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Hospitals Tally Their Avoidable Mistakes

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Washington Post Staff Writer
Tuesday, July 21, 2009

Surgery on a patient with a debilitating spinal-cord disease went terribly wrong in a District hospital last year: The patient was discharged only to be readmitted a few days later complaining of severe leg pain. The surgeon, it turned out, had operated on the wrong part of the spine.

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A 44-year-old man who came to the emergency room of a Maryland hospital with painful swelling in his groin received a hernia diagnosis from a physician's assistant, who operated without consulting a physician. Fifteen minutes later the man went into cardiac arrest and died.

Meanwhile, over the course of the year, patients at one hospital in Northern Virginia developed life-threatening blood infections at a rate of 2.1 for every 1,000 times doctors inserted an IV tube to deliver medication.

These are among the hundreds of incidents of death or serious medical harm disclosed in the past year by hospitals in the Washington region, preventable errors that until recently have not required public reporting. Under laws that took effect last year in Virginia and a few years earlier in the District and Maryland, hospitals must report to health regulators many serious injuries that patients suffer in the course of treatment.

The laws are different in each jurisdiction. For example, Virginia's public records identify the hospitals by name, while Maryland's and the District's do not. But they all allow the public to glimpse the breadth of mistakes that health experts dub "never events" (because they should never happen): sponges left inside patients after surgery, operations on the wrong limb, medication errors, falls that lead to needless deaths. At least 20 states require hospitals to report every incidence of hospital-acquired infection.

Picking Up Steam

Patients, insurers and regulators are beginning to use this information to prod health-care providers to ensure that such events really never happen.

It used to be that if a doctor, nurse or technician was responsible for injuring you, your insurance company was billed for the action that caused the injury as well as what might be needed to treat it. Maryland health regulators estimate that insurance companies paid $522 million last year to cover preventable complications in hospitals, which occurred in 55,000 of the state's 800,000 inpatient cases.

Now, following the lead of Medicare, some other public and private insurers are starting to refuse payment -- for example, they won't pay for treatment of urinary tract infections caused by a catheter. It's on the same theory, as some put it, that if a lawn service mowed down your rosebush while cutting the grass, you wouldn't pay the company to replace it.

This activity is part of a patient safety movement that is picking up steam across the country, led by patients and family members who've suffered devastating errors and are pressing lawmakers to enforce accountability. One of these is Sorrel King, a Baltimore County woman whose toddler daughter Josie fell into a tub of scalding water eight years ago and was rushed to Johns Hopkins Children's Center in Baltimore with severe burns. The hospital staff missed mounting symptoms of dehydration her mother had observed. Josie died after an injection of a narcotic, despite orders that she receive no further medication.

Johns Hopkins acknowledged a series of errors and miscommunications and took full responsibility, although King says the hospital billed her insurance company for Josie's care.

Though nothing can make up for such a tragedy, King sees the denial of payment as the most effective way of getting hospitals to improve their performance.

"I accept that it boils down to money," she said. "It's unfortunate that it has to come to that. But you need incentives."

In Maryland, where hospitals have been required for five years to report errors that led to death and serious harm, the hospital association made voluntary agreements with insurance companies last year not to bill for eight medical errors, including transfusions that use the wrong blood type and surgery on the wrong side. And starting this month, the state commission that sets hospital rates is using a new system that ranks hospitals on how often they commit 52 specific mistakes, from preventable obstetrical complications to infections of wounds that develop after surgery. Hospitals that report the most mistakes from that list will be required to bill insurers at a lower rate, while those with fewer can charge more; the total amount spent should remain about the same, but more money will flow to the hospitals with fewer errors.

"This is an incentive to change behavior and provide better care," said Stephen Ports, principal deputy director of the Maryland Health Services Cost Review Commission.

Maryland also requires hospitals to come up with plans for preventing the reported mistakes from happening again. And it is instituting rules such as noting any underlying medical problems on a patient's chart at check-in, so it will be clear if a new condition arises. If the hospital is at fault, it will be denied payment for 85 percent of the cost of care to reverse the error. That 85 percent figure, Ports said, is an acknowledgment that "nothing is 100 percent preventable."

Fines are also part of the incentive program: Doctors Community Hospital in Prince George's County was fined $30,000 this spring after failing to notify regulators of staff errors that caused one death and serious harm to at least seven other patients. The hospital also promised to spend $65,000 on a patient safety program.

Sending a Message

A handful of other Maryland hospitals have received warnings for delays in reporting and follow-up reviews. The state Office of Health Care Quality cited Laurel Regional Medical Center in October, for example, for failing to submit an analysis of three deaths in 2007 that were caused by hospital errors: one patient in diabetic shock who died in the emergency room after a delay in treatment, an emergency Caesarean section on a 16-year-old girl that resulted in the baby's death, and the death after a delay in treatment for a patient's cerebrovascular accident. Laurel promptly submitted a plan of correction, said Renee B. Webster, assistant director of the state Office of Health Care Quality.

In Virginia, which so far is requiring reporting only of serious infections caused by IV insertions, the state hospital association is trying to get ahead of the curve: On behalf of the state's 95 hospitals, it reached a deal last month not to bill for several errors caused by hospital staff. "The hope is to send a message that if we make a mistake, we're going to own up and take the consequences," said Katharine Webb, the association's lobbyist.

Anthem Blue Cross and Blue Shield, Virginia's largest private insurer, has stopped paying hospitals for four surgical mistakes: when a wrong procedure is done; when the wrong body part is operated on; when the wrong patient is operated on, and when a foreign object is left inside the patient, requiring another incision. "We wanted to raise the profile of patient safety," said Jay Schukman, regional president and senior medical director for Anthem Blue Cross and Blue Shield's East Region.

In the District, which began reporting preventable errors in 2007, hospitals, clinics and nursing homes disclosed 529 mistakes from July 2007 through June 2008. Fourteen led to the death of a patient. The most commonly reported errors, most of which occurred at hospitals, were pressure ulcers, retained foreign objects after surgery and infections from IV tubes. Other mistakes included a patient who developed an arrhythmia after chest surgery had a temporary pacing wire inserted into the heart's ventricle instead of the atrium; doctors improperly put a catheter in a patient with terminal kidney disease on the same side as the patient's dialysis shunt, and the catheter had to be removed. In another case, a surgeon performing a breast biopsy made an incision to the woman's left breast instead of the right.

So far, the District has not tried to use financial incentives to affect the hospitals' behavior.

Patient safety laws like Maryland's are not designed to be punitive: For hospitals, the real price of mistakes often comes through the courts, when patients or their families take legal action. It's too early to tell if the new laws are reducing errors. Some institutions in Maryland are reporting more errors, year over year -- but for now, regulators consider this a good sign of increasingly accurate reporting rather than a reflection of more mistakes.

Said Webster: "Just requiring hospitals to have regular communication with us is invaluable."

Comments: reinl@washpost.com.



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