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Making Hospitals Safer for Hoosiers: State's Efforts Include Patient-Safety Center, Error Reporting

Posted on: Thursday, 1 June 2006, 06:00 CDT

By Jennifer L. Boen, The News-Sentinel, Fort Wayne, Ind.

May 31--While public-health officials track bird flu, tuberculosis and AIDS, others are keeping tabs on what some experts say is an epidemic of a different kind: medical errors made in hospitals. Beginning this year, Indiana hospitals must now report serious mistakes. Indiana is the second state behind Minnesota to require it.

HealthGrades, a for-profit company that examined records of 40 million Medicare patients, reported in May that incidents such as post-operative infections and surgical instruments being left in people increased from 1.14 million (1999-2001) to 1.24 million (2002-2004). Those patients have a one in four chance of dying during hospitalization, the study found.

But hospital personnel pointing fingers at one another, victims seeking excessive damages, and hospitals failing to admit errors have hurt patient safety and worsened a "do no harm" culture.

The Indiana Hospital & Health Association hopes to change with the start of the Indiana Patient Safety Center on July 1, in

collaboration with Indiana University School of Medicine, Purdue University's Regenstrief Center for Healthcare Engineering and the Indiana State Medical Association.

"Patient safety is moving away from 'If the wrong leg is cut off, who did it?' to finding out how we approach what it is that caused the fault and building a system to prevent it from happening again and sharing it widely in the field," said Bob Morr, vice president of the association.

Indiana is one of a handful of states to develop patient-safety centers in response to the federal Patient Safety and Quality Improvement Act of 2005. The goal is to have a blame-free culture in which hospitals voluntarily share "not only the serious errors but also the near-miss occurrences," said Betsy Lee, director of the Patient Safety Center.

Morr said all 167 member hospitals in the association will be encouraged to participate. "This will not be a report card on who is the safest. This is not about competition. The primary focus is not the public, but it is in the care-giving family to build a system to prevent harm." Eventually, the public will be informed of lessons learned and what role it can play in change, he said.

Federal rules covering safety centers will grant immunity for hospitals sharing their medical errors, although Lee said those rules are not yet finalized. "There is a lot that needs to be forthcoming. But the goal is confidentiality and protection of sharing between organizations."

Dr. Michael Schatzlein, chief operating officer of Dupont Hospital, supports the center. "I see this as a systems approach. There aren't people doing wrong things. There are complex systems that need to be refined and improved.

"We need to disclose outcomes and complications," similar to the way the Federal Aviation Administration did to improve airline safety. "Consumerism is on the rise and should be. Professionals -- hospitals and doctors -- have to be able to present this information that is really honest and meaningful information to the consumer."

When the FAA created a system in which flight crews members did not have to fear job loss or retribution for disclosing impaired pilots or "near misses," the FAA improved communication and the number of crashes fell. "It's not about looking at the crashes. I'm more interested in not letting that crash ever happen," Schatzlein said.

Likewise, revising the way of thinking in hospitals -- doctors always being right, nurses or other personnel fearful of questioning or disagreeing with them -- creates a more amenable culture for improved communication, Morr said.

The Regenstrief Center will analyze hospital data to look at such things as root cause. "We know certain conditions may lead to an error, (but) how do we change the system to prevent the error?" said Steve Witz, director of healthcare engineering within Regenstrief.

David Farnbauch, a medical-malpractice lawyer in Fort Wayne, is dubious about how effective the Patient Safety Center will be unless hospitals are completely transparent in their mistakes. "Only a very small percentage of medical errors are ever charted," he said.

According to a study by Dr. Saul Weingart, director of the Harvard-affiliated Center of Patient Safety at the Dana-Farber Cancer Institute, nearly half of "adverse events and near misses" hospital patients and their families report were not found in patients' medical records.

"The No. 1 problem with medical malpractice is in the vast majority of instances resulting in medical malpractice, the errors are never charted," Farnbauch said. Patients and families, with their attorneys, must push for answers, he said.

Tom Manges, a personal-injury lawyer in Fort Wayne, agrees. "The internal reports are not kept in the patients' charts." Attorneys must do a lot of digging to access the information, he said. "I don't see how they're going to do this. What incentive are they going to have?" he asked of hospitals' willingness to divulge errors.

Indiana's new Medical Error Reporting System rule mandates that hospitals report any of 27 "adverse events" or errors, to be made public along with the name of the hospital; names of patients, doctors and nurses will not be public.

The first reports will be available in January, said Terry Whitson, assistant commissioner of the state's Health Care Regulatory Services, although a limited report may be issued before then. But the weak link in the state's system is that the reporting is retrospective, not prospective, Schatzlein said. Near misses or close calls are not reported.

Dr. Jamie Roche, senior vice president of medical affairs for Parkview Hospital, points to the fact the state is not calling for action plans, only reports of problems. "With the Patient Safety Center ... we are starting at the beginning as opposed to after the event."

Hospitals treating Medicare patients must also make quarterly reports to the federal Centers for Medicare and Medicaid Services on how well they are meeting specific quality measures. For example, they must track if older patients are being vaccinated against pneumonia and whether heart-attack patients are given aspirin on admission and being sent home on an aspirin regimen. The quality measures are based on evidence gathered on best patient outcomes.

Roche says, like the state medical error reporting system, these reports , which are then tied to Medicare reimbursement, do not necessarily speak to the changes needed. Morr agreed, saying even highly qualified people could be working within a flawed system.

The Patient Safety Center will build on still another health-care-improvement program called the 100,000 Lives Campaign, a 15-year-old, voluntary effort of the Institute for Healthcare Improvement to reduce needless hospital deaths, pain and suffering. The campaign's goal is to reduce by 100,000 annually the number of hospital deaths caused by medical and safety errors.

The Joint Commission on Accreditation of Health Care Organizations, or JCAHO, the main accrediting body for hospitals, has still another system of measuring hospitals' quality-of-care.

"Outcomes data is being reported in so many different ways by so many different people," Schatzlein said. As for the Indiana Patient Safety Center, "It may be five years before there's actual information for patients.

"But in the meantime, if I were a Hoosier, I'd say I'm glad that the hospital association, the state medical association and the other sponsors of the patient safety center are working together on processes," he said. "Through improved processes we can prevent the 'nevers' and promote positive outcomes, rather than just exposing the 'nevers.' "

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Patient safety: By the numbers

--98,000: The estimated number of deaths occurring each year in U.S. hospitals because of medical errors, according to a 1999 Institute of Medicine report

--82,000: The number of Medicare patients dying each year due to preventable hospital medical errors, according to HealthGrades, a company that rates hospital performance

--Indiana's first hospital-errors report will be made public in early 2007.

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Copyright (c) 2006, The News-Sentinel, Fort Wayne, Ind.

Distributed by Knight Ridder/Tribune Business News.

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Source: The News-Sentinel (Fort Wayne, Ind.)

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