Challenges in Healthcare

Preventable Harms, Patient Experience, and Associated Costs

Incredible advances in medicine and technology are available to prevent, diagnose, and treat diseases, but our increasingly complex healthcare system still fails many patients.   Yet patient satisfaction, preventable harms during medical care, and penalties that medical institutions and physicians receive due to preventable errors are significant issues that plague the medical system.

Preventable Harms

Preventable harm causes up to 440,000 deaths per year in hospitals, making it the third leading cause of death in the United States today.1 Approximately 45-66% of these adverse events are related to surgery.2-4 It is almost ironic that while patients undergo surgery to get better, many of them will be subjected to further harm.  According to the CDC, about 51.4 million inpatient procedures are performed each year in the US.5 Based on calculations using published incidence rates for surgery-related adverse events,  between 976,600 to 1,850,000 people will potentially suffer from preventable harm during the perioperative period.2-4

While it is difficult to know for sure how many people die needlessly, the table below presents preventable harms data. While not every single incident of these events is preventable, focused efforts directed at reducing them individually can prevent as much as two-thirds of them.6,7

Table. Preventable Adverse Events – Annual Averages

Preventable Adverse Events Patients Per Year
Health-care acquired infections (HCAIs) 100,000 deaths8
Sepsis 200,000 deaths9
Deep Vein Thrombosis 300,000-600,000 incidences10
Diagnostic Errors 80,000 incidences11

Patient Experience

For many years, medicine has been based on a paternalistic patient-physician relationship, which has resulted in patients who do not fully understand their surgery, its risks, benefits, or alternative options, nor what to expect afterwards.  Such passivity and lack of knowledge often means that the people with the biggest stake in their health care outcomes – patients and their families – are ill-equipped to advocate for the best and safest care. Due to the poor patient-physician relationship and its lack of appropriate communication, patient satisfaction rates in medical care tend to be fairly low. One study found only about half (54%) of patients reported being satisfied with their care,12 while another found that lower rates of patient satisfaction were associated with higher 30-day risk-standardized hospital readmission rates.13

Associated Costs

In recent years, the Centers for Medicare and Medicaid (CMS) has begun to focus on preventable harms and patient satisfaction rates and developed metrics that seek to penalize those medical institutions and physicians with high rates of preventable adverse events and low patient satisfaction rates. CMS has developed various measures designed to address poor patient-physician communication, adverse events, hospital readmissions, and various other areas of patient safety and care quality. In 2014, nearly 1,500 hospitals will have their payments reduced up to 1.25% due to penalties based on quality,14 while 2,225 hospitals will pay $280 million in penalties for readmissions.15 Starting in 2015, an additional penalty will be imposed on close to 750 hospitals for hospital-acquired conditions, and hospitals stand to lose an estimated over $330 million in penalties.16

These increases in costs are not limited to the healthcare system. Patients are often affected, with costs frequently being passed on to them, either directly in the form of increased co-pays, or indirectly in the form of excess and unnecessary care. As healthcare costs continue to increase, more employers are moving to high-deductible plans, making patients responsible for more routine medical costs and a larger proportion of expensive treatments and hospitalizations. Around two-thirds of companies offer these high-deductible plans, with almost 20% offering nothing but. and another two-fifths considering it.17 This is potentially detrimental to patient care, with higher costs shown to make patients delay or skip needed care, leading to further costs.18  Employee contributions to their health care premiums have also increased nearly 150% in the past decade.19

The Solution: Patient Engagement

Despite CMS’s efforts, progress in reducing preventable harm and improving patient satisfaction remains slow across the U.S. Reports of transformative efforts for hospital-wide preventable harms are few and far in between. One avenue for decreasing preventable medical errors and improving patient satisfaction is through increased patient participation.20-23

Research into the causes of medical errors suggests that many of them could have been mitigated by patient involvement at various points, either as individuals or as a group.24  The World Health Organization World Alliance for Patient Safety campaign focuses on patients and their families as the core of their worldwide safety movement, to ensure legitimate and sustainable improvements in patient safety.25

Studies have shown that patients are ready to play a role in error prevention. Among nearly 2100 surveyed patients, the vast majority (91%) reported feeling that they could prevent medical errors occurring in hospitals, and almost everyone (98%) felt that hospitals should educate patients about how to help prevent errors.26 When patients were educated at the start of their hospital stay to ask their medical staff to wash their hands, the use of soap increased significantly (34% to 94%).27,28 In patient surveys taken after discharge, 90% to 100%27,29 of patients reported having asked a nurse and 31% to 35% asked a physician to wash their hands.28,29 Greater patient and family engagement in medical care also played a role in decreasing the incidence of medication errors by half at the Dana-Farber Cancer Institute.30

