Preventable Medical Errors

Missouri Purges Data From Infection Records

An article by Jim Doyle exposes the fact that the State of Missouri has deleted hospital infection data from their records citing that it is too costly to maintain and too sensitive for the public to review for more than a year. 

Doyle writes:  "Without access to infection data from previous years, consumers won't be able to adequately assess a hospital's performance in preventing infections, consumer advocates say. Specifically, the policy of the Department of Health and Senior Services makes it difficult to review how hospitals have performed over time and whether they perform consistently above or below the national average."

This decision to purge data has stirred a heated political, legal and social debate regarding public health records. 

Rep. Rob Schaaf, R-St. Joseph, a family-practice physician who pushed the infection bill in the Legislature is quoted as saying, "It's pretty sad to me that the (health) department can't give you a trend to show that a hospital is getting better or worse. It shows that the department doesn't really care,"

Senator Sarah Steelman, one of the original bill's sponsors, said "I'm surprised at the agency. The job of the health department is to protect people. It makes no sense at all to eliminate data after one year."

Ken Bunting, executive director of the National Freedom of Information Coalition, weighed in on the topic by stating, "It sounds like they're violating the spirit if not the letter of the law, If it's being posted online, they don't need to take it down."

To read Doyle's entire article please visit "Missouri Purges Data From Infection Records".

If Higher Quality Care Costs Less, Why Does Health Care Still Produce Potentially Avoidable Complications? -- by Francois de Brantes, MS, MBA


For years, healthcare services researchers have maintained that there is little, if any, link between the cost of care and its quality. They drew this erroneous conclusion by using both flawed data and flawed methods of analysis.  The researchers used claims data to measure quality (flawed data because quality can only be reliably measured using medical records), and looked at total costs of care (flawed method).


During the past several years we have focused on improving our understanding of variation in the total cost of care, using defined windows of time to bound medical episodes of care.  For example, we can reasonably bound a medical episode for acute myocardial infarction within a 30 day time window, including the hospitalization of the patient and any care post-discharge during the balance of the window.  As we’ve performed these analyses, we noticed that we could split the total costs consumed during these windows of time into two components — typical or evidence-informed care (costs that are to be expected in such cases) and costs associated with potentially avoidable complications (costs that should not occur if care were delivered optimally. What we found is that these potentially avoidable costs consume anywhere between 15% and 20% of all dollars spent in the US health care system.  More importantly, we also found that higher quality providers had far fewer costs associated with potentially avoidable complications and that, as a result, their episode costs were also lower.

So if better quality costs less, why aren’t we seeing providers rush to improve the quality of care they deliver and lower overall costs? Because the way they’re paid encourages them to do the opposite. If a patient develops an infection during a hospital stay, the hospital gets more money due to a longer stay and the attending physicians bill for more services. No wonder then that health care costs are rising faster than the general rate of inflation.  And until we get the payment incentives right, it’s hard to see how we will ever achieve a high-performing health care system. The bottom line today is that what we call potentially avoidable costs, someone else in the industry is calling revenue.  That has to change.


Francois de Brantes, MS, MBA is CEO of Bridges to Excellence and Prometheus Payment, Inc.



Diagnotic Errors Warrant Attention Too

In a commentary released earlier this week in the Journal of the American Medical Association, Drs. David Newman-Toker and Peter Pronovost of Johns Hopkins suggest that far too little attention has been paid to diagnostic errors and the harm they cause.   In comparison to wrong-site surgeries, medication errors and hospital acquired-infections, they argue, diagnostic mistakes may account for a greater number of medical problems and preventable deaths.

While the patient safety movement has highlighted the need for "systems" approaches to reducing medical mistakes, as opposed to better training of individual physicians, for example, it has not focused on the need to improve systems for diagnosis.  Instead, the emphasis has been on the individual physician's ability to diagnose early and correctly.

Newman-Toker and Pronovost suggest that computerized decision support tools and and checklists can help physicians check for critical diagnoses and each patient's level of risk for certain diseases.

Saying Sorry - by Suzanne Delbanco, Ph.D.

If our health care system were highly reliable, the debate whether to say sorry to patients harmed by preventable medical mistakes would occur far less frequently.  However, until we have the processes and systems in place to reduce the incidence of preventable errors drastically, everyone from individual clinicians to patients' families to CEOs of major health care systems will have to discuss what's right to do when mistakes happen.

