Health care's culture doesn't encourage doctors to report medical errors of colleagues; article says patients should come first

By Melissa Patrick
Kentucky Health News

Doctors are often aware of their colleagues' medical errors, but fail to report them because of a culture that does not support or encourage such actions, Marshall Allen writes for ProPublica, a non-profit, non-partisan journalism organization.

Medical errors are estimated to kill 400,000 people in U.S. hospitals each year according to an online article by John T. James in the Journal of Patient Safety, causing some to say that medical errors are one of the nation's leading causes of death, Allen reports.

According to a report from the U.S. Department of Health and Human Services, most health-care providers employ a philosophy of "deny and defend" when confronted with issues related to medical errors. Providers fear full disclosure will lead to more lawsuits, higher jury awards, higher insurance premiums, and the loss of reputation or coverage for the provider, the opposite is true, the HHS report says. It says honest and open communication helps to lessen malpractice costs.

The Department of Veterans Affairs Medical Center in Lexington has led the way in the move toward health-provider transparency. It has worked under a philosophy of full transparency and disclosure since 1987, requiring prompt reporting and investigation of medical errors and near misses, full investigation, full disclosure of investigation results to the patients and families who have been injured because of accidents and medical negligence, and expressions of apology and  fair remedy, including compensation for injuries, according to the HHS report.

Several years ago, Allen contacted a Las Vegas surgeon to follow up on hospital data that showed peers of this surgeon that had high rates of surgical injuries. Allen reported that before he could reveal the list of peers to the surgeon and request his services in the investigation, the surgeon shared stories of the many surgeries he and his partners did to "clean up" the mistakes of "the worst surgeons in town" and said "he did not need a database to tell him which surgeons made the most mistakes."

An article in the New England Journal of Medicine, “Talking With Patients About Other Clinicians’ Errors,” says that although there is a common belief that there is an ethical duty to inform patients who have been harmed by medical errors, physicians often do not.

The existing guidelines emphasize ethical duties related to self reporting when physicians make  errors, says the report, but offers little guidance about what to do when they discover someone else's mistake.

In a survey separate from the New England Journal of Medicine report, but led by the same main author, more than half of doctors said that in the previous year they had identified at least one error by a colleague.  Gallagher told Allen that the survey did not ask what the doctors did about it.

For the New England Journal report, Dr. Thomas Gallagher, an internist and professor at the University of Washington, led a team of 15 experts who identified possible reasons doctors stay silent about errors by their peers. One reason is the system of referrals on which doctors depend, Allen reports; if a physician "becomes known as a tattler" he or she will lose referrals, and thus suffer financially.

The report lists other reasons for not reporting colleagues' medical errors, such as lack of time to investigate, a culture that promotes loyalty and solidarity, concerns about harming one's institution or becoming involved in a medical malpractice case,  concerns about causing a colleague to face legal issues,risk of acquiring an unfavorable reputation with colleagues and issues related to cultural differences, gender, race and seniority.

The bottom line, Gallagher told Allen, is that "physicians are not learning from their errors and patients are not getting the information they need to receive proper treatment or compensation when the outcome is harmful."

Dr. Brant Mittler, a cardiologist who works as a medical malpractice attorney in Texas, told Allen that in almost four decades in medicine he often saw errors and stayed quiet because "there would have been hostility" if he had reported them. “There’s not a culture where people care about feedback,” Mittler said. “You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you."

Gallagher told Allen, "The result of this culture is too much leniency toward mistakes."

The New England Journal article said that despite the challenges of disclosure, the patient comes first, and doctors should "explore, not ignore" a colleague's error, Allen notes.

Once an error is suspected, the report suggests, the doctor recognizing the error should find the facts, starting with a direct conversation with the physician who made the error so together they can decide how to inform the patient. The article also suggests that hospitals and other health-care institutions lead by supporting transparency.

Dr. David Mayer, vice president of quality and safety at Medstar Health, which runs 10 hospitals in Maryland and Washington, D.C., told Allen that "reporting of medical errors (and near misses) is a top priority at the organization so everyone can learn from mistakes, saying that each month there are about 1,400 reported safety events."

The safety events are analyzed for trends, Mayer told Allen.  If a patient is harmed, an investigation is conducted and the information is disclosed to the patient and family, an apology can be made and compensation can be offered.

