good tidings to come: the support
of the hospitals being asked to report. It might seem a little
startling that the hospital industry would endorse a reporting
system that may draw unfavorable publicity to a few hospitals
each year. But Kathy Ciccone of the state hospital trade association
waxes enthusiastic about the new bill. “Infections are an
area that hospitals work very hard on,” argues Ciccone. “Our
patients have told us they want more information about infections,
and this gives us an opportunity to develop information that’s
You’re Checking Into A Hospital
would Don Berwick want you to know?
Much of the information that hospitals are using in the 100,000
Lives Campaign is, well, impenetrable to laypeople. But for
patients concerned about getting a hospital-acquired infection—and
if you’re not, you should be—100K Lives has valuable information
Here are some questions to ask your surgeon from IHI’s How-To
Guide on Preventing Surgical Site Infections. The right
answer is in parentheses, although it should be noted that
there are always patients for whom the standard procedure
may be incorrect.
Do you give antibiotics within one hour of incision time?
Do you stop giving antibiotics within 24 hours of surgery
end time? (Yes.)
Do you shave your patients with a razor prior to surgery?
Do you take steps to prevent patients from becoming hypothermic
(cold) during and after surgery? (Yes.)
Do you maintain glucose control in your patients? (Yes.)
The full text of each how-to guide is on IHI’s Web site at
www.ihi.org/IHI/Programs/Campaign. Also, Don Berwick wrote
a request for proposals to find a surgeon to replace his right
knee. Every hospital patient in America should have a copy.
It’s available at: http://tinyurl.com/6ydk6.