Preventability of Adverse Events in Healthcare – Who Decides?

Prevention of adverse events in healthcare has rightfully become a cornerstone of progressive risk management and has been assuming greater importance every year. It is interesting that this focus on preventing adverse events in healthcare is relatively new and is now being increasingly linked with reimbursements and liability.

What is seldom understood is that as more and more is considered to be preventable in healthcare, the potential for liability for those events now deemed to be preventable also increases- or in other words… when nothing was preventable there was little liability.

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2cad158I personally give much of the credit for the increased focus on preventability to a physician from Johns Hopkins (Dr. Peter Pronovost) who several years ago designed a study directed at instituting a series of interventions or best practices (now appropriately called a “bundle”) to reduce the incidence of central line-associated bloodstream infections or CLABSIs in intensive care units in Michigan hospitals.

Not only was Dr. Pronovost successful at reducing CLABSI incidence but his series of interventions or bundle pretty much ELIMINATED this very costly and very serious infection from the facilities utilizing these interventions. After the results of this study were published, the concept of prevention began to hit the healthcare radar screens just as the notoriety and incidence of healthcare-associated infections began to skyrocket.

The knowledge and understanding that prevention of at least some infections as well as other healthcare related adverse events was now possible (even though it was probably possible for many years before) earned Pronovost a BBW dating app for Android and iPhone… “genius” award but probably more importantly, got the attention of the government, the insurance industry, and the legal community.

For the government, this knowledge translated into requiring increased reporting by states of adverse healthcare events so that facility performance comparisons could be made.

For the insurance industry (and organizations such as Centers for Medicare and Medicaid Services-CMS), consideration was now given to withdrawing reimbursements for an ever-growing list of preventable healthcare events.

For the legal community, changes to the standard of care, the burden of proof, along with increased liability and more late night infomercials followed shortly thereafter.

And in healthcare, risk managers and infection preventionists began to focus on “zero” with respect to infections as well as other adverse events to maintain reputation, retain reimbursements, prevent liability, and improve the standard of patient care.

While few would dispute the significance and importance of the focus on preventability of adverse events, there is much less agreement with respect to what is actually preventable as well as the degree of preventability. The reasons for this are that healthcare issues and especially infections are complex matters which have in many cases been oversimplified in the quest to regulate, insure, and reimburse.

In fact, some really smart clinicians have told me there are some infections that are actually not preventable at all and achieving a sustainable zero result in healthcare for almost any issue is not particularly realistic or possible. Despite this, the regulations are coming, the reporting requirements are coming, the reduction in payments are coming, and the litigation will follow and healthcare is supposed to improve as a result.

But is there a danger here in overregulating and diverting resources in order to comply with something that may be unattainable… and who is making those decisions? Patient fall prevention is one of those adverse events which everyone would agree is a noble goal and is always given top priority especially in acute care facilities, however there is considerable debate as to whether patient falls are actually preventable.

Excellent research papers, written by folks way smarter than myself, have determined that most falls cannot be consistently and effectively prevented through the application of evidence-based guidelines and that no intervention has been shown to reduce the risk of serious injury. Yet CMS, has determined that falls should not occur after hospital admission and so has curtailed reimbursements for this issue. Ironically, this may encourage the increased use of physical restraints to reduce falls which can actually result in more patient harm (loss of mobility, pressure ulcers, agitation, etc.).

The danger here is that we may have become so focused on the very noble goal of achieving 100% prevention of any and all adverse events in healthcare that in our zealousness we may have forgotten that creating unrealistic and unachievable goals can have negative consequences. In addition, in this complex healthcare arena, the failure to involve clinicians in the decision making process at all levels-regulatory, reimbursement, and legal may lead to what H.L. Mencken called the easy solution to all problems- “neat, plausible, and wrong.”

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