Report: Hospitals' reporting systems don't capture most patient harm

Inspector General Report: Hospital Incident Reporting Systems Do Not Capture Most Patient Harm

February 10, 2012|by Jay Scherder, KY3 News | jscherder@ky3.com

SPRINGFIELD, Mo. -- Health care is a complex industry. It's unique. A single mistake made by the staff could seriously injure you or possibly kill you.

Contact KY3 examined what Consumer Reports has to say about Cox and Mercy hospitals, as well as how Missouri laws help protect you from deadly infections. Digging deeper, we found a type of error that can't be found in a report because it isn't public knowledge.

"We go into this field to take care of people and do the best job we can," said Vicki Good, a nurse who is CoxHealth's director of patient safety.

Doctor visits, blood tests, CAT scans, and therapy -- going to a hospital can be overwhelming, especially when it comes to medication.

"I do think we have an opportunity to do a better job in explaining medications to patients," said Dr. Alex Hover, Mercy Health System's senior vice-president of Clinical Excellence.

"Medication labels were confusing for them to read," said Good.

According to Consumer Reports, Cox and Mercy hospitals fall short when it comes to explaining exactly what the patient is taking and what possible side effects it comes with.

"Standardization is one of the key ways hospitals have been able to make hospitals safer," said Good.

Both hospitals admit there have been problems, and creating a medication labeling standard across the board is improving the situation.

Another area of concern, according to Consumer Reports, is communication about discharge -- what you need to know when you go home.

"We've standardized that in terms of the person-discharged instructions. I think our results have been better," said Hover.

"Do we deliver that electronically? Do we deliver that in paper form? How do we reiterate that message on every encounter with that patient?" said Good, listing some of the things that health providers think about before a discharge.

Thanks to a Missouri law, the Missouri Hospital Infection Control Act of 2004, health care facilities have to report how many infections patients get while in the hospital.

The Missouri Department of Health and Senior Services says Cox had a medical and surgical infection rate similar to hospitals in Missouri and across the nation.

Mercy, however, had a lower medical infection rate compared to state and national hospitals. It evened out with Missouri hospitals in surgical infections, but again beat the national average.

"Our goal is really is for zero harm, even though that's very difficult to achieve and a very complex environment," said Hover.

There is a certain type of patient harm that isn't being reported to the general public -- a harm that one national group is trying to get in the spotlight.

"We do, in this country, have a system that at least gives the appearance that accountability is happening, but it is broken down," said Safe Patient Project spokeswoman Lisa McGiffert.

"We've heard from mothers whose children have died because of medical error," said McGiffert.
"We've heard from healthy, working people who are harmed and it changes their lives forever."

They're called adverse events.

"Adverse events are any event that happens when things do not go as planned," Good said.

According to a new Inspector General report, hospitals across the country are not capturing adverse events. In simpler terms, they are not capturing patient harm.

The report says, 86 percent of the time , medical staff didn't report errors to incident reporting systems. The report says that's partly because of staff misperceptions about what constitutes patient harm. Of the events experienced by Medicare beneficiaries discharged in October 2008, for example, hospital incident reporting systems captured only an estimated 14 percent.

"They face a lot of public scrutiny when adverse events happen," said Good, "and they have the fear of, 'Am I going to get in trouble?'"

"That's a very definite problem," said Hover. "We ask those questions: Are you afraid to report? Are you afraid to challenge physicians?"

"At least one in four patients is harmed when they are in the hospital. That's about 9 million people every single year," said McGiffert. "A lot of hospitals don't really know what's happening in their facilities as far as medical harm."

McGiffert believes current error reporting systems aren't working. And, she said, you wouldn't know even if they were. That information is not public knowledge.

"There is a system break down of accountability I think. One of the pieces of that is public reporting of these events," McGiffert said.

Cox and Mercy have error reporting systems in place. Mercy told Contact KY3 they report all errors to their community board. The board then holds them accountable for any errors.

1 | 2 | Next

|

|

|