In an on-line commentary posted yesterday to the BBC Web site, Sir Liam Donaldson, Chief Medical Officer for England, argues that the National Health Service (NHS) needs to apologize more, and to mean it.

NHS clinical staff have a range of attitudes about apologizing, with some favoring being open in the face of errors, and others saying "over my dead body."  Being fully or partly responsible for harming a patient can be just as painful emotionally for the clinician as for the patient or patient's family.  And while saying sorry may be the start of emotional healing for all parties, Donaldson suggests that an apology is not meaningful until it becomes the start of a process to learn from the mistake so that future patients are spared similar harm.

This is remarkable leadership from the head of a closely-watched health care system.  We have much more to learn about this issue and far to go in evolving "apology" policies that work for both health care professionals and patients.  Many have studied the connection between apologies and lawsuits, finding that saying sorry can reduce the likelihood of a patient bringing suit to seek compensation for injuries from medical care.  Liability concerns raise the costs of care through rising malpractice insurance premiums.  Such concerns may also lead to the delivery of defensive medicine, during which clinicians may, for example, order extra but unnecessary tests to avoid accusations of not being thorough.

Reducing the likelihood of medical mistakes through methods like Hospital Video Auditing from Arrowsight, Inc., as well as others, is a critical aspect of moving forward.  But let's figure out how to work in "saying sorry."  It's the right thing to do and the benefits will likely have a beneficial ripple effect for all involved.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Fatigue Among Medical Residents Dangerous for Patients

Yawn The Institute of Medicine has released a new report that stresses the need for reforms to medical resident education and work hours. 

While in-depth, first-hand experience caring for patients is a critical aspect of medical education, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety suggests that the long hours residents work and the resulting fatigue contribute to medical errors.  The report argues that the workloads and duty hours for residents should be revised both to protect patients from mistakes as well as to enhance the learning experience for the residents.  Specifically, the report recommends regular opportunities for sleep each day and each week during training.  It suggests that the Accreditation Council for Graduate Medical Education enhance its monitoring of duty hour limits and that residency review committees create guidelines for the patient caseloads given to residents.  The report also recommends that residency programs enhance supervision of their residents as well as improve their procedures for the handover of patients. 

More statistics on preventable medical errors located here.

Telephone Errors Lead to Catastrohpic Injuries and Costly Legal Settlements -- by Pat F. Bass III M.D., M.S., M.P.H.

Pat F. Bass III M.D., M.S., M.P.H. is Assistant Professor of Medicine/Pediatrics at Louisiana State University Health Sciences Center - Shreveport.

Medical errors related to telephone care in the ambulatory setting are a significant and costly patient safety and malpractice issue that is tied to quality of care, according to a recent article published in the Journal of General Internal Medicine (J Gen Intern Med 2007; 23(5):517-22).

Harvey P. Katz, MD of the Department of Ambulatory Care and Prevention at Harvard Medical School, along with two colleagues, performed a retrospective case review of closed malpractice claims for 40 provider-defenders from 32 cases coded specifically as telephone-related by a major provider of malpractice insurance.

The study found 24 (60%) cases were settled or awarded in favor of the plaintiff.  Failed diagnosis (68%) and death (44%) were the most common allegation and injury, respectively.  The general medicine ambulatory practice was the most common setting.  Documentation (88%) and faulty triage (84%) were the leading errors.  However, dysfunctional office systems, such as lack of office policies, multiple calls for the same problem without a visit, and covering MD factors, were also a significant aspect of the malpractice claims.  Average compensation per incident was $518,932, with a total plaintiff compensation of $12,454,375.

Continue reading "Telephone Errors Lead to Catastrohpic Injuries and Costly Legal Settlements -- by Pat F. Bass III M.D., M.S., M.P.H. " »

Hospitals greet success with preventing bloodstream infections-- by Robin Walters, R.N., B.S.N.

As part of our guest contributor program, we thank Robin Walters R.N., B.S.N, for her article below that examines how hospitals are working to prevent bloodstream infections. Be sure to also read Robin's other contribution on hand-washing compliance right here.

Central venous catheter-related bloodstream infections (CR-BSIs) remain among the most common types of healthcare-associated infections and could be costing U.S. hospitals well over $2 billion annually. In the intensive care unit (ICU), the national average rate for these infections is 5.3 per 1,000 catheter days, but some hospitals have reduced their rates, even drastically.

