Adverse events refer to situations where a patient experiences unintended harm as the result of medical care. Examples of adverse events include: medication errors, hospital negligence, diagnosis errors, wrong-site surgeries and other types of medical malpractice.
]]> As part of Oregon's adverse event reporting program, the state requires that patients be notified in writing by healthcare providers of serious adverse events. Unfortunately, there currently is only about 50 percent compliance with this requirement.The Oregon Adverse Event Disclosure guide was developed in conjunction with the Oregon Medical Association and the Oregon Association of Hospitals and Healthsystems. It is intended to assist healthcare providers in improving disclosure programs and better understanding the purpose of disclosure.
According to the executive director of the Oregon Patient Safety Commission, "A crucial component of a culture of safety is a transparent health system where doctors and healthcare organizations are able to effectively share information about adverse events with patients and families." She went on to explain that the written disclosure should not be the only method of communicating with the patient, but should be used in addition to an open discussion.
The guide will hopefully assist in improving patient safety and creating better outcomes for Oregon patients.
Source: Oregon Patient Safety Commission, New Guide Available to Help Healthcare Organizations Disclose Adverse Events, 10 May 2012
]]>According to a study by researchers from Johns Hopkins University School of Medicine and published in the Journal for Healthcare Quality, only 21 states require hospitals to disclose surgical site infections, a mere eight of which make the data available to the public. Moreover, only 10 of the 250 types of surgeries are reported.
]]> There is significant variation between the states on which surgeries are reported and made public. Although Oregon does require hospitals to report surgical site infection rates, it only publishes data on two types of surgical procedures.The lead author of the study, Dr. Martine Makary explained, "People are shocked when they find out that simple healthcare metrics [such as readmission and infection rates] are being collected, but that they are not made available to the public."
Hospitals have lobbied against federal reporting standards, but Dr. Makary is advocating for full disclosure by hospitals, "In order for the free market to work in healthcare, hospital performance, specifically their outcomes, needs to be public information." This gives potential patients the opportunity to compare neighboring hospitals, and select the facility with the better safety record.
Research has shown that when hospitals are mandated to report on surgical infections healthcare quality improves. Experts suggest that this is because patients are empowered, forcing hospitals to address issues and improve quality to attract business.
Source: Forbes, Lack of National Reporting Mandate for Hospital Infections Hurts Consumers, Gergana Koleva, 5 April 2012
]]>The Oregon Patient Safety Commission is also planning activities to observe Patient Safety Awareness Week. The Commission kicked off the events with a breakfast that recognized the best participants in Oregon's Patient Safety Reporting Program and brought attention to programs advancing patient safety in the state. These programs hopefully reduce instances of medical errors and Oregon medical malpractice.
]]> NPSF is also highlighting the introduction of a board certification called the Certification Board for Professionals in Patient Safety. Those wishing to obtain certification can have a background in any area of health care, but must show an understanding of a variety of patient safety topics. Additionally, NPSF has launched online curriculum on patient safety that provides basic information about the key principles of patient safety and how they can be applied in daily practice.As part of Patient Safety Week health care providers are encouraged to host events that focus on improving patient safety within their systems. The President of NPSF explained, "We hope that the activities we have planned and the resources we make available will encourage providers, patients and the general public to recognize Patient Safety Awareness Week and consider their roles in this important endeavor."
Source: NPSF, "NPSF Urges Be Aware for Safe Care," Mar. 1, 2012
]]>This is why the American Medical Association (AMA) is calling for more patient safety research focused on outpatient settings such as doctor's offices, clinics, nursing facilities and outpatient surgery centers. The AMA makes the point that since most of the attention and funding around patient safety has focused on medical errors in hospitals, little research has concentrated on the issue of outpatient medical errors.
Indeed, a large majority of people receive their care in an outpatient setting. For each hospital admission there are approximately 300 patient visits in outpatient settings. With reform efforts focused on preventative care, this ratio is only likely to increase.
]]> The relatively small amount of research that has been done on outpatient safety found some concerning safety issues. These included: medication errors, diagnosis mistakes and problems with communication. These are the types of medical errors that may be less obvious but are still very dangerous.Once research identifies problems in outpatient settings, corrective plans can be designed complimenting those developed for inpatient facilities. Hopefully this will result in an improved health care system.
Source: American Medical News, Looking beyond the hospital for patient safety, 20 February 2012
]]>Those in favor of malpractice caps are threatening to block the health care reform bill's passage unless the limits are included. Proponents of caps argue they are necessary to reform. However, critics point to studies that indicate such limits don't produce touted savings, and stress the need for doctor accountability and the importance of the larger issue of patient safety.
