Hospitals Unlikely to Put Mistakes in Writing

February 11, 2010 -- Despite a concerted effort by the Oregon Patient Safety Commission, Oregon hospitals are falling short in providing written notice to patients that a mistake occurred within their facility.

 

Medical liability experts say the mere acknowledgement of a mistake and telling patients “I’m sorry” reduces the number of malpractice lawsuits. But physicians are still largely reluctant.

 

In more than half of all serious hospital errors in Oregon, patients failed to receive written notice that acknowledged a serious error occured, based on a summary of reports submitted to the commission, which is charged with reducing medical errors.

 

The Patient Safety Commission collects reports on serious adverse events in hospitals, nursing homes and ambulatory surgery centers. Common medical errors include falls, infections or retained objects.

 

Last year, the rate of written notices went down from 62 percent of all cases reported to the commission in 2008 to 54 percent in 2009. In about a third of all cases (29 percent), notice of serious harm was given orally last year.

 

The commission prefers that every hospital give written notice of medical errors all of the time, but as it stands now, just seven Oregon hospitals notified patients in writing for every serious mistake and 14 never did.

 

Since 2006, the commission’s been pushing hospitals to provide such written notice. Among several efforts, it convened a workshop and provided draft language for notices that didn’t admit guilt or open the door to potential lawsuits.

 

 

A failure of hospitals to acknowledge mistakes in writing is just one of the areas where the commission has fallen short of its stated goals. The voluntary reporting program is still largely believed to collect far too few of the actual serious medical errors occuring in Oregon hospitals. One large hospital submitted just one report, but because the program enjoys confidential protection, not even commissioners are privvy to hospital-identified information.

 

“We’re pretty clear that one report isn’t accurate. There’s probably more than that going on,” said Leslie Ray, PhD, RN, the commission’s field coordinator.

 

Hospitals reported a combined 20 incidents in 2009 of retained objects, 15 medication errors, 26 falls, 10 pressure ulcers and 7 infections, among other cases. The actual number of each of these mistakes is likely much higher, acknowledged Dr. Glenn Rodriguez, chief medical officer for Providence Health System. “We know this in no way represents the universe of events,” he added.

 

The commission also faces participation challenges by ambulatory surgery centers. And its program to collect pharmacy errors has completely stalled because large chains refuse to participate. It will soon roll out a reporting program for renal dialysis centers.

 

 

On the positive side, a one-year initaitive by the commission to institute a World Health Organization surgical checklist in every hospital has been well received, with 80 percent of Oregon hospitals on their way to adoption.

 

A surgical checklist has been widely advocated by author Dr. Atul Gawande. In his recent book, The Check List Manifesto, Gawande reports that check lists are the easiest way to reduce medical errors and save lives, but just 10 percent of U.S. hospitals use them. A Johns Hopkins University study showed the benefits of checklists in ICUs.

 

Of the 51 non-VA hospitals in Oregon that perform surgical procedures, 41 hospitals are in various stages of adopting the WHO check list (80.4%), according to the Patient Safety Commission. The remaining 10 hospitals have yet to begin adoption, and the commission doesn’t have information on five hospitals.

 

“Every hospital knows about it. That’s the one thing you can be sure,” said Ray, the commission’s field coordinator. “There are a lot of competing priorities. It’s not that they can’t be bothered.”

 

Even among hospitals that don’t use the WHO checklist, the facilities still use a check list, Ray said, adding, “All Oregon hospitals, without exception use checklists for surgery. These checklists are quite detailed and usually are discipline specific. The WHO checklist, which could be considered an expansion, focuses on a narrower and slightly different range of items that the surgical team as a whole needs to consider and provides a process for sharing that information. Adopting it requires surgical teams to rearrange their activities, which is not a trivial undertaking.”

 

Checklists reduce the rate of death from 1.5 percent to 0.8 percent and reduced complications from 11 percent to 7 percent, according to a January 2009 study published in the New England Journal of Medicine.

 

Diane Waldo, director of quality and clinical services for the Oregon Association of Hospitals and Health Systems, said hospitals are continuing to adopt the WHO checklist more broadly. “I’m encouraged,” she added.

 

 

At the Feb. 9 meeting of the Patient Safety Commission, members offered feedback about the past year. Several commissioners said they were proud of the checklist initiative while others said the commission needed to do a better job empowering consumers and reporting results.

 

“I’m still patiently waiting for something to happen,” said Nancy Chi, director of healthcare informatics at Regence BlueCross BlueShield.

 

“We need more data and more information, for instance, about what types of falls are most common,” said Naomi Price, a consumer advocate.

 

Administrator Jim Dameron defended the commission’s progress while focusing on the challenges. “I’m proud of what we’ve accomplished but it feels like there’s much more to do,” he added.

 

 

For more information about the Oregon Patient Safety Commission click here.

 

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