Better communication and shared decision-making between patients and doctors are also key components to help ease the complex journey of surgery, prevent medical errors, and improve patient satisfaction.31-33 Improving communication can also strengthen the relationship between doctors and patients. Research shows that patients who have a good relationship with their healthcare providers receive better care and are happier with their care.34 Even in the unfortunate event of a complication or error, good communication and a strong patient-physician relationship can decrease malpractices cases by as much as half.35,36 However, despite the existing successes and known benefits, more needs to be done.

Checklists for Patient Engagement

Checklists for doctors have long been shown to reduce patient complications and even death.37 Checklists have been particularly successful in improving outcomes after surgery. Training surgeons in communication and using a procedure checklist before, during, and after surgery has been shown to significantly decrease patient complications up to 30 days after surgery.38 One study found that a surgical safety checklist used at hospitals around the world reduced major complications after surgery by 36% and lowered the death rate by nearly half.39

Patient checklists can also help to reduce harm by helping patients to manage the complex preparation tasks that they need to accomplish, such as stopping certain medications before surgery or knowing when to stop eating or drinking prior to their procedure. They can also help alert patients to key safety points, for instance, enc death.37 Checklists have been particularly successful in improving outcomes after surgery. Training surgeons in communication and using a procedure checklist before, during, and after surgery has been shown to significantly decrease patient complications up to 30 days after surgery.38 One study found that a surgical safety checklist used at hospitals around the world reduced major complications after surgery by 36% and lowered the death rate by nearly half.39

ouraging patients to check with their doctors about DVT prophylaxis and perioperative antibiotic use to prevent infection.

A recent study of patients undergoing hip or knee replacement surgeries found that, when patients asked their surgeons a structured checklist of questions about their procedure, both patients and surgeons reported improved satisfaction with their communication, and patients reported being able to make a more informed decision regarding their medical care.40 Another study found that cancer patients who were given a list of common questions to ask their doctors about their care, reported feeling better and more informed about the care they received during their appointments.41

Electronic Tools for Health

Cell phones, electronic tablets, and other such devices are vital tools used ever-increasingly by patients for health purposes. For example, 31% of cell phone owners reported using their phones to look for health information in 2012, compared to only 17% in 2010.42  mHealth programs have successfully tackled aspects of various acute and chronic conditions like pneumonia, diabetes, HIV, tuberculosis and mental health.43,44 Significant benefits have also been demonstrated in care related to chronic disease conditions in the form of health information systems, appointment reminders, medication compliance, patient monitoring and education, mental health support, and supply chain management.43,44,45-47

Tapping into the large proportion of patients with mobile devices, text messaging and other mobile applications are being used to deliver health information and services in the palm of their hands. Services for patients include medical appointment and medication reminders, self-tracking tools, educational resources, lab and clinical results delivery, and many more through timely and often personalized applications.48 For example, a recent study showed a 2% decrease in Hemoglobin A1C in diabetic patients who used a mobile phone–based monitoring and insulin-dosing coaching system.49 However, the realm of patient engagement has been largely neglected by the growing use of mobile technologies in healthcare.50,51

Electronic Tools + Patient Engagement = Doctella

Doctella has created a simple solution that aligns required actions and incentives across the vast and complex healthcare system. Doctella democratizes critical information that has thus far been only accessible to highly trained medical professionals. This is particularly important given that patients and families are the only stakeholders in the healthcare system that span the entire continuum of care starting with the discussion of symptoms with family and friends, progressing onwards to specialized surgical care, and finally post-operative recovery and hopefully a return to health and wellness.

Checklists are a proven and tested way to ensure that complex tasks are completed in a high-quality manner. Doctors and nurses use checklists everyday to help them to effectively perform their difficult jobs. The complexity of the healthcare system also makes the job of being a patient a hard one. Using checklists can activate and engage patients and families in ways that have been shown to provide benefits of higher patient satisfaction, adherence, and ultimately better health, which often results in lower costs to the entire healthcare system.

Doctella helps patients to benefit from checklists. Our new mobile, web, and print platform hosts checklists created for patients. The platform is designed with easy-to-use search technology, reminders, and step-by-step questions patients can ask their healthcare providers.