]]> The facts show that Oregon physicians and their insurers generally aren't paying out large amounts in malpractice suits. Malpractice insurance rates in Oregon have actually remained steady or declined since 2004, according to Oregon's top insurer, The Doctors Company. Moreover, the number of claims paid per doctor has also dropped to approximately the lowest point in over 10 years. The amount paid out for claims has remained steady.According to the Kaiser Family Foundation, in 2010 insurers and physicians in Oregon paid out 97 claims. The average payout was approximately $420,000, already significantly less than the cap legislators wish to impose.
Beyond what seems to be little savings provided by malpractice caps, there are also legal concerns. Oregon's constitution prohibits limiting damages in lawsuits unless a public entity is the defendant. Thus, there are serious questions whether such a measure would be constitutional.
Source: OregonLive.com, Oregon's long-running malpractice debate flares up in Salem as key health reform bill nears vote, Nick Budnick, 14 February 2012
]]>Despite being aware of this significant problem, hospitals have either been unable or unwilling to take steps to improve patient safety. There are a variety of reasons for this including: hospitals' hierarchical nature, lack of transparency, resistance to change and reluctance to make patient safety a top priority.
Kaiser Health News reported that hospitals could dramatically improve patient safety by taking a few basic steps. These include: consistent use of checklists to ensure all medical providers follow proper procedures, encouraging more collaboration and teamwork between doctors and nurses, and stressing the importance of hand washing to all employees.
]]> Hospitals who have adopted checklists have reported an impressive 47 percent decrease in deaths and 36 percent decline in major surgical complications. These checklists address even routine and mundane items, like washing one's hands, but it is these types of tasks that often get forgotten about when interruptions or distractions occur.A collaborative environment allows nurses and others to question if a doctor may have overlooked something. Traditionally, the hierarchical structure at hospitals created an atmosphere where health care providers were uncomfortable questioning superiors. This needs to change for potential mistakes to be caught and prevented.
Some hospitals have begun to implement checklists and flatten hierarchies in the interests of patient safety. Hopefully the trend will continue and medical errors will finally begin to decrease.
Source: Kaiser Health News, Doctor, Did You Check Your Checklist?, Bara Vaida, 30 January 2012
]]>Disturbingly, the types of medical errors or "adverse events" that didn't get reported included some major mistakes, even some which resulted in the death of the patient. Examples of adverse events include wrong site surgeries, hospital acquired infections and medication errors.
Reporting of Adverse Events By Oregon Hospitals
The Oregon Patient Safety Commission is hoping to significantly increase the reports of adverse events it receives voluntarily from over 50 hospitals in the state. In 2010, Oregon hospitals reported less than 150 adverse events, over 30 of which resulted in patient deaths. The Commission hopes the number of error reports will be up to 500 by 2015.
]]> Of course, no one wants more medical errors to occur, but what seems to be happening in Oregon hospitals, and those across the nation, is that mistakes are happening but remaining unreported. In order for patient safety to improve, experts first need to know when and how adverse events are occurring.According to the federal report, hospital employees often assumed someone else would report a mistake. Even more troublesome, some errors seemed so routine to medical providers they didn't feel they warranted reporting.
Although Oregon hospitals have been working to prevent errors, in particular to reduce hospital-acquired infections, much work still needs to be done. Adverse events need to be consistently reported so necessary changes can be made. To encourage proper notifications the Commission is developing state standards for error reporting to provide hospitals guidance regarding best practices and information about when and how adverse events should be reported.
Source: OregonLive.com, Making hospitals safer, Oregonian Editorial Board, 9 January 2012
]]>Unfortunately, the easy availability of electronic devices has also caused what is being termed "distracted doctoring," which puts patients at risks for surgical injuries and other forms of medical malpractice.
The New York Times recently reported on this issue, and found that "distracted doctoring" is a trend that seems to be on the rise at hospitals. For instance, in a survey over half of those technicians who monitor bypass machines admitted they spoke on their cellphones while heart surgeries were taking place.
One patient was left partially paralyzed after a neurosurgeon made at least 10 personal calls on a wireless headset during an operation. There are other reports of healthcare providers using computers in intensive care units to check personal emails and shop online.
]]> Dr. Charles Prober from Stanford Medical School explained the crux of the issue, "Devices have a great capacity to reduce risk," he said "But the last thing we want to see, and what is happening in some cases now, is the computer coming between the patient and his doctor."After receiving complaints of nurses and physicians using their smartphones during times they should have been focused on patient care Dio Sumagaysay, the administrative director of over 20 operating rooms at Oregon Health and Science University hospitals, took action. Mr. Sumagaysay banned all activities in operating rooms not centered on patient care. Even after the policy was enacted, however, he needed to reprimand a nurse he witnessesed checking on airfare prices in the midst of a spinal operation.
