A Modest Proposal: Let’s Create A National Patient Safety Reporting System …


by Kevin Fickenscher

First posted on The Fickenscher Files on 9/13/2013

Kevin Fickenscher, MD, CEO AMIAInformation for your consideration…

In my various presentations across the country, I frequently begin by quoting Marcel Proust who said, “The issue is not in finding new lands.  The issue is in seeing the territory with new eyes.”  We are at that point.  The disruption in the traditions of healthcare is all around us.  And, even though I’m a technophil, I also recognize that technology – in all of its various manisfestations – is the core reason for much of the disruption.  The Internet and mobility are changing our approach to professional collaboration.  Knowledge diffusion and virtual delivery are further altering the framework of how and where we deliver various services.  The end result is that the healthcare system needs to move toward “knowledge creation”.  So, the question is – how do we accomplish that goal?  There are multiple avenues but one such avenue that needs to be seriously considered is the creation of a national “Healthcare Patient Safety Reporting System.”

But, rather than jumping into the concept, let’s take a look at another industry – aviation.  In April 1976, through an act of Congress, the Aviation Safety Reporting System was implemented.  In essence, the system allows pilots, cabin crews, dispatchers, maintenance personnel – virtually everyone who is in and around an airplane to submit a report on a safety problem.  When the system was originally turned on it generated about 400 reports a month; however, it now generates over 5000 reports per month – with the vast majority of those reports submitted by the air carriers themselves.  Why?  Because it generates knowledge on safe airline practices!  The process for the system allows for anyone to submit a report, which is then screened, alert messages are dispatched (if necessary), matching of similar alerts is made, an analysis of the data completed, de-identification occurs, quality checks are performed, and, process improvements are suggested – for ech and every problem that is submitted!!  Imagine that type of system for healthcare…

I fly every week.  I don’t worry about a plane crash.  In fact, the odds of an accident if you fly one of the top 39 airlines in the world is 1 in 10 million and the odds of a fatality are 1 in 20 million.  By the end of 2014, we will have invested close to $25B toward transforming healthcare by shifting it from a “dead data” system of paper charts to a “live data” system that involves the use of health information technology.  Suddenly, we will have information that is digital.  We will be able to capture it, analyze it, de-identify it, perform quality checks on it.  In other words, we will be able to dramatically improve the care that is delivered.  This is the promise of health information technology.

So, let’s consider just one problem – hospital acquired infections (HAIs).  The Centers for Disease Control and Prevention (CDC) estimates that there are roughly 1.7 million hospital-associated infections which cause or contribute to 99,000 deaths each year at an annual cost of between $4.5 billion to $11 billion.  A more recent review suggests that the cost for five of the most common problems represents an additional cost of $9.8 billion of wasted expenditures. Those most frequent type of infections are urinary tract infections (36%), followed by surgical site infections (20%), and bloodstream infections and pneumonia (both 11%).  On September 2, a new meta-analysis was released on JAMA Net noting that the central line–associated bloodstream infections were the most costly HAIs at $45,814, followed by ventilator-associated pneumonia at $40,144, surgical site infections at $20,785; and, catheter-associated urinary tract infections at $896.

In 2012, there were 35 million admissions to hospitals across the nation resulting in about one infection for every 20 admissions and one death for every 350 admissions.  That means, that the average 350 bed community hospital with roughly 25,000 admissions would experience 70 deaths from hospital acquired infections on average or, about five deaths per month or roughly one a week.  So, if you figure out the odds of death, it comes to roughly one in 100.

Now, we know that nosocomial infection rates can be dramatically reduced. We are doing it…slowly.  We could go much faster, however, if we had a national Healthcare Patient Safety Reporting System in place.  We also know that the rate of such infections rate varies considerably from hospital to hospital.  If we had a national Healthcare Patient Safety Reporting System in place, we could learn from one another.  We could identify best practices.  We could be like the airplanes – a relatively safer place to be than it was back in 1976 when the aviation safety reporting system was first put in place.

