Patient safety has received more attention than usual recently – with a new survey by The Leapfrog Group, a Senate inquiry, articles in the consumer media and our own cover story this month.

There's no escaping this knotty and weighty problem. It's a matter of life or untimely death for so many. 

As prominent patient safety expert Peter Pronovost, MD, put it at a Senate hearing on July 18, "What these numbers say is that every day, a 747 – two of them – are crashing. Every two months, 9-11 is occurring…we would not tolerate that degree of preventable harm in any other forum."

Pronovost was one of several patient safety advocates speaking before the Subcommittee on Primary Health and Aging.

Healthcare IT figured prominently, with several speakers agreeing with Pronovost that despite large investments in information technology, the promise of improved patient safety and savings have yet to be realized. 

We agree. While we can't discount the incremental improvements in patient safety made year over year, something broader and bigger needs to occur – more attention, more effort, better tools – specifically better electronic medical records. 

"… The potential is not going to be realized unless those tools are really focused on improving patient safety," Ashish Jha, MD, professor of health policy and management at Harvard School of Public Health," told the Senate panel. "The tools themselves won't automatically do it."

The most recent survey from The Leapfrog Group shows that on computerized physician order entry, even more than a decade later, big problems remain. The increase in uptake of CPOE technology is promising for patient safety. But, deploying CPOE is not enough.

As Leapfrog's Erica Mobley told us, " It's not one of those systems that "once you get it, you're set." The technology must be updated, modified and adapted to each hospital. And, it's critical to test the system every year, she added. "Just because it was working well once doesn't mean that it's going to continue to work well."

In its most recent survey released last month Leapfrog showed that the number of potentially fatal medication orders that did not receive an appropriate warning went from 14.2 percent in 2012 to 12.5 percent in 2013 – an improvement, but ever so small.

"In 2013, CPOE systems did not alert physicians to one-third of the test orders that would have led to an adverse patient event," according to the Leapgrog report. "Even more troubling, the CPOE systems did not catch one in six of the test orders that would have resulted in death had the order been administered to a real patient. This failure rate is far too high, and points to the critical need for hospitals to make additional improvements to their medication ordering processes."

Indeed.

Yes, the tools – CPOE, EHRs and so many others – require retooling. In tandem, it is also critical to provide caregivers with the training, support and guidance that is critical to keeping them at the top of their game, with the right can-do attitude and problem-solving skills required every day on the job. 

Someday, the esteemed Institute of Medicine might issue a report titled "To Correct is Human," instead of "To Err is Human."

"The tragedy that we're talking about here (is) deaths taking place that should not be taking place," said subcommittee Chair Sen. Bernie Sanders, I-Vt., in his opening remarks of the Senate subcommittee hearing. 

Well put.

In his column below, Neil Versel describes indignities – some suffered, others averted – that he witnessed before his father died: eye drops that had not been ordered; a diabetes test that was intended for a patient in another room; intubation against an advance directive on file; contraction of pneumonia – yes, one of those ubiquitous hospital-acquired conditions.

The healthcare system – each practice, each hospital, each physician, nurse, technologist, patient and consumer – can and must do better. We're working on it, but we as the collective "system" need to expect better, demand better and do better – and do so with more care, determination, energy and speed than ever before. We need improved attention, advocacy, care – and technology, and we need it STAT.