Hopefully, if more hospitals and clinics develop policies similar to the one Mr. Sumagaysay enacted, the problem of distracted doctoring will diminish before it gets any worse.
Source: The New York Times, As Doctors Use More Devices, Potential for Distraction Grows, Matt Richtel, 14 December 2011
]]>For the study, researchers from Levine Children's Hospital in Charlotte, North Carolina, trained a safety team at a large pediatric clinic on a new error-reporting system. Under the new system, all error reports would be anonymous and no one would be punished for making an error. The team comprised doctors and nurses as well as front desk staff and office managers, according to Reuters Health.
]]> In the year before the new error-reporting system was implemented, the clinic had five error reports. In the two and a half years after the new system was installed, the safety team collected and reviewed 216 error reports.Although the number of reported errors increased significantly, from an average of five errors each year to a yearly average of 86, the lead author of the study emphasized that the clinic probably did not have significantly more incidences of medical errors. Instead, it is likely that roughly the same number of medical errors occurred as in previous years, but simply more were reported under the new system.
Increased reporting of medical errors can help identify problems that lead to mistakes so the problems can be fixed. Indeed, the safety team's monthly review of reported errors at the clinic led to changes in the practice that addressed three-quarters of the reported errors, like medication errors. Over time, it is expected that the total number of reported errors will decrease, reflecting a true reduction in medical errors because of the changes made to improve patient safety.
Source: Reuters, Blame-free system increased medical error reports, Kerry Grens 21 November 2011
]]>Electronic medical records do have many benefits. For example, they can prevent sometimes-deadly medication errors by alerting a doctor who is about to prescribe a drug that a patient is allergic to.
However, many of the record-keeping systems suffer from usability problems. The report warns that "designed and applied inappropriately, health (technology) can add an additional layer of complexity to the already complex delivery of health care, which can lead to adverse consequences." For example, the report noted that system crashes and software quirks can contribute to medication dosage errors and can cause doctors to miss the warning signs of a potentially fatal illness.
To make matters worse, competing software products are often unable to communicate with each other. Further, many suppliers' contracts prohibit doctors and hospitals from openly airing concerns about errors or defects in the software.
]]> New Investigative Agency ProposedDespite these concerns, the Institute of Medicine is not recommending that the transition to electronic medical records be scrapped. Rather, it is suggesting that the federal government set up an investigative agency to look into claims of injury or death resulting from the use of electronic medical records. The agency would be modeled after the National Transportation Safety Board, which investigates aviation-, highway-, railroad- and other transportation-related accidents.
The goal of the recommendation was to balance the drive toward technological innovation with the need to protect patient safety.
Patients can help protect themselves by being proactive in their communications with their medical professionals. They should make sure their doctor understands all the symptoms they are experiencing and all the medications they are taking. Most importantly - if something doesn't seem right, say something. It may be that the doctor is misinterpreting or receiving incorrect information from your electronic record.
Source: The New York Times, "Panel Emphasizes Safety in Digitization of Health Records," Steve Lohr, 8 November 2011
]]>Now the radiologist reading your scan is often in a different hospital, state or even country. Teleradiology, where digital versions of X-rays, CT or MRI scans are sent to off-site radiologists, is commonplace. Some hospitals contract with an outside company for the reading of certain scans, while others have outsourced the entire department. "The majority of hospitals use teleradiology in one form or another," explained Jonathan Linkous, the CEO of the American Telemedicine Association.
]]> The Problem With TeleradiologyYou might be wondering why it matters if radiologists are on-site as long as they are qualified. The answer mainly comes down to one word: communication. Radiologists in other locations may only submit a written report, and never consult with the on-site physician. This can result in mistakes, radiology errors and sometimes tragic results.
Take the case of a Pennsylvania woman who arrived at the hospital with severe head pain. A digital copy of her CT scan was sent to one imaging company who then sent it to another subcontractor. That subcontractor sent it to a radiologist at his home in Hong Kong, who noted a ring around a mass in the patient's head. Unfortunately, the radiologist didn't explain in his written report what the ring meant-a buildup of fluid that is frequently fatal if not treated immediately. Since no alarm was raised, the woman was discharged.
In the morning, another off-site radiologist looked at the scan to review the diagnosis. Since he agreed with the findings of the Hong Kong radiologist, and assumed the ER doctors had connected the dots, he did nothing to alert ER physicians either.
The woman was later found by her parents lying unconscious in her bathroom. She now has permanent brain damage.