Dr. Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, which provides guidance for how state boards regulate doctors, told Allen that doctors and other providers should be more assertive about reporting errors. "Failing to tell a patient about another doctor's mistake undermines the doctor-patient relationship," Chaudhry told Allen. "It makes patients wonder if they can trust their own physicians and the profession of medicine."

Speakers at conference discuss impacts and possible solutions for deadly mistakes and near misses in hospitals

By Melissa Patrick
Kentucky Health News

Medical mistakes made in hospitals cause 98,000 deaths per year. Or four times that many?

That is the widely accepted number based on a 1999 Institute of Medicine report, but a study published in the Journal of Patient Safety says that as many as 210,000 to 440,000 Americans die each year in the hospital because of a preventable harm, Marshall Allen of ProPublica reports on NPR. But the current culture in health care does not support the reporting of mistakes or near misses, said speakers at the Health Watch USA 2013 Conference on Nov. 1 in Lexington.

Keith Widmeier, training officer for the Wayne County Emergency Medical Service, talked about the importance of reporting medical errors: "How are we supposed to fix things if we don't address the near misses?" he asked. "We must look at patterns and address them, learn from the data. Reliable data helps promote systemic change. The current system creates a system of not reporting."

Helen Haskell, president of the grassroots patient-safety organization Mothers Against Medical Error, said there are many contributing factors to this culture, and suggested that there is much to be learned from patient stories.

She told story after tragic story of young patients who had died because of medical error, including the story of her son, Lewis Blackman.

Lewis was a healthy 15-year-old who developed severe upper abdominal pain while on a non-steroidal anti-inflammatory drug and a narcotic following an elective surgery. Nurses and residents failed to act upon increasing signs of instability, including 24 hours with no urine output and four hours with no blood pressure. Haskell asked repeatedly for an attending physician. Four days after the operation, her son died. The autopsy showed a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity. He had been bleeding internally.

It is the responsibility of our health care system to become more transparent, listen to people's stories and put systems in place to decrease the chance of medical errors, Haskell said. Health care must improve in the areas that errors most commonly occur, she said, such as true informed consent, unnecessary surgeries, medication and diagnostic error, failure to rescue, and communication errors.

To decrease medical errors, Haskell suggested that the system use technology as the driver of improvement, providing continuous feedback between everyone involved in the care of a patient and involve the community and government.

Nurse burnout and job dissatisfaction also lead to medical error in hospitals.

"We cannot expect high quality health care with burnout," said Jeannie Cimiotte, a Ph.D., RN and associate professor at the Rutgers University College of Nursing and executive director of the New Jersey Collaborating Center for Nursing.
Cimiotte cited a Pennsylvania study that found the implications of increases in nurse workload are burnout and job dissatisfaction, missing important changes in patient conditions and failing to report important patient information at shift change. She said the study also found high nurse burnout appears to be a possible explanation for the association between nurse staffing and infection, jeopardizing patient safety resulting in hospital-acquired conditions and poor health care outcomes.

A culture of change and transparency has been implemented and is working at the Department of Veterans Affairs hospitals in Lexington since 1987, said Dr. Steve Kraman, who was chief of staff and chairman of the Risk Management Committee of the hospitals from 1986 to 2003. They not only require the reporting of medical errors and near misses, but provide full disclosure to patients who have been injured because of accidents or medical negligence, and offer fair compensation for injuries, Kraman said.

The VA has used this model since 1987 and has had "encouragingly moderate liability payments," said Kraman. In 2010, the University of Michigan reported remarkable decreases in suits, costs, trials and time to resolution. They also linked the openness of such a program with patient safety benefits due to reduced need for secrecy surrounding errors. The University of Illinois reports no increase in either number or suits or payouts since participating in this model of care, according to Kraman.

Kraman asked the participants: Is full accountability and transparency the way we should do health care? The answer was a resounding yes.

"This is a decision based on how we behave in society.  We should behave in a stand-up manner," Kraman said.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website.

Kentucky and online audiences hear discussion of proposed system for patients to report medical errors; comments due July 8

By Molly Burchett
Kentucky Health News

The Obama administration is creating a new system for patients to report medical mistakes because existing systems fail to do so, and if all goes as planned, the pilot program will launch this fall, a federal official told a Health Watch USA meeting in Kentucky and online Wednesday night.

