Source: Fortune
Summary
Anders Pederson died after donating a kidney to his sister, Kelly, due to preventable medical errors. His case highlights a systemic issue in healthcare, where preventable harm leads to thousands of deaths annually. Experts argue that existing evidence-based practices could reduce these deaths by 90%. Despite this, many hospitals have not implemented these protocols. A hospital in California achieved zero preventable deaths by adopting these practices and aligning incentives with safety goals. A 2023 report outlined policy changes to incentivize hospitals, but implementation stalled. Critics argue that the cost of inaction is too high, and hospitals must prioritize patient safety as urgently as other national priorities.
Our Reading
The numbers tell one story.
Preventable medical harm kills 250,000 a year in the U.S.
Existing protocols could cut that by 90%.
Hospitals rarely implement all 20 evidence-based practices.
A single reimbursement change could drive adoption.
Systemic failure is not a crisis — it’s a choice.
Author: Evan Null
The number hiding in plain sight
For more than two decades, patient safety experts have warned that preventable medical harm is one of the most urgent public health crises in America. Research suggests medical errors contribute to roughly 250,000 deaths each year in the United States, placing them behind only heart disease and cancer as a cause of death. Globally, the toll may reach 3 million deaths annually.
But here is what rarely gets stated plainly: if every hospital in this country implemented all of the evidence-based practices that researchers and clinicians have already identified and validated, we could reduce that death toll from approximately 200,000 a year to as few as 20,000, a 90% reduction. Not through new drugs or breakthrough science. Through protocols that exist today, posted on our website, available to any hospital administrator who cares to look.
That is not an aspirational goal. It is a quantifiable, achievable outcome that we are choosing, collectively, not to pursue.
In 1999, the Institute of Medicine’s landmark report To Err Is Human shocked the nation by estimating that 44,000 to 98,000 Americans were dying each year from preventable medical errors. That report was meant to ignite transformation. It promised accountability, transparency, and systemic change. By 2011, an OIG report showed we were losing 200,000 patients a year. Twenty-five years after that first alarm, families like the Pedersons are still paying the price.
Why the aviation comparison misses the point
When people talk about patient safety, they inevitably reach for the aviation analogy. Airlines transformed their safety culture; why can’t hospitals? It’s a fair comparison as far as it goes, but understanding why it breaks down reveals the real problem.
First, when a plane goes down, it dominates the news cycle for days. Medical errors kill the equivalent of two fully-loaded passenger jets every single day in America, and it barely registers. The absence of a single catastrophic, visible event means there is no public outrage, no pressure campaign, no congressional hearing.
Second, when a plane crashes, the pilots die too. That brutal alignment of incentives — skin in the game — drove aviation to make safety non-negotiable. When a patient dies from a preventable error, the doctors and nurses go home. That is not a criticism of healthcare workers, most of whom entered the profession to heal people. It is a structural reality: the system does not force those who design and deliver care to bear the consequences of its failures in the same visceral way.
Third, passengers can choose not to fly. That market pressure gave airlines a powerful financial incentive to fix safety problems fast. Patients who need hospital care have no such choice. They come because they must, which means hospitals face no equivalent consumer penalty for unsafe outcomes.
The lesson from aviation is not simply that bold safety goals work, though they do. The lesson is that healthcare lacks the self-correcting mechanisms that forced aviation to change. Which means those mechanisms have to be built deliberately, from the outside in.
What actually works: the CHOC model
We know this can be done because we have done it.
When I was asked to chair the quality committee at Children’s Hospital of Orange County, we brought in all 20 of the evidence-based practices the Patient Safety Movement Foundation had identified; standardized protocols for the specific, known causes of preventable harm: failure to rescue, medication errors, hospital-acquired infections, sepsis, communication breakdowns, venous thromboembolisms, falls, and diagnostic errors. The result: zero preventable deaths for more than six years straight, with serious harms dramatically reduced as well.
But the clinical protocols alone were not what made it work. The turning point was a governance decision.
When I joined the quality committee, I noticed that the hospital measured itself primarily against peers on a narrow set of Medicare “never events.” As long as they were slightly below the peer average, leadership felt comfortable. I asked a simple question: why isn’t the goal zero? To their credit, they agreed — and shortly after, the faculty suggested and the board voted to tie one-third of faculty bonuses to achieving zero preventable harm.
What happened next taught me everything about how institutional change actually occurs. Instead of hoping for zero, the hospital started planning for zero. Staff pulled every one of our evidence-based practices, color-coded their compliance — green for what they were doing, yellow and red for what they weren’t — and built a mitigation plan to close every gap. They didn’t achieve zero the first year. Instead of retreating, they doubled down. And then they did achieve it, year after year.
The policy fix that almost happened
The structural barriers to change are real, but they are not immovable. Between 2021 and 2024, I served on President Biden’s President’s Council of Advisors on Science and Technology, where we produced a detailed patient safety report outlining exactly what the federal government could do, without new legislation, to drive adoption of evidence-based practices across the healthcare system.
The report was released in September 2023 with significant attention and real momentum. Then October 7th happened, and it was overtaken by events.
As the Biden administration wound down, executive orders were drafted that could have used the levers of CMS reimbursement to create meaningful incentives for hospitals to act. CMS itself asked the White House to hold off, promising to implement the recommendations administratively. When the transition came, those recommendations were not implemented.
It is a familiar story in this space. I have spent years walking the halls of Congress, meeting with senators and members from both parties who express genuine alarm about preventable patient deaths, and then watching hospital industry lobbyists arrive to warn of financial burdens and regulatory overreach until the political will evaporates. The American Hospital Association is good at its job to the detriment of its members and patients.
The carrot, the stick, and the fix
What the PCAST report proposed, and what I believe remains the most viable path forward, is a reimbursement reform with real teeth.
Under the current system, a hospital can perform a hip replacement, cause a patient to die from a medication overdose, and still collect full payment for the original surgery. There is no financial consequence for the failure; in some cases, the complications generate additional billable care.
The proposal flips that logic. If a hospital has implemented all evidence-based practices and a patient is still harmed, the hospital continues to receive full reimbursement — for the original procedure and for any secondary care required to address the harm. We are not asking for perfection. We are asking hospitals to show up and do the work.
But if a hospital has not implemented the evidence-based practices and a patient is harmed, reimbursement stops, not just for the harm-related care, but for the original procedure as well. And the converse, if a patient is injured and the hospital had implemented the evidence-based practices to avoid that harm, then the hospital should be paid fully for everything, including the harm-related care. The argument to hospitals is simple: just dress for the game. We will worry about the scoreboard later.
I believe if that single reimbursement change were made, we would see rapid, widespread adoption of evidence-based practices within a few years, like we saw at the hospital that I chaired its quality committee. The hospitals that insist implementation is too costly would discover that not implementing is far more expensive.
