In November, Florida voters approved a state constitutional amendment that finally gives patients the right to review the records of any healthcare facility’s or provider’s adverse medical incidents, including those that could cause injury or death. Previous law prohibited the practice.
The vote came in a year when Sarasota hospitals had made headlines for several of these so-called "adverse events," or medical mistakes. At Sarasota Memorial, they included medication and transfusion errors. At Doctors Hospital, an arthroscopic procedure was performed on the wrong joint. The errors were reported in the local press, but neither hospital released public statements detailing the mistakes until questioned by reporters, and the information they offered was sketchy at best.
Hospitals have reasons to be skittish. In 1999, the Institute of Medicine (IOM) published a groundbreaking study called To Err is Human that claimed at least 44,000 (and perhaps as many as 98,000) Americans die in hospitals each year as a result of preventable medical errors. That’s more than are lost to car accidents, breast cancer and AIDS.
Healthcare costs for preventable medical errors reach an estimated $50 billion annually; and they cost the nation between $17 billion and $29 billion more every year in additional care necessitated by the errors, lost income and household productivity, and disability.
To Err attributed our "nation’s epidemic of medical errors" to a decentralized and fragmented system, where "faulty processes and conditions.lead people to make mistakes or fail to prevent them." It also blamed the current medical liability system for impeding efforts to uncover and learn from errors.
"The patient safety movement is only about five years old," explains Jeff Gregg, Bureau Chief of Health Facilities Regulation for Florida’s Agency for Healthcare Administration "It is still trying to decide how to perpetuate itself in a system that has become so complicated."
Hospitals have employed safety officers for years, but their function has been to oversee accidents in the workplace. Programs to ensure patient safety are so new that they’re just beginning to determine what an error is. Florida was one the first places in the world to require that by law, Gregg says, but, "We’re still a very young system in how you define an adverse incident."
The IOM, a component of the National Academy of Science, defines an adverse event as any injury caused by medical management rather than an underlying disease or patient condition. Its report urged a series of strategies that could help the government, healthcare providers and consumers cut these errors in half by 2005.
On the basis of those recommendations, Congress appropriated $50 million to the Agency for Healthcare Research and Quality, and private sector efforts are following suit. In 2000, the Business Roundtable, a coalition of more than 150 Fortune 500 companies, created the "Leapfrog Initiative," to provide financial incentives to organizations that voluntarily implement safety plans.
Their first target was medication errors, says Suzanne Delbanco, CEO of Leapfrog. "Most medical errors happen when a drug is ordered, not when it’s administered," says Delbanco. One report claims that medication errors contribute to 7,000 deaths every year.
Electronic prescribing, or computer physician order entry (CPOE), can intercept errors by automatically checking a patient’s history and warning against drug interactions, allergies or potential overdoses.
At Boston’s Brigham and Women’s Hospital, CPOE reduced error rates by 55 percent overall and serious medication errors by 88 percent. Antibiotic-related errors were reduced by 70 percent in a related study. Researchers believe CPOE could prevent as many as 900,000 serious medication errors every year if it were implemented at all urban American hospitals.
Still, CPOE is no panacea. More than 3,000 staff members at Sarasota Memorial have been using it since 1998; but last September, four patients there still received the wrong medication after a pharmacy employee filled syringes with the wrong drug. In June, a patient died after receiving the wrong blood type. (Although the hospital did not return requests to comment for this article, it has maintained in other published reports that the error did not contribute to the patient’s death.)
Ironically, Sarasota is the only local hospital using computer order entry. Englewood and Doctors Hospital, both owned by HCA, expect to begin by 2006. Until then, Doctors Hospital has begun bar coding all the drugs in its pharmacy, in part to comply with a recent ruling by the Food and Drug Administration that requires them on all new drugs (existing drugs have two years to comply). A Veteran’s Affairs medical center that tested the coding system administered 5.7 million does of medication to patients with no errors. FDA estimates the bar code rule could prevent 500,00 adverse events and transfusion errors over the next 20 years.
Preventing medication mistakes is just part of the equation. Some 4 million patients enter intensive care units every year to receive treatment for life-threatening illness or injury, but up to 500,000 of them die there. Leapfrog suggests that hospitals could reduce that number by hiring "intensivists," board-certified doctors who are subspecialists in critical care medicine or have received additional critical care training, and by closing their ICUs to physicians who are not critical care specialists.
A review of "closed" ICUs by Johns Hopkins Hospital discovered a 30 percent reduction in hospital mortality and a 40 percent reduction in ICU mortality. Leapfrog maintains that at least 54,000 deaths could be prevented if its standards were adopted by all of America’s urban hospitals.
This approach is not feasible for all hospitals, however. Englewood Hospital has only eight intensive care beds, so funding isn’t available for critical care specialists. Instead, it’s gone to "Night Hawk" satellite systems that link them to IPS centers.
Leapfrog members reward providers with preferential use, reimbursing hospitals that implement CPOE more than they would to hospitals without it. They reason they’ll pay less overall because of the reduction in costly errors down the line.
They also funnel patients with high-risk conditions to hospitals associated with better surgical outcomes and higher volume, something called evidence-based referral. Want to live through a heart-bypass? Then choose a successful cardiac program (such as Sarasota Memorial’s) that handles the most heart patients.
