This report originally appeared in the August 2011 issue of DOTmed Business News

For anyone requiring medical care in a hospital or clinic in the United States, the odds of having a mistake-free visit are not too comforting.

A study in the April issue of Health Affairs found one out of three people will experience some kind of medical mistake during their hospital stay. The finding, which is based on a new system for measuring hospital errors, is about 10 times higher than previous estimates using older methods.

But the issue of patient safety and quality health care is not a new one. Patient safety has always been of great concern for both the health care industry and the patients who put their trust in physicians, with an increased interest after the Institute of Medicine released its 1999 landmark report “To Err Is Human: building a safer health system.” The report revealed that at least 44,000, or perhaps as many as 98,000, people die each year from preventable medical errors. The IOM statistics made medical errors the eighth leading cause of death in the U.S., and the numbers still hold true more than a decade later.

One of the report’s main conclusions was “the majority of medical errors do not result from individual recklessness or the actions of a particular group,” but rather errors are commonly “caused by faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them.”

These medical mistakes prove costly to patient health as well as the industry’s purse. In another study in the same April issue of Health Affairs, a Denver-based consulting firm estimated that in 2008, the annual cost of medical errors that harm patients was $17.1 billion, based on insurance claims filed that year.

The study found 10 types of medical errors were responsible for more than two-thirds of the total cost, with the most common errors resulting in bedsores, postoperative infections and constant back pain following back surgery.

Many patients who fall victim to these medical errors often sue the hospital or their doctors. A study in the June 15 issue of The Journal of the American Medical Association found there were 10,739 malpractice claims paid on behalf of physicians in 2009. Of these paid claims, almost half (47 percent) were because of events that happened during an inpatient hospital stay.

Scott Eldredge, an attorney at Burg Simpson in Englewood, Colo., who specializes in medical malpractice, says although his firm reviews hundreds of potential cases each year, they only move forward with about 2 percent of the cases where true negligence can be proved.

“We take on those cases where there has been serious injury that was brought about by negligent acts by physicians and health care providers,” he explains. “Sometimes it’s a simple error and sometimes it’s inattention, but most of the cases are simple negligence where there is an error made unintentionally.”
Eldredge recalls a recent case where he represented a Colorado woman whose baby developed a serious birth defect as a result of the physician’s failure to timely deliver the baby who was showing signs fetal distress.

“The doctor ignored signs of distress even though nurses were pushing to get the baby delivered,” says Eldredge. “The doctor said, ‘No, let’s let labor take its course’ and the baby was born with cerebral palsy and will never walk or function normally.”

He says his firm settled the case for millions of dollars—“enough to take care of child for the rest of his life.”

Ending wrong-site mistakes
One major component of hospital errors is the occurrence of “wrong-site surgeries.” Wrong-site surgery includes invasive procedures done on the wrong patient as well as the wrong procedure, wrong site and wrong side. Mistakes that have occurred in the past include amputating the wrong leg, performing the wrong operation or removing a kidney from the wrong patient.

These types of wrong-site surgeries are considered so blatant and avoidable that they were given their own classification as “never events.” The term was introduced in 2001 by Dr. Ken Kizer, former CEO of the National Quality Forum, to describe medical errors that should never occur. Over time, the “never event” list has been expanded to include 28 errors, such as delays in treatment, leaving a foreign object in a patient after surgery and medication errors.

The Joint Commission for Transforming Healthcare, the Chicago-based group that accredits the nation’s hospitals, reported this June that despite efforts to prevent wrong-site surgeries from happening, they still occur about 40 times each week—more than 2,000 times a year—in hospitals and clinics across the country. Last year, 93 cases were reported to the Commission, compared with 49 in 2004.

In most states, reporting wrong-site surgeries to the Commission is voluntary as well as confidential—to encourage doctors and hospitals to come forward and to make improvements, officials say.

“While wrong-site surgery is not an everyday occurrence, all facilities and physicians who perform invasive procedures are at some degree of risk,” Joint Commission President, Dr. Mark R. Chassin, said on a June conference call on the organization’s Wrong Site Surgery Project. “The magnitude of this risk is often unknown or undefined. Providers who ignore this fact, or rely on the absence of such events in the past as a guarantee of future safety, do so at their peril.”

Eight U.S. hospitals and ambulatory surgical centers recently teamed up with the Center on the Wrong Site Surgery Project. They used methods such as Lean Six Sigma and change management to discover why these mistakes continue to happen and how they can be stopped. At the end of the project, the groups identified 29 main causes of wrong-site surgeries that occurred during scheduling, in pre-op/holding or in the operating room or which stemmed from the organizational culture.

Two such causes were ineffective communication and distractions in the operating room. Melody Dickerson from the Center says distractions occur much too often.
“Typically, what you’ll see in the operating room is someone reading off the signed surgical schedule and rattling off information while other people in the room are doing work or setting up equipment, but they’re just going through the motions and really aren’t paying attention,” says Dickerson, a Black Belt in the Division of Support Operations who trains Joint Commission staff in Robust Process Improvement, which was used during the project.

She says problems with scheduling and documentation also contribute to costly errors.

“Some of the risk points we found in surgical booking were multiple forms being faxed over two or three times, so the person receiving it doesn’t know if it’s the same form or if there’s been a change because changes were not obviously marked,” explains Dickerson.

Over the course of the Wrong Site Surgery Project, the Center and participating organizations were able to reduce the number of defective cases (defects are the causes of risks that could result in wrong-site surgery) in surgical booking from 39 percent to 21 percent; in pre-op from 52 percent to 19 percent; and in the operating room from 59 percent to 29 percent.

But Dickerson says there’s still work to be done. “When you consider the number of defects that hospitals had before our project, these reductions are certainly a remarkable improvement,” she says. “But of course you would like to get that number down to as close to zero as possible.”

Steps in the right direction
The good news is that some of the solutions provided by the Wrong Site Surgery Project seem simple to put into practice. They require, for example, the doctor to physically mark the site of the surgery during the pre-operative preparation; make both doctors and nurses double-check one another as to the proper site of the surgery; and for physicians to speak with patients in the operating room before surgery begins to verify the patient’s name and what procedure is to be performed.

Dickerson says a Web-based application tool is currently in development that will provide hospitals with the information they need to implement strategies to prevent wrong-site surgeries on their own. The application is expected to be available to all 19,000 organizations that the Joint Commission accredits by this fall.

What’s more is that there is also strong financial incentive for physicians and hospitals to reduce these errors. Since 2009, Medicare no longer pays any of the expenses associated with wrong-site surgery.

Many large insurance agencies, such as CIGNA, have also followed suit and refuse reimbursement facilities for any service involving a case of wrong-site surgery and other preventable medical errors that appear on National Quality Forum’s “never event” list. And as of 2008, hospitals in several states had issued policies to not bill patients who are victims of these mistakes.