At UCLA Medical Center, concerns about rising rates of CR-BSIs in the medical ICU led to the implementation of new facility guidelines for central venous catheter care and unique strategies to promote compliance. Nurses were given scripted coaching to help them talk with both physicians and coworkers to support use of the new guidelines and were empowered to facilitate proper procedures as they assist physicians in inserting central venous catheters. Subsequently, by 2007, the CR-BSI rates had declined from 7.5 to 2.9 per 1000 catheter days in one unit and from 10.4 to 0 per 1000 catheter days in another.

CR-BSI rates in the ICU at Rochester General Hospital, NY, were well below national benchmarks, but they were on the rise in the non-ICU settings and had reached 6.9 per 1000 catheter days in 2002. Together, the nursing director and the clinical leader of the peripherally inserted central catheter (PICC) team got creative with the budget to expand the role of the PICC team to manage central venous catheters in the general patient areas. A cost benefit analysis supported this change, which was enacted with other measures, and by 2005 the hospital CR-BSI rate had dropped to 1.9 per 1000 catheter days.

Much success in lowering CR-BSI rates has come from using evidence-based prevention strategies, such as those in the Institute for Healthcare Improvement’s Central Line Bundle. And, hospitals that significantly reduced their central venous CR-BSI rates report that the following have also been instrumental: monitoring progress through ongoing data collection, providing routine feedback to patient units, physicians and hospital leaders, and receiving support from hospital leaders.

To find out what fostered the adoption of the most important CR-BSI prevention measures, Mayo Clinic researchers surveyed in 2005 a sampling of hospital infection control coordinators. The results suggest that to improve compliance with these measures, hospitals can start to promote a “culture of safety,” support infection control professional certification and take part in infection prevention collaboratives such as the 5 Million Lives Campaign and the National Healthcare Safety Network.

About the author: Robin Walters, R.N., B.S.N., has been privileged to provide care in hospitals, clinics, schools and physician offices, at sites ranging from large urban to remote rural.

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Interview Series: Dr. Meghan Dierks discusses how HVA increases hand-hygiene compliance

As we continue our interview series with today’s thought leaders in patient safety, we spoke with Dr. Meghan Dierks, Assistant Professor, Harvard Medical School.

HVA (Hospital Video Auditing) is an innovative, non-intrusive, 24/7 auditing technology that significantly improves compliance with patient safety and hand washing practices and protocols

In structuring the HVA program at a surgery center in the southeastern United States, Dr. Dierks has witnessed compliance scores soar from 35% to 90%+... and even more striking, she's seen compliance rates remain there.

In what ways, and to meet which specific goals, is the healthcare facility using HVA?

"We applied the technology to tackle a refractory problem in the healthcare compliance arena--the very basic safety protocol revolving around hand-hygiene and getting physicians to modify their safety behavior. The technology was two-fold: first, it would provide us the ability to collect highly reliable data and we hadn't been able to in the past. And, second, by nature of collecting high-quality data and instilling a feedback loop to relay that data to physicians practicing in that environment we could achieve a behavioral change.

We had two goals, both of which were achieved through the use of HVA. First, we needed to be able to collect highly reliable data over a sustained period of time on hand hygiene behaviors--something that has been difficult to achieve using other strategies. Second, in order to achieve a behavioral change, we needed to be able to use this data to provide continuous performance feedback to the healthcare workers practicing in that environment."

What significant points of success and improvements have you witnessed from the surgery center using the technology?

"Prior published studies have demonstrated that other efforts and interventions--such as employing human observers or posting educational signage--achieve short term, but not sustainable improvements in compliance. HVA is a highly reliable data-collection technique that enabled us to continuously measure performance over a long period of time in the surgery center, and document positive movement toward an established goal.

We are now reaching our sixth month of continuous measurement and feedback. Using HVA, we identified a relatively low baseline compliance rate of 38%. We provided weekly feedback, and over the next several weeks, saw dramatic improvements in compliance. This relatively high compliance rate has now been sustained in the 88%-98% range for six months. While the fact that we achieved 98% compliance within four weeks is remarkable, equally striking is the sustainability of the behavior change."

Continue reading "Interview Series: Dr. Meghan Dierks discusses how HVA increases hand-hygiene compliance" »

Interview Series: Dr. Kumar discusses PMEs and Fatal Care

As part of our interview series with today’s thought leaders in patient safety, we spoke with Dr. Sanjaya Kumar, author of the just-released book Fatal Care.