If only the ER doctors and off-site radiologists had actually spoken, the severity of the woman's condition would likely have been conveyed. Her case highlights the dangers of too great of reliance on technology, and too little emphasis on physician communication.
Source: MSNBC, Is a doctor reading your X-ray? Maybe not, Katherine Eban, 26 October 2011.
]]>In 2008, medical errors cost the American public $17.1 billion dollars. Nearly 100,000 people die each year due to the common medical error of hospital-acquired infections. One in every seven Medicare recipients is a victim of medical errors, and medical errors occur in about one-third of all hospital admissions across the nation. Reduction of medical errors could save billions of dollars and countless lives.
In 2010, experts reported the 10 basic elements that contribute to medical errors. Among these elements, environmental factors were prominent. Caregiver distractions during drug administration or care administration increase the risk for adverse medical incidents. To solve this problem, professionals devised NIZs, also called quiet or med-zones, in which nurses could prepare orders without distractions.
]]> A number of hospitals across the country are piloting interruption-free zone programs. Under some existing NIZ programs, nurses wear designated markings, such as colored sashes or vests and work in clearly marked designations. In others, large signs above medication carts and red tile borders on the floor were used to create the NIZ. During this time, members of the nursing staff process medication orders and administer medications.Applying the NIZ practice to hospital environments was born out of a recommendation from the Institute for Safe Medication Practices. The North American nonprofit fashioned the practice after the aviation industry's "sterile cockpit rule." The idea is that minimizing distractions reduces the potential for serious errors. In one hospital the system reduced medication errors by two-thirds.
Many, including Dr. Donald Berwick, Administrator for the Centers for Medicare and Medicaid Services (CMS), applaud this practice. Harvard-trained, Berwick is acutely aware that even very conscientious doctors and nurses can make serious and costly mistakes, and that systems must be in place to reduce these risks.
Source: Los Angeles Times, Pressing for better quality across healthcare, Noam N. Levey 4 October 2011
]]>While the unanimity of the compliance among hospitals is a good thing, it is a long time coming. The state's reporting initiative began in 2003. There is also room for significant improvement in the area of patient safety, with 34 patient deaths attributable to medical errors in 2010.
Gaps That Remain
Some sizable gaps remain in the medical error reporting system. Fifty percent of surgery centers are not reporting, and twenty-five percent of nursing homes are not participating.
There is also a lack of participation from pharmacies. Oregonian reporter Nick Budnick examined the issue and found "the Oregon Board of Pharmacy receives about 600 complaints a year." However, according to the Commission's report, pharmacies reported just six errors since fall 2008.
]]> Since the program is voluntary, hospitals are able to disregard certain aspects they dislike. For instance, very few hospitals are following the Patient Safety Commission guideline that all patients harmed by a serious adverse event receive a written notification. Currently patients receive such notice in fewer than 50 percent of cases. According to the Oregon Association of Hospitals and Health Systems, written notification is not always appropriate of feasible. Nine hospitals, however, have demonstrated full compliance is possible.The Importance of Medical Error Reporting
A medical facility can only improve systems and procedures if it is aware there are problems with its present operations. A uniform system of error reporting allows the medical facilities to better understand patterns of medical errors, and importantly, how to better prevent mistakes in the future.
Source: OregonLive.com, Patient Safety: All Oregon's hospitals join error-reporting safety drive; pharmacies, surgery centers lag, 13 October 2011
]]>Since 1986 the database has been used by hospitals, insurers and medical boards. Additionally, the "public use file" of the database is frequently utilized by journalists or researchers looking into medical malpractice and disciplinary actions as well as physician oversight. In the public use portion of the databank doctors' names and addresses are removed.
The Health Resource and Services Administration, which is an agency under the Department of Health and Human Services (HHS), blocked the public access after there were concerns about a reporter obtaining information from the non-public areas of the database. The reporter, however, clarified that he only accessed the public use file to obtain information.
]]> Reporters and national journalism organizations have protested the removal of the database. The president of the Association of Health Care Journalists explained, "Reporters across the country have used the public use file to write stories that have exposed serious lapses in the oversight of doctors that have put patients at risk."The agency is continuing to review the public use file to ensure physicians' privacy is protected. An agency spokesperson would not speculate about potential changes to the database, but stated that he hoped it would again be accessible to the public within six months.
In the meantime, ConsumerAffairs reports that the information on the database is accessible on a website run by Investigative Reporters and Editors (IRE), a group that obtains government information and makes it easier for reporters to access and use. Although traditionally IRE only allows member journalists to access its information, the IRE has opened up this information to the public.
Source: The New York Times, Withdrawal of Database on Doctors Is Protested, Duff Wilson, 15 September 2011
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