Tracking Medical Errors Remains Stubbornly Inconsistent

As complex as health care and health care policy are, some simple truths cut through the fog: It is better to help sick people than to hurt them. And it's also cheaper.

If that seems obvious — and it should — a related truth may not be: Despite the best intentions of the people and hospitals that care for the sick, it turns out to be harder to avoid hurting patients than you might think.

Each year millions of Americans are harmed during hospital stays. Much of the harm, which comes at great human and financial cost, is preventable, but efforts to improve the situation are falling short.

The people and institutions entrusted with caring for patients and protecting their interests — physicians, nurses, technicians, hospital administrators, accreditation services and government regulators — must do better.

Last week, Daniel R. Levinson, inspector general of the U.S. Department of Health and Human Services, released the latest in a series of reports on "adverse events" at hospitals, defined as "harm to a patient as a result of medical care." Taken together with a previous report in November 2010, the findings are troubling.

The earlier report looked at a random sample of Medicare patient hospital stays in just one month, October 2008. It found that 13.5 percent of the patients were harmed seriously, sometimes fatally. Examples of adverse events include internal abdominal bleeding caused by anticoagulant medications, hospital-acquired infections and failure to prevent bed sores from progressing to severe.

An equal number of the Medicare patients suffered temporary harm — including delirium and hallucinations from narcotic pain medications, diarrhea from antibiotics and bleeding and bruising at the site of an IV insertion.

Reviewing physicians judged 44 percent of the incidents as "clearly preventable" or "likely preventable."

The cost of treating the adverse and temporary harm events, the report projected, was about $4.4 billion annually — and this involved only Medicare patients. Other studies have projected unacceptably high rates of medical errors among other populations of hospital patients.

In last week's report, Levinson found that systems designed to identify, track and help prevent the recurrence of such incidents at 189 hospitals caught only about 14 percent of them.

Sixty-two percent of the incidents weren't reported because hospital staff didn't recognize them as reportable. Another 25 percent weren't reported, inexplicably, even though similar incidents had been reported previously.

Industry and government commitments to reduce medical errors have helped, as have tracking systems. But clearly some hospitals have yet to embrace a culture of responsibility.

Medicare officials have begun to implement one of the new report's recommendations: They're creating lists of adverse events that have been reported and getting those lists to health care providers and instructors and students at nursing and medical schools. The new report urges hospital-accrediting groups to give greater weight in their assessments to how a hospital responds to adverse events.

Both recommendations make sense. So do new Medicare rules that will limit or eliminate some payments to hospitals for care required because of medical mistakes.

Mandatory public access to all data about hospitals' quality of care, infection rates and other adverse events also makes sense. Right now, it's up to individual states to decide whether statistics are made public. Only about half the states allow public access to some information. All of them should.

A little sunlight could help the healing.

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