Research suggests that many adverse medical events go unreported in current systems that don't allow patients to provide input about their care, said James Battles, Ph.D., of the Agency for Healthcare Research and Quality. To fix this problem, AHRQ has funded the development of a prototype patient reporting system through a contract with RAND Corp.

Called the Consumer Reporting System for Patient Safety, the project is designed to collect information from patients "about medical errors that resulted or nearly resulted in harm or injury” and can also secure reports from family members, said Battles. The data will be available for use by providers and health systems that wish to create or enhance their own local reporting systems.

Here's how the system will work: When a patient recognizes a medical error, an intake form will ask what happened, including questions about the details of the event and the health care provider(s). Providers and patient safety officers are expected to follow up with the patient, which AHRQ estimates would add 28 hours to the provider's annual work load. The collected data will be analyzed to produce estimates about the patient safety events, which will be shared with health institutions.

There is concern about how the project findings will be used and that "frivolous" patient reports may lead to increased medical malpractice liability for providers. Despite apprehension that findings could possibly be linked to financial or legal penalties for poor performance, hospitals say they are receptive to the idea, Robert Pear of the New York Times reported last fall when project was first posted in the Federal Register.

"The question then would become, frivolous to whom?" Battles said when asked what he would say to concerned providers. Patient input is critical to gaining a full understanding of an adverse event, he said, and the overall project will include public awareness campaigns to let patients know their care experience is valued: "The purpose of the system is to improve patient safety, develop ways to prevent future harm and inform policy."

Patients, physicians, hospitals and other health care providers have until July 8 to comment on revisions to the government proposal, says the notice published in the Federal Register. (Click here for more information.) Battles said AHRQ has made substantial changes to the proposed reporting system's data collection tools, based on comments received last fall when the project was originally outlined.

After approval from the federal Office of Management and Budget, Battles said, a pilot program will be launched this fall near Philadelphia, then the system will be tested on a regional basis while considering reports from providers and patients.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website. The organization's next meeting will be held July 31 at 5 p.m. and will feature Dr. Patrick Conway, chief medical officer for the federal Center for Medicare and Medicaid Services.

Hospitals are not reporting cases of harm to patients; electronic health records may be key to solving the problem

By Tara Kaprowy
Kentucky Health News

Hospitals aren't reporting cases in which medical care harmed a patient, making it difficult for providers to identify problems and fix them, according to a report to be released by the U.S. Department of Health and Human Services.

The report indicates many hospitals are ignoring state regulations by not reporting preventable problems. In Kentucky, there are no mandatory public reporting requirements for hospitals. They must only inform the state Department of Public Health about infectious outbreaks, but the definition of an outbreak varies from facility to facility, based on the number of patients seen in a specific period of time.

Dr. Kevin Kavanaugh, a retired physician and chairman of Health Watch USA, said the report points to "the need for greater health care transparency and state government engagement."

The study's lead researcher, Lee Adler, is looking to electronic health records to set things right since "we may be able to prevent events, we may be able to ameliorate events, and (electronic records) may become your surveillance system," he said.

The software can be designed to "catch triggers for potential errors," Kelly Kennedy reports for USA Today. One example could involve a patient that is given an antidote after a medication overdose. The fact that the antidote was used would trigger an alert to a hospital quality control officer, who would them follow up in turn. (Read more)

About half of doctors are using EHRs nationwide, the latest survey from the Department of Health and Human Services shows. "That's a pretty high number, historically speaking," reports Sarah Kliff for The Washington Post. "As recently as 2005, just about a quarter of doctors' offices had gone digital."

In February, Health and Human Services Secretary Kathleen Sebelius said the percentage of hospitals using electronic health records has doubled in two years, Medical News Today reports. The shift at doctors' offices and hospitals stems from a provision in the federal health-care reform law, which gives financial incentives to facilities that switch over to EHRs.

In Kentucky, 723 eligible professionals and 15 hospitals have already been paid their incentives, which totaled more than $155 million as of May. In February, Sebelius said almost 2,000 hospitals and more than 41,000 doctors had received more than $3 billion in incentive payments to use health information technology. The proportion of hospitals that now use EHRs went up from 16 percent in 2009 to 35 percent in 2011. More than 80 percent of hospitals said they intend to advantage of the incentives by 2015.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Revealing patient safety issues and medical errors are goals of Facebook page set up by ProPublica

Photo by iStockphoto.com/selimaksan

Interested in creating a venue for those who have been harmed while undergoing medical treatments, ProPublica, the nonprofit, investigative news organization, has set up a Facebook page on the issue.