Each year as many as 98,000 patient deaths occur in the United States as a result of preventable medical errors (PMEs) in hospitals--with PMEs impacting or harming at least 5 million Americans annually and costing more than $17-21 billion.

These sobering statistics from the Institute of Medicine (IOM) and the Institute for Healthcare Improvement (IHI) provide a glimpse into a national crisis that harms or kills hundreds of innocent people each day. But they are only nameless, faceless numbers and can't illustrate the human cost behind the data. Moreover, they only reveal the problem and not the underlying causes or potential solutions.

Unique and unlike other healthcare-related books, Fatal Care blends true, real-life dramas that illustrate gaps in the healthcare system with factual information and analysis for healthcare consumers and professionals.

What inspired you to write Fatal Care?

"There is an epidemic in this country called preventable medical errors. They, for the most part, go unnoticed while claiming the lives of hundreds of people in the United States each day.These deaths are sacrifices that are unreported, unrecognized and not acknowledged.

I wrote Fatal Care in an effort to provide a voice and a face to those nameless and faceless victims. I want the world to know that this epidemic exists and that they can easily become the next victim. My hope is that this book helps both those accessing care and those who provide that care."

In your opinion, what are the "top actions/priorities" that will move the industry much closer to eradicating PMEs and HAIs?

"First and foremost the actions and priorities outlined are long-term solutions. There are no easy fixes to complex system issues such as preventable medical errors. That said, there are several high priority actions healthcare providers and consumers need to address in order to drive positive change. First, healthcare providers need better cataloging of errors in a standardized fashion. This will allow for accurate trend and intervention identification leading to preventable medical error reduction.

Secondly, the industry needs increased shared knowledge access for cross industry learning. Also, healthcare organizations have to embrace adherence and compliance to evidence-based best practices as this ensures known mistakes are not repeated.

Finally, consumers really need to become educated advocates for their own care. Gone are the days where people can go blindly to their healthcare provider and expect that everything will be taken care of for them."

Continue reading "Interview Series: Dr. Kumar discusses PMEs and Fatal Care" »

Interview Series: Dr. Halamka discusses how technology can improve patient safety

As part of our interview series with today’s thought leaders in patient safety, we spoke with John D. Halamka, MD, MS.

Dr. Halamka is Chief Information Officer of the CareGroup Health System, Chief Information Officer and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE (the Regional Health Information Organization), Chair of the US Healthcare Information Technology Standards Panel (HITSP), and a practicing Emergency Physician.

If that sounds like a tremendous amount of responsibility, it is--in all, his work supports 3,000 doctors, 18,000 faculty and 3 million patients... not to mention his finding time to publish an informative and enlightening blog.

Q: How are the hospitals that you’re working with using technology to reduce errors and lower risk?

A: “Populate electronic medical records: Achieve 85% electronic clinical documentation by 2011 via consistent use of automated history and physicals, electronic progress notes, eForms and scanning technologies.

Medication Management: Achieve end to end electronic medication administration by 2009 through the consistent use of provider order entry in all inpatient areas, electronic prescribing in all ambulatory areas, medication reconciliation at each transition in the care process, and electronic medication administration records based on bar coded medications.

Training, education and competency: complete a new hospital policy requiring the consistent use of our EMR to manage problem lists, medication management, notes and ordering by July 2008.”

Q: Do you think technology (or tech innovations/solutions) has the potential to help hospitals improve patient safety, and why?

A: “Coordination of care among providers via e-Prescribing and use of electronic health records will ensure smooth handoffs, reducing medical error. Empowering the patient to be the stewards of their own data via personal health records will encourage doctor/patient shared decision making, transparency into the medical record including the correction of errors, and respect for patient privacy preferences when sharing data.”

Q: In your opinion, what are the “top actions/priorities” that will move the industry much closer to eradicating PMEs and HAIs?

A: "End to end electronic medication workflows including e-Prescribing, provider order entry, and electronic medication administration records.

100% electronic documentation including all outpatient and inpatient notes, diagnostic test results and images.

Decision support systems which enforce best practices including guidelines, protocols and care plans."

  • For Dr. Halamka's blog, please go here.
  • Is there a thought leader that you would like to see interviewed? Please email us here.
  • For all interviews with today's patient safety thought leaders, please go here.

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