Getting a handle on patient harm

The worst harms that befall patients – removing the wrong limb, receiving a lethal overdose of medication, being accidentally set on fire during a surgical procedure – are always horrifying to hear about, yet there’s growing evidence that these are only a tiny subset of all the things that go wrong in patient care.

A raft of studies suggests that in spite of an unprecedented national focus on patient safety, errors and harm to patients remain vastly underreported.

One of the largest of these studies was issued this past month by the Office of the Inspector General of the U.S. Department of Health and Human Services. (A summary can be found here; the full report is here.)

A few take-home points from the report: Nearly one in three Medicare patients experienced an adverse event in the hospital, yet the internal systems created by hospitals for reporting adverse events captured only a fraction of them. Statewide reporting systems didn’t necessarily help either. Overall, 60 percent of adverse events occurred at hospitals in states with mandatory reporting systems – but only 1 percent of events actually were reported, and most of the harms that went unreported to the state system also were undetected by the hospital’s own reporting system.

Several of the events were serious. In one case, a patient died when poor insulin management led to hypoglycemic coma. In another, a patient died of acute kidney failure after the hospital failed to recognize and treat a serious systematic inflammation.

The report notes that even though many of the adverse events required life-saving intervention and undoubtedly would have been noticed by hospital staff, they went unreported.

This was just one analysis of many that have been done in recent years on the ability of the reporting process to accurately identify patient harm. For instance, a 2005 study of a month’s worth of patient visits to an urban, academic emergency room found that only about half of errors were voluntarily reported – and most of the reports came from nurses, not physicians. Other studies have found that voluntary reporting, complaints from patients and even malpractice allegations tend to uncover only a fraction of the things that go wrong.

Although it would be easy to conclude that health care providers are deliberately covering up their mistakes, the real picture is more complicated than this.

One key point made by the OIG report is this: When adverse events weren’t reported, often it was because the hospital staff didn’t recognize that an adverse event had taken place. Indeed, in many cases they seem to have assumed that what happened to the patient was a complication rather than an adverse event.

Cumbersome reporting systems can be a disincentive for reporting all but the most obvious or significant incidents. Many studies also have documented that health care workers frequently remain silent about mistakes because they fear being punished.

For more than a decade, there has been considerable debate in the U.S. over reporting patient safety incidents. Many institutions and health care professionals are adamantly opposed to mandatory reporting, and this is reflected in the fact that only half of states require reporting of patient safety incidents (Minnesota was the first to adopt such a system). Nor is there a national mandatory patient safety reporting system.

By all accounts, adverse event reporting here in Minnesota is fairly robust and seems to capture most of the incidents that meet the criteria for reporting.

But even when states have their own reporting systems, there’s a weakness: They still rely mostly on the honor system in collecting reports, so it’s possible for some incidents to slip under the radar. They tend to be very specific about what must be reported – wrong-site surgery, for example, or serious pressure ulcers that develop or progress during a hospital stay. They also focus on more severe cases of patient harm, hence may miss numerous harms that are smaller and more common yet have the potential to add significantly to the burden on patients, the health care system and health care costs. Moreover, reporting systems focus mainly on the hospital setting, when most encounters for the majority of patients are in medical clinics.

Why report at all? Because it’s only by collecting and analyzing the data that health care organizations can truly see where the vulnerabilities lie. Often the problem areas aren’t what you’d think. When Rice Memorial Hospital here in Willmar did a study on which older patients were more likely to be readmitted to the hospital, they expected it would be those who were still living independently at home and perhaps didn’t have someone checking on them 24 hours a day. But when they actually looked at the data, most of the readmissions were among patients living in nursing homes.

There’s also this to be said for voluntary reporting: It keeps everyone accountable.

Exactly how to define “patient harm” seems to still be evolving. One person’s adverse event might be, to someone else, a known (and therefore unsurprising) complication. Nor is there universal agreement about the extent to which adverse events can be prevented, or mitigated once they happen.

There’s a certain tension here. Should some level of patient harm simply be accepted as an unavoidable consequence of receiving medical care? Or should health care do more to recognize that just because bad things can happen, they don’t have to be inevitable? Those who work deep in the trenches of patient safety would say that even when complications are known and somewhat expected, health care should do its best to keep them from happening – and should be honest about reporting them when they do take place.

Until these tensions can be better resolved, health care likely will continue to struggle with recognizing and reporting adverse events and getting a better handle on the how and why of patient harm.

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