The Hospital Safety Plan That Could Have Saved Thousands of Lives Stalled

WASHINGTON — Preventable medical errors kill an estimated 250,000 patients in the United States every year, according to a landmark study by Johns Hopkins University researchers published in *The BMJ*. That places medical failures behind only heart disease and cancer as a cause of death in the country. The World Health Organization estimates that preventable medical harm claims up to 3 million lives globally each year.

Patient safety advocates say as many as 90% of those domestic deaths could be avoided if hospitals adopted 20 established, evidence-based clinical protocols. Yet a major federal effort to connect Medicare and Medicaid reimbursements to those protocols stalled during the transition between administrations, leaving advocates and healthcare experts warning that hundreds of thousands of preventable deaths will continue to go unaddressed.

The stalled policy also exposed the systemic barriers and powerful lobbying interests that have blocked clinical safety reforms for a quarter of a century. The American Hospital Association (AHA) and other industry representatives have historically opposed such measures before Congress and federal agencies, arguing that strict reimbursement penalties would create undue financial burdens, worsen staffing shortages, and fail to reflect the clinical complexities of high-risk patients.

Anders Pederson’s death illustrates the consequences of those gaps. From early childhood, Pederson protected his sister, Kelly, whose kidneys had been severely damaged by an illness when she was 15 months old. When Kelly turned 30 and her kidneys began to fail, he immediately volunteered to donate one of his kidneys.

The transplant surgery was initially considered successful. The following morning, Pederson visited Kelly’s hospital room and told her that donating his kidney had been the best day of his life. Hours later, he developed severe postoperative pain and vomiting. Staff changed his pain medication, but clinical monitors failed to identify critical signs that his condition was deteriorating.

When Pederson’s mother returned to his room, she found him cold to the touch, with blue lips and no breathing. He fell into a coma and died nine days later. His family was first told that his heart had simply stopped, but after demanding a further investigation, they learned that inadequate postoperative monitoring, poor medication management, and other preventable failures had caused the death of the healthy donor.

The proposed federal response emerged from work conducted between 2021 and 2024 by the President’s Council of Advisors on Science and Technology (PCAST). In September 2023, PCAST issued *A Report to the President on Transforming Patient Safety*, describing how the federal government could use existing authority to speed adoption of evidence-based safety practices without new congressional legislation.

The plan centered on drafted executive orders using the financial leverage of the Centers for Medicare & Medicaid Services (CMS). Under the current U.S. healthcare billing system, hospitals generally face little or no financial penalty when a patient is harmed by a preventable error. A patient undergoing an elective hip replacement, for example, may suffer a life-threatening medication overdose during recovery while the hospital still receives full payment for the original surgery. The hospital may also bill government and private insurers for additional care needed to treat complications caused by the error.

The PCAST proposal would have created a “carrot and stick” reimbursement model. The carrot would give a hospital full reimbursement for the original procedure and all subsequent complication-related care if it had implemented all 20 recognized evidence-based safety protocols and the patient still experienced an adverse event. The stick would allow CMS to withhold reimbursement for both the complication treatment and the original surgical procedure when a hospital had failed to implement the 20 protocols and a patient was harmed.

Proponents said the approach would make hospital administrators treat safety protocols as financial necessities instead of voluntary guidelines. During the drafting process, however, CMS officials asked the White House to pause the executive orders, promising to carry out the recommendations through administrative rule-making. The administrative changes were not finalized before the presidential transition, and the initiative stalled.

Patient safety experts contrast healthcare’s continued mortality from medical errors with commercial aviation’s safety revolution. An airliner crash is a highly visible, singular event that dominates global news and prompts immediate federal investigations. Medical errors, by comparison, kill the equivalent of two fully loaded passenger jets every day in the United States, but the deaths occur quietly in isolated hospital rooms without a collective public outcry.

The industries also differ in what safety experts call “skin in the game.” Pilots share the immediate physical risk of a crash with passengers. Clinicians can be deeply affected emotionally by patient deaths but do not face the same physical consequences, while hospital corporations often remain financially insulated from the clinical outcomes of their errors. Consumers can also avoid airlines with poor safety reputations, creating a market incentive for carriers to maintain flawless records. Patients who need urgent care or specialized procedures rarely have comparable consumer choice, leaving hospitals protected from market-driven safety pressure.

A localized model at the Children’s Hospital of Orange County (CHOC) demonstrates that a zero-harm threshold is clinically achievable. A quality committee previously chaired by Joe Kiani, a PCAST member and founder of the Patient Safety Movement Foundation, implemented all 20 of the foundation’s Actionable Patient Safety Solutions (APSS).

The protocols address failure to rescue deteriorating patients, medication administration errors, hospital-acquired infections and sepsis, clinical communication breakdowns, venous thromboembolisms or blood clots, patient falls, and diagnostic errors. CHOC’s board of directors tied one-third of the clinical faculty’s financial bonuses directly to achieving zero preventable patient harm. Staff used color-coded compliance trackers—green, yellow, and red—to map adherence and systematically close operational gaps.

After the measures were introduced, CHOC recorded zero preventable patient deaths for more than six consecutive years, as well as a steep decline in overall patient harm. Fewer than five hospitals nationwide, however, have implemented all 20 validated, evidence-based practices, according to patient safety organizations. Most U.S. hospitals have adopted only three or four.

The slow adoption rate followed repeated federal warnings. In 1999, the Institute of Medicine, now the National Academy of Medicine, published *To Err Is Human*, estimating that preventable medical errors killed between 44,000 and 98,000 Americans annually. By 2011, an Office of Inspector General (OIG) report said the yearly death toll had moved closer to 200,000.

“We are not asking for clinical perfection,” Kiani said in past discussions on safety metrics. “We are asking hospitals to dress for the game. If every hospital tried, even if we fell short of zero, we would still save more than 180,000 lives a year. That would stand as one of the greatest public health achievements in American history.”

With federal administrative reforms still on hold, patient safety advocates continue lobbying state regulators and private insurers to adopt similar reimbursement penalties, arguing that until hospitals face direct financial consequences for failing to implement safety standards, patients will continue to face preventable risks.