Chuck Lauer's Insights

Healed, Not Harmed

IDN Admin - Wednesday, February 08, 2012

By Chuck Lauer
Remember the report issued by The National Academy of Sciences in 1999 titled,"To Err is Human," claiming that over 100,000 patients a year are literally killed in hospitals because of human error and negligence?

The report literally stunned everyone both in and out of healthcare, and many top leaders in the government as well as in the industry itself vowed that they would get to the bottom of things and resolve the problems that enabled the killings to occur.

When I use the 100,000 stated in the 1999 NAS study there are many in and out of the industry that claimed that the number was probably much higher.

But the point is that everyone at the time furrowed their brows and pronounced that everything would be better and that we should all be patient while very learned healthcare experts studied the matter and eventually come up with a report to end the deaths in hospitals from medical errors and adverse events.

But that hasn't really happened the way everyone claimed it would. There are studies that show we are still losing over 100,000 lives a year because of medical errors and the killings continue almost seemingly unabated. To make things even worse, there are many who claim that going into a hospital is like throwing the dice. It's at best a gamble. Then a couple of years ago the head of the Leapfrog Group stated that being admitted into a hospital could be equated with being shot out of a cannon.

Of course I don't think there are any of us who are not concerned, especially with the recent release of a new study a few days ago by Daniel R. Levinson, the Inspector General of the Department of Health and Human Services.

The press release stated, "Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized." The release goes on to say that, “even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the 'adverse events.'" The report gets even more interesting with Dr. Levinson saying that, "despite the existence of incident reporting systems, hospital staff did not report most events that harmed Medicare beneficiaries…"

He goes on to say that some of the most serious problems, including some that caused patients to die, were not reported. The report defines adverse events as medication errors, severe bedsores, and infections that patients acquire in hospitals; delirium resulting from overuse of painkillers; and excessive bleeding linked to improper use of blood thinners. The inspector general estimated that in any single month there are more than 130,000 Medicare patients who have experienced one or more adverse events in hospitals.

Back in 1999 when the National Academy of Sciences report came out, it seems many experts suggested that hospital employees were often too afraid to admit mistakes. But that hypothesis doesn't seem to hold up today with Dr. Levinson saying that many hospital employees just don't recognize "what constitutes patient harm" or that particular events caused harm to patients and should be reported.

So in an attempt to get some order back into this mess, Medicare officials are now saying they will develop a list of "reportable events" that hospitals and their employees could use to report adverse events.

Medicare officials suggest that hospital executives give employees "detailed unambiguous instructions on the types of events that should be reported." The report found that hospitals made few changes to policies and practices after employees reported harm to patients.

Federal investigators did an in-depth study of some 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers and 28 were investigated by the hospitals, but it seems only five led to changes in policies or practices. Even though the study was limited to Medicare patients, there is no reason to believe that the same type of adverse events is not occurring with younger hospital patients. It would be illogical to think otherwise and that's the dilemma that hospitals face.

I believe there have to be major changes in existing policies and additional training so hospital employees can both identify and avoid harming patients in the future. After all, patients come to a hospital to be healed, not harmed or even killed by carelessness and ignorance. That should be the minimum expectation for any patient entering a hospital. How many more patients are going to be harmed or killed before something is done? If the private sector doesn't get with it, the government will again move in which may lead to a less desirable outcome.

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Chuck Lauer
Former Publisher
Modern Healthcare

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