Hospitals' reluctance to report problems makes fixes difficult

by: PHOTO RE-PRINTED WITH PERMISSION OF SOUTH AFRICAN JOURNAL OF SURGERY, VOL. 50, NO. 1 - Surgical objects such as this swab left inside a patient remain the most frequently reported hospital medical error, despite numerous attempts to address the problem.The Oregon Patient Safety Commission held its annual awards breakfast three weeks ago to honor hospitals that had met goals for confidentially reporting adverse events or medical errors.

But there were a number of notable absentees among the hospitals singled out for their transparency — not one Portland-area hospital received recognition for meeting the modest standards set by the commission.

The commission was set up by the 2007 Legislature to help reduce mistakes made at health care institutions. It gathers the hospitals’ error reports and sends to all institutions advice on how not to make the same mistakes.

With a 2010 U.S. Department of Health & Human Services report noting that one in seven hospital patients experiences some sort of adverse event, few doubt there are incidents to be reported. But six years into the Oregon program, local hospitals have been reluctant to fully participate.

The state commission doesn’t release the number of reports each hospital submitted, so the only thing for certain is how many they didn’t submit. Each hospital had a report submissions goal: Providence St. Vincent Medical Center’s was 25 and Legacy Meridian Park Medical Center’s goal was six. Neither hit the target.

Bethany Walmsley, executive director of the commission, says she understands hospitals are busy with a number of quality improvement programs. The commission, she says, has tried to accommodate the hospitals by letting hospital administrators decide which adverse events they are going to report, and by moving two years ago to a simplified online reporting system.

“I have no intention of saying you have to tell us about every single thing that happens, but you are community partners, and we’re extremely hopeful that the reporting will continue in a positive direction,” Walmsley says.

Walmsley notes that overall there were 160 events reported in 2012, up from 146 in 2011. A number of smaller hospitals across the state are meeting their reporting goals. The most common preventable mistake reported was leaving a foreign object in a patient after surgery, which was reported 27 times.

“We’ve whittled it down that you should be able to report this information to us in no more than 10 to 15 minutes,” Walmsley says. “But there’s a perception that that’s the problem. ‘It’s one more thing for us to do.’”

Walmsley says local hospitals already are tracking their problems in-house, so she’d simply like them to share what they know. But that might not be the case, says Dr. Thomas Gallagher, a University of Washington School of Medicine professor considered a national authority on medical errors.

Fear of retaliation

Gallagher is convinced that many adverse events are never reported up the line of authority within a hospital, especially at large urban hospitals.

“A lot of it has to do with a culture of fear,” says Gallagher, who paints a picture of nurses fearful of recrimination if they report a mistake made by a physician, and physicians fearful of punishment by hospital administrators if they report their own mistakes. In that atmosphere, he says, nobody feels as if they are part of a team and everyone tends to look out for their own self-interest.

Gallagher says that might help explain why Oregon hospitals aren’t making many reports to the commission even though they are promised confidentiality when they do.

“It just shows you how pervasive that fear is,” Gallagher says. “It’s been woven into the fabric of the way health care providers and organizations operate. It’s not always rational.”

Nevertheless, Gallagher says the Oregon Patient Safety Commission’s confidential and voluntary reporting model is probably better than a more punitive model he sees in place in Washington state. There, he says, surgeons who have more than once left a foreign object in a patient after surgery have had the state medical board threaten to revoke their licenses.

“Surgeons know it,” he says. “They’re less likely to report mistakes.”

Center builds culture of trust

Tina Caster, executive director of the Center for Specialty Surgery on Southwest Barnes Road, says her staff has no problem reporting mistakes. The center was the only Portland-area hospital or surgical center to meet its reporting goal.

Dr. Rolf Sohlberg, Center for Specialty Surgery chairman, says it’s easier for a small facility to build the type of culture that encourages doctors and nurses to admit to problems. In a hospital, he says, layers of bureaucracy make it harder for people to trust that they won’t get into trouble.

Caster says building a culture of trust starts with the hiring process.

“Every person hired was interviewed with the notion that their opinion matters and their input was valued,” she says. “That is how this place evolved.”

Caster says she’s puzzled as to why more specialty surgery centers haven’t opted into the patient safety program (a little more than half have). Reporting adverse events has been anything but onerous.

“It’s been a rather easy process for us to follow,” she says.

Caster recalls a minor mistake that was revealed by a staff member — a diabetic patient in for surgery wasn’t given a glucose test as scheduled. The staff, she says, rallied to make sure that would never happen again, even making their own signs to remind themselves precisely when the tests were to be administered.

Large hospitals do face more obstacles to reporting, says Oregon Health & Science University Chief Medical Officer Chuck Kilo. Kilo says he supports the patient safety commission.

“They’re doing important work and asking important questions,” he says.

But Kilo says OHSU contributes to a number of patient safety programs, some of which yield more helpful data than the Oregon program. For instance, OHSU submits patient safety data every month to a consortium of 110 academic medical centers and gets back data that compares OHSU to other academic medical centers.

“We know from things like that where our primary efforts need to be,” Kilo says. “We have so much input on safety issues, it’s not like we need additional information on where our gaps are.”

Last year, Kilo says, OHSU made a decision to only report to the Oregon program what are known as sentinel events — the most serious, sometimes life-threatening cases.

Some states are more specific than Oregon on what events must be reported, and a number of states have gone to mandatory reporting systems. But Walmsley isn’t convinced requiring Oregon hospitals to report their events would increase the overall number of reports significantly.

“The thing about mandatory (reporting) is, if it’s going to be effective, you’ve got to have teeth, and we’ve tried to keep that negative tone out of there. We don’t want to be regulatory,” Walmsley says.

On the other hand, she acknowledges the value of the commission — helping hospitals learn from the mistakes and corrections made at other hospitals — is limited when hospitals make few reports.

“I can’t give you something back of high quality if the active participation does not occur,” Walmsley says. “I think we’ve met them halfway as much as we possibly can.”

California’s Center for Health Care Quality administers that state’s adverse event reporting program, where hospitals are required to report serious events, and fines can be issued if they don’t. In addition, when reports to the California program result in fines for medical errors, the names of the hospitals are made public.

Last year, the California program resulted in 1,558 reports, a substantial body of data from which to make recommendations. But more than 450 California hospitals were required to submit reports. On a per-hospital basis, the mandatory California program is getting about the same number of reports as the voluntary one in Oregon.

State Rep. Mitch Greenlick, D-Portland, says he isn’t pleased that no Portland hospitals are meeting the reporting goals, but he is confident that legislation recently approved by the state Senate could help make a difference.

Senate Bill 483 is focused on medical malpractice, but will give $1.6 million to the patient safety commission to develop a program to bring together doctors and patients willing to discuss and potentially resolve their serious events. Greenlick hopes the legislation, should it become law, will encourage more physicians to voluntarily report adverse events and even apologize directly to patients.

“That’s going to be kind of a breakthrough,” Greenlick says.

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