Doctella seeks to harness the power of an electronic platform to engage patients and their loved ones during their medical care. Patient outcomes and satisfaction have been shown to improve as patients get more involved and engaged in their care, whether by being able to fully participate in decisions, carefully select when to receive care, or have the knowledge to choose between therapies that may or may not work for them.

Doctella’s goal is to help every patient ask the right questions and best prepare for their surgeries or other procedures by creating partnerships for better, safer health care. We believe that Doctella checklists, powered by the Doctella mobile app and website, will empower patients to watch out for preventable harm, better engage with their doctors, and ultimately lead to improve satisfaction and better long-term health outcomes.


  1. James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety. 2013; 9(3):122–128.
  2. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA: The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999, 126:66-75.
  3. Zegers M, de Bruijne MC, de Keizer B, Merten H, Groenewegen PP, van der Wal G, Wagner C: The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies. Patient Saf Surg 2011, 5:13.
  4. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams TBS, Elliott J, Mason HK, Weiler PC, Brennan TA: Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000, 38(3):261-271.
  5. CDC/NCHS National Hospital Discharge Survey, 2010.
  6. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-32.
  7. Brilli RJ, McClead RE Jr, Crandall WV, Stoverock L, Berry JC, Wheeler TA, Davis JT. A Comprehensive Patient Safety Program Can Significantly Reduce Preventable Harm, Associated Costs, and Hospital Mortality.  J Pediatr. 2013 Dec;163(6):1638-45.
  8. Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR, 2007.
  9. Wang HE, Devereaux RS, Yealy DM, Safford MM, Howard G. National variation in United States sepsis mortality: a descriptive study. Int J Health Geogr. 2010 Feb 15;9:9.
  10. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010 Apr;38(4 Suppl):S495-501.
  11. Pham JC, Aswani MS, Rosen M, Lee H, Huddle M, Weeks K, Pronovost PJ. Reducing medical errors and adverse events. Annu Rev Med. 2012;63:447-63.
  12. Rahmqvist M, Bara AC. Patient characteristics and quality dimensions related to patient satisfaction. Int J Qual Health Care. 2010 Apr;22(2):86-92.
  13. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011 Jan;17(1):41-8.
  14. Rau J. “Nearly 1,500 Hospitals Penalized Under Medicare Program Rating Quality.” Kaiser Health News. Nov 14 2013.
  15. The Advisory Board Company. “CMS: The 2,225 hospitals that will pay readmissions penalties next year.” Aug 5 2013.
  16. Rau J. “More Than 750 Hospitals Face Medicare Crackdown On Patient Injuries.” Kaiser Health News. June 22 2014.
  17. Hancock J. “Employer Health Costs Are Expected To Rise In 2015.” National Public Radio. June 24 2014.
  18. Galbraith AA, Soumerai SB, Ross-Degnan D, Rosenthal MB, Gay C, Lieu TA. Delayed and forgone care for families with chronic conditions in high-deductible health plans. J Gen Intern Med. 2012 Sep;27(9):1105-11.
  19. Kaiser Family Foundation and Health Research & Educational Trust. Employer Health Benefits: 2010 Summary of Findings. Accessed at on 20 April 2011
  20. Howe A. Can the patient be on our team? an operational approach to patient involvement in interprofessional approaches to safe care. J Interprof Care 2006;20(5):527-534
  21. Awé C, Lin SJ. A patient empowerment model to prevent medication errors. J Med Syst 2003;27(6):503-517
  22. Shaw JM, Letts M, Dickinson D. Adverse events reporting in English hospital statistics: patients should be involved as partners [letter]. BMJ 2004;329(7470):857
  23. The Committee on Identifying and Preventing Medication Errors; Institute of MedicineAspden P, Wolcott J, Bootman JL, Cronenwett LR, editors. , eds. Preventing Medication Errors Washington, DC: National Academies Press; 2006.
  24. Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010 Jan;85(1):53-62.
  25. World Health Organisation London Declaration: Patients for Patient Safety Published March 29, 2006 Geneva, Switzerland: World Health Organisation; Accessed July 15.
  26. Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. Brief report: hospitalized patients’ attitudes about and participation in error prevention. J Gen Intern Med 2006;21(4):367-370.