"Group members have already shared stories of personal disability or the death of a loved one due to surgical mistakes, becoming infected with deadly drug-resistant bacteria and dental mishaps — including cases they claim were not properly addressed by health care providers," Daniel Victor and Marshall Allen report. The page will be moderated by Victor and Olga Pierce.

The page is also open to doctors, nurses, regulators, health-care executives and others interested in discussing medical errors, their causes and solutions. Question-and-answer sessions with experts will be posted, along with links to the latest reports and policy proposals. (Read more)

Hospital employees report only 1 of 7 medical errors, study finds

In keeping with other studies on the subject, a new report shows hospital employees only report and recognize one out of every seven medical errors, accidents or other events that harm Medicare patients. "Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the 'adverse events'," reports Robert Pear of The New York Times.

While hospitals serving Medicare patients are supposed to track and analyze the cause of medical errors and most hospitals do have a system in place to inform administrators about adverse events, "Hospital staff did not report most events that harmed Medicare beneficiaries," said Daniel R. Levinson, inspector general of the Department of Health and Human Services and author of the report.

Levinson said more than 130,000 beneficiaries were subject to one or more adverse events in hospitals in one month. An adverse event includes medical errors, severe bedsores, hospital-acquired infections, delirium as a result from too many painkillers, or excessive bleeding because blood thinners were used improperly.

The study involved the input of independent doctors, who reviewed 293 cases in which patients had been harmed. Forty of the cases were reported to hospital managers and 28 were investigated by hospitals, "but only five led to changes in policies or practices," Pear reports.

One of the major issues is that hospital employees don't recognize when a patient is harmed, Levinson said. In some incidents, "employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported," Pear reports. In other cases, employees thought an event was so unusual it wouldn't be likely to recur.

In answer, Medicare officials said they will come up with a list of "reportable events" for hospitals and employees to use. Hospitals, in turn, should give detailed instructions to employees about what kinds of events should be reported. (Read more)

A culture of silence remains about medical errors, but things are slowly improving, physician-activist says

There has been a culture of silence when it comes to talking about medical errors, but things are slowly changing, writes Dr. Kevin Kavanagh, right, in an op-ed piece in the Lexington Herald-Leader.

Kavanagh, who is chairman of Health Watch USA, recalls an incident in which a patient came to be treated for a severe sinus infection. Upon being rushed to surgery, Kavanagh discovered "an old smelly gauze pack" had been left in the sinus from a previous operation. When an assistant asked Kavanagh what he should tell the patient, "I answered, 'The truth'," for which he was disciplined by a senior surgeon.

"Years have passed, and things are starting to change in medicine," Kavanagh writes. "Telling patients that something went wrong is slowly being accepted — a revolutionary idea to medicine."

Studies have shown that hospitals with full-disclosure policies actually have lower patient death rates, which Kavanagh just called "common sense." "If preventable patient harm occurs on a ward and the patient is not told, almost all of the employees on the ward will know about the cover-up," he writes. "How then will the administration garner the respect to effectively oversee the functioning of personnel? If hospital staff are not performing adequately, how do you discharge them when there are skeletons in the closet?"

Full disclosure also lowers malpractice expenses, Kavanagh contends. Stanford University hospitals had a 36 percent drop in malpractice claims and has saved $3.2 million since it adopted a full-disclosure policy in 2007. University of Michigan had a 40 percent drop in new claims and saves $2 million each year.

But full disclosure is not common in Kentucky, despite the Veterans Affairs hospitals in Lexington being the first to implement full disclosure in the country. "Instead of this practice spreading throughout Kentucky, the next health-care system to implement it was the University of Michigan," Kavanagh writes.

Things need to change, especially in the face of superbugs like MRSA. As he looked back at the incident involving the botched sinus surgery, "I am most bothered that I apologized for my actions," Kavanagh writes. "Now I would reserve the words, 'I'm sorry' for the patients who have been harmed." (Read more)