More importantly, hospital acquired infections are just one problem!!  Imagine if we “reported” all incidents and all problems in healthcare?  Imagine if we were like the airline industry and had a “healthcare patient safety reporting system?”  You would all volunteer to be admitted to the hospital…  Let’s see: one in 20 million as a change of death by flying an airplane today or 1 in 100, as a result of being admitted to the hospital.  My friends – which would you rather do today?

We have the capability.  There is a way.  We need the will. Now is the time.

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Dr. Kevin M. Fickenscher is the Founder of CREO Strategic Solutions, LLC – an organization focused on senior executive strategic support, leadership development and assistance with evolving care delivery models. Previously, he served in a variety of leadership roles within the healthcare industry on both a domestic and international basis. He is a recognized physician executive with extensive experience in strategic and operational development in complex healthcare organizations. He is a thought leader related to technology and information management and holds extensive experience in organizational transformation and development, physician management, health policy analysis, leadership development, clinical quality and resource/care management, among other areas. Dr. Fickenscher is considered to be a dynamic, visionary leader in healthcare throughout the world has consistently been ranked among the Most Powerful Physician Executives in Healthcare by Modern Healthcare.


  1. While needed, I predict a break down in the reading and follow-up process. My complaints probably would be sorted into the nuisance pile. My normally good doctor refused to treat out-of-range hypothyroidism for 6 months. I finally began harassing him through the EHR. I’m feeling a little better, but I realized that I have some blood infection. I found an 80 year-old Dr. at Urgent Care that listened to my complaints and ran a strep test-ACUTE.

    OK, Nov 16, 2013, my son’s birthday, I was diagnosed with an aggressive atypical BCC under my nose. The ACS stop-gap temporary recommendation is cutting out nose, bone, flesh, skin beyond the cancer field. Prosthetics. The catches: doctor added eye and sinus cavities, wouldn’t tell me what would happen to my body while waiting for prosthetics, how long B4 new face, they refused to run lab work to see if I was a good surgery candidate, etc. It takes a year to do this after I lie down on the surgery table. I took a biker to scare some answers out of the quack on the only follow up that I had with him. I had radiation-I seem 2B in remission. I went up and tried to talk to clinic supervisors, I called, I wrote letters , sent Emails , I even called and tormented MD Anderson in Houston. At the end of radiation, I went up and screamed, cursed, pounded the desk, kicked the walls. While part of my nose is gone, with part of lip and tissue in between. Nobody notices-really- I had a good surgeon do the biopsies. Problem, I wasn’t given any pain killers to take home-I’m allergic to NSAIDs and ace taphemins. The muscles to suck on a straw were removed. I lived on sherbert for weeks. The inside of my mouth swelled up.

    So how do I complain that some of my doctors don’t want to care for me because of the type of cancer that I have? How do I complain that my head oncologist didn’t schedule any follow-ups, but wouldn’t release me to another doctor? I do have another doctor-he’s good and kind, but my PCP expects me to get all of my care in oncology. He keeps saying that he doesn’t do cancer. I have a follow up for the strep on Friday. I need to see if my PCP cancelled that appointment too.

    Because I’m not dead. I’m disappointed in some of the doctors. They didn’t run tests that I wanted (lab work and strep). I wasn’t given pain killers. What section would my complaints be in? I was bit by a dog, was in ED withing 15 minutes, told them that I had cancer-radiation, wasn’t treated properly, given a low dose of antibiotics. I told everybody the teeth scraped the bone. 50 hours later I was admitted to the main hospital with green pus in each puncture. Through misreading of the EHR, I was released with antibiotics. I complained about that. They wouldn’t call my doctor; they told me that I was old, high on codeine and morphine. I was scared to go back to the ER, wouldn’t you? I checked with every pharmacy. My PCP started the correct antibiotics, then ignored my later complaints of fever, sore throat, a few days on a few days worse.
    I just sound like a disgruntled patient to a software program, and to administration people reading my complaints an old and grumpy patient. My goal-to get as well as I was when my radiation ended.