Mistakes Common in U.S. Hospitals

[Willow Moonsidhe]

Mistakes Common in U.S. Hospitals

By Julie Steenhuysen

CHICAGO (Reuters Health) Apr 07 - About one in three people in the United States will encounter some kind of mistake during a hospital stay, U.S. researchers said on Thursday.

The finding, which is based on a new tool for measuring hospital errors, is about 10 times higher than estimates using older methods, suggesting much work remains in efforts to improve health quality.

"Without doubt, we've seen improvements in health care over the past decade, and even pockets of excellence, but overall progress has been agonizingly slow," said Susan Dentzer, editor-in-chief of Health Affairs, which published several studies in a special April issue on patient safety.

The special issue came 10 years after an influential Institute of Medicine report that found significant gaps in health quality.

"It's clear that we still have a great deal of work to do in order to achieve a health care system that is consistently high-quality -- that is, safe, effective, patient-centered, efficient, timely, and devoid of disparities based on race or ethnicity," Dentzer said.

Medical errors can range from bedsores to objects left in the body after surgery to life-threatening staphylococcal infections.

A study by Dr. David Classen of the University of Utah and colleagues compared a new quality yardstick developed at the Institute for Healthcare Improvement in Massachusetts, with two common older methods of detecting errors -- reports of errors voluntarily included in the medical record and an older method for assessing errors developed by the U.S. Agency for Healthcare Research and Quality, or AHR.

"A key challenge has been agreeing on a yardstick for measuring the safety of care in hospitals," the researchers wrote.

To find the best yardstick, the team tested three methods of tracking errors on the same set of medical records from three different hospitals.

Among the 795 patient records reviewed, voluntary reporting detected four problems, the Agency for Healthcare Research's quality indicator found 35, and the Institute for Healthcare Improvement's tool detected 354 events -- 10 times more than AHR's method.

"Our findings indicate that two methods commonly used by most care delivery organizations and supported by policy makers to measure the safety of care ... fail to detect more than 90% of the adverse events that occur among hospitalized patients," the team wrote.

The findings suggest there may be many errors that go undetected.

In a separate study in the same issue, a team led by Dr. Jill Van Den Bos and colleagues at the Denver Health practice of the Milliman Inc consulting firm, used insurance claims to estimate the annual cost of medical errors that harm patients to be $17.1 billion in 2008 dollars.

They found that 10 types of errors accounted for more than two-thirds of the total cost, with the most common ones being pressure ulcers or bedsores, postoperative infections and persistent back pain following back surgery. The researchers recommended that those three types of errors receive top priority for intervention and improvement.

Both studies were supported by the Robert Wood Johnson Foundation, which focuses on U.S. healthcare issues.

SOURCES:

http://bit.ly/ftoNg3

http://bit.ly/gvMTlm

Health Affairs 2011.

http://www.medscape.com/viewarticle/740479?src=mp&spon=24

[merlee]

I don't know how they measured the errors, but the last time I was in the hospital I waited over three hours for pain meds. I am sure that there is no way to 'measure' that, but I feel an incident report may have been in order. No one records the time that a pt first asks for pain meds - there should be a way to document it.

I have been offered meds I never heard of, only to find out something wasn't coded correctly.

Does being served eggs when your chart is clearly marked 'allergic to eggs' count as an error? At the very least, who holds the kitchen line responsible? I am sure those 'errors' never make it into the chart!

[TheMoonisMyLantern, ADN, LPN, RN]

I wonder if they look at patient compliance when they're crunching on these numbers. Let's face it, a lot of patients these days raise holy cain when you have to turn and reposition them every 2 hours and god forbid they use an IS. Yes, it is their right to refuse, but when a patient is non compliant with the plan of care YES they probably will have complications and how is that OUR fault?

[Emergency RN]

Many hospital errors are due to issues with staffing, failing equipment, mismanagement, or antiquated systems. What compounds these problems is that there is also an longstanding culture that thinks it's cheaper to fire an individual nurse for what are, in reality, institutional failures. They don't want to face the costs of having to revamp entire hospital systems.

When "mistakes" are reviewed with a punitive eye, the people who "make" them will endeavor to hide or cover up. Only when the health care industry adopts the same methodologies of NASA and or the Federal Aviation Administration (where mishaps are investigated non punitively), will people not feel threatened in coming forward honestly; only then can systems solutions be found to prevent recurrence of mistakes.

This is something too, that sadly, Nursing Unions have yet to universally pick up on...