Leapfrog claims that some 100 studies tie high volume in specific procedures to higher success rates. Patients who received treatment for abdominal aneurysms at hospitals that performed fewer than 50 of these procedures a year were 30 percent more likely to die following the surgery. Babies born with birth defects survived more often at hospitals with neonatal intensive care units.
Since it released its first study in 2002, the number of hospitals participating in Leapfrog has grown to more than 1,000. (Locally, only Blake Medical Center, Doctors Hospital and Englewood Hospital participate.) Even so, five years after To Err’s publication, fewer than two percent of America’s hospitals use CPOE, citing expense. It cost Brigham and Women’s Hospital nearly $2 million to develop their system, and requires $500,000 every year to sustain. But the hospital estimates it’s saved between $5 million and $10 million in internal hospital expenses by reducing the need for staffing to clarify illegible doctor orders and by reducing money spent on unnecessary drugs and duplicate laboratory results.
Only 10 percent of the country’s intensive care units meet Leapfrog’s IPS safety standard, because of staffing shortages and budgets that won’t support additional specialists; and evidence-based hospital referral has problems, too. Many patients can’t afford to travel to hospitals that might operate in their best medical interest, and many prefer their hometown doctors. Plus, it’s still difficult to tell which hospitals have the best (or worst) surgical outcomes for a high-risk procedure. Only four states-California, New Jersey, New York and Pennsylvania-publish their mortality rates for coronary artery bypass graft surgery (heart by-pass). Information for most high-risk surgeries is unavailable.
"It comes down to the leadership as to whether or not they believe in sharing this information with their communities," says Delbanco. In response to To Err’s call for mandatory reporting systems, 22 states have enacted some type of reporting mechanism. Florida joined these last summer with the Florida Patient Safety Corp., an educational program for providers that hopes to create a near-miss incident reporting system.
But as the National Academy for State Health Policy (NASHP) discovered, there remains widespread suspicion among state agencies about how much information to disseminate to the public. NASHP discovered a culture of nonreporting, fear of liability and fear of publicity, concluding that "states are hesitant to release data that the public might misunderstand or could unfairly punish compliant reporters."
In Florida, medication errors are not even reported unless they lead to death, says AHCA’s Gregg. And he says the inormation is often "qualitative," "written for clinicians by clinicians," and few patients could understand it well enough to draw informed conclusions.
Sarasota attorney Ted Eastmoore disagrees. "If you have a particular disease, most people would read everything they could to educate themselves. The public has a right to know to make intelligent decisions."
Eastmoore believes the system is broken because the medical profession isn’t doing enough to police its own ranks. "It’s a fact that six percent of doctors in Florida are responsible for half of all claims, and the public has a right to know who they are."
Jill Rosenthal, who co-authored the NASHP report, says only seven of the 22 states with mandatory reporting systems release information about specific incidents and where they took place. The rest, including Florida, release aggregate reports, which means "good luck" trying to determine how many of these events take place by county, much less an individual hospital.
Adverse events here are lumped together with those that occur in Charlotte, DeSoto, Collier, Hendry, Lee and Glades counties. Manatee is counted with Hardee, Highlands, Hillsborough and Polk counties.
But the AHCA does act as a watchdog. According to the Sarasota Herald Tribune, in late October a surprise visit by agency officials identified numerous areas for improvement at Sarasota Memorial, prompting the hospital to allot $500,000 to hire an executive director of patient safety and train its medical staff.
According to Gregg, adverse incidents in Florida’s hospitals make up about 6 percent (about 1,300) of the 2 million hospital discharges every year. But as Delbanco notes, "We can all count errors until we’re blue in the face. What we’re concentrating on is preventing them in the first place."
How to avoid surgical accidents.
It’s easy to miss information in pre-op discussions. Take a family member or friend with you or record the session.
CHECK YOUR ID
Verify that the information on your hospital ID bracelet is correct. If you’re John Doe in for a bunion removal, this will prevent you from having Jack Smith’s appendectomy.
GET IT IN WRITING
Make sure anything you sign indicates the correct procedure. Ask the nurse or doctor to mark the surgical site in ink. If they decline, do it yourself. One young woman who was having a limb removed wrote on the wrong foot, "Not this one!"
How to avoid medication errors.
Make a list: Keep an updated list of all medications, including vitamins, herbs and supplements. Take this list, along with any known medical allergies, to every doctor or hospital visit.
Don’t mix and match: Make your doctor explain what each medication is and why you’re taking it. Use the same pharmacy for all your medications so the pharmacist can watch for potential drug interactions.
Be vigilant: Generic drugs look different from their name-brand counterparts.
Ask your pharmacist to confirm that the drug you receive is the drug your doctor prescribed and in the correct dose. Make sure you understand what four times a day means, as opposed to every six hours.
Speak up: In the hospital, never allow someone to administer a drug before cross-checking your ID bracelet.
Source: American Pharmacists Association (www.pharmacyand you.org) and Virginians Improving Patient Care and Safety (www.vipcs.org)
Best month to have surgery: November, which recorded 52 adverse incidents in 2003; or June, which had only 58. Worst month: October. In 2003, Florida hospitals reported 96 medical accidents that month.