  27. McGuckin M, Waterman R, Porten L, et al. Patient education model for increasing handwashing compliance. Am J Infect Control 1999;27(4):309-314.
  28. McGuckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. Am J Infect Control 2004;32(4):235-238.
  29. McGuckin M, Waterman R, Storr IJ, et al. Evaluation of a patient-empowering hand hygiene programme in the UK. J Hosp Infect 2001;48(3):222-227.
  30. Conway J, Nathan D, Benz E, et al. Key Learning from the Dana-Farber Cancer Institute’s 10-year patient safety journey. In: American Society of Clinical Oncology 2006 Educational Book. 42nd Annual Meeting, June 2-6, 2006 Atlanta, GA: 2006:615-619.
  31. Tripathy D, Durie BG, Mautner B, Ferenz KS, Moul JW. Awareness, concern, and communication between physicians and patients on bone health in cancer. Support Care Cancer. 2014 Jan 30. [Epub ahead of print].
  32. Black N, Varaganum M, Hutchings A. Relationship between patient reported experience (PREMs) and patient reported outcomes (PROMs) in elective surgery. BMJ Qual Saf. 2014 Feb 7.
  33. Trudel JG, Leduc N, Dumont S. Perceived communication between physicians and breast cancer patients as a predicting factor of patients’ health-related quality of life: a longitudinal analysis. Psychooncology. 2013 Nov 11. [Epub ahead of print].
  34. Tips & tools – Agency for healthcare research and quality (AHRQ) [Internet]: Agency for Healthcare Research and Quality; 2011 [updated August 2011]. Available from:
  35. Chamberlain CJ, Koniaris LG, Wu AW, et al: Disclosure of “nonharmful” medical errors and other events: Duty to disclose. Arch Surg 2012;147:282-286.
  36. Wu AW: Handling hospital errors: Is disclosure the best defense? Ann Intern Med 1999;131:970-972.
  37. Health Research & Educational Trust. (2013, June). Checklists to improve patient safety. Chicago: IL. Illinois. Health Research & Educational Trust. Accessible at:
  38. Bliss LA, Ross-Richardson CB, Sanzari LJ, Shapiro DS, Lukianoff AE, Bernstein BA, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg. 2012 Dec; 215 (6) :766-76.
  39. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29; 360(5):491-9.
  40. Bozic KJ, Belkora J, Chan V, Youm J, Zhou T, Dupaix J, Bye AN, Braddock CH 3rd, Chenok KE, Huddleston JI 3rd. Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. J Bone Joint Surg. 2013 September 18; 95(18):1633-9.
  41. Yeh JC, Cheng MJ, Chung CH, Smith TJ. Using a question prompt list as a communication aid in advanced cancer care. J Oncol Pract. 2014 Mar 4. [Epub ahead of print].
  42. Abebe NA1, Capozza KL, Des Jardins TR, Kulick DA, Rein AL, Schachter AA, Turske SA. Considerations for community-based mHealth initiatives: insights from three Beacon Communities. J Med Internet Res. 2013 Oct 15;15(10):e221.
  43. Martin T. Assessing mHealth: Opportunities and Barriers to Patient Engagement. Journal of Health Care for the Poor and Underserved. Volume 23, Number 3, August 2012
  44. 935-941.
  45. Fox S, Duggan M. Pew Internet and American Life Project. Washington, DC: 2012. Nov 08, [2013-06-20]. webcite Mobile Health 2012
  46. de Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for facilitating self-management of long-term illnesses. The Cochrane database of systematic reviews. 2012;12:CD007459. Epub 2012/12/14.
  47. Kumar S, Nilsen WJ, Abernethy A, Atienza A, Patrick K, Pavel M, et al. Mobile health technology evaluation: the mHealth evidence workshop. American journal of preventive medicine. 2013;45(2):228-36. Epub 2013/07/23.
  48. Car J, Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R. Mobile phone messaging reminders for attendance at healthcare appointments. The Cochrane database of systematic reviews. 2012;7:CD007458. Epub 2012/07/13.
  49. Price M, Yuen EK, Goetter EM, Herbert JD, Forman EM, Acierno R, et al. mHealth: A Mechanism to Deliver More Accessible, More Effective Mental Health Care. Clinical psychology & psychotherapy. 2013. Epub 2013/08/07.
  50. Sloninsky D, Mechael P. Towards the development of an mhealth strategy: A literary review. New York, USA: WorldHealth Organization and Earth Institute, 2008.
  51. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev. 2010 Apr; 32(1):56-69.
  52. Quinn CC, Shardell MD, Terrin ML, Barr EA, Ballew SH, Gruber-Baldini AL: Cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care 34:1934–1942, 2011.