An Epidemic of Hospital Safety Problems?

The following is an editorial published on April 20, 2006 in USA Today:

“Whose side are they on?

The thought of a surgeon taking a scalpel to the wrong limb, organ or patient sends chills down the spine of anyone who has been in a hospital.

Eighty-four cases of what’s known in the business as “wrong-site surgery” were reported in the USA last year. But that’s just the “tip of the iceberg,” because many hospitals across the country aren’t obligated to account for such blunders publicly, says Dennis O’Leary, who heads a group that inspects health care facilities.

The chances of wrong-site surgery are slim — about one in 113,000 operations, a study published Tuesday in Archives of Surgery notes. Still, any incident is unacceptable. In one typical case, instead of removing a benign tumor from Doug McCoy’s right ear last September, surgeons at Maricopa Medical Center in Phoenix operated on his left ear — which had no tumor.

In an effort to eliminate such blunders, surgeons have been required since 2004 to mark the spot they plan to cut while consulting with their patient before the operation. Nurses are supposed to call a “time out” in the operating room to conduct a final safety check to ensure that the right procedure is performed on the right patient.

So why do these catastrophic mistakes keep happening? Mainly because systems designed to prevent errors are faulty, or not followed, researchers say.

Some surgeons who think they’d never make such a stupid mistake often ignore safety protocols. Stubborn resistance to standardized conduct is part of the culture of medicine.

Airline pilots overcame this barrier long ago. Even the most experienced pilots must run through a checklist before taking off. It may be embarrassing for surgeons to be asked if they know for sure which side — or patient — they’re about to operate on. But it’s a lot less embarrassing than making a grievous error. Swallowing a little pride may save a limb, or a life.

Hazards in hospitals. Surgical screw-ups are a small part of a much larger patient-safety problem in hospitals.

Incidents such as bedsores, post-operative infections and failure to diagnose and treat conditions that develop in the hospital continued to plague American hospitals, according to a new study of Medicare patients by HealthGrades, a health care ratings company.

The study found that 1.24 million patient safety incidents occurred in nearly 40 million hospitalizations from 2002 to 2004. Those incidents were associated with 250,000 potentially preventable deaths and $9.3 billion of excess costs. For the second straight year, incidents increased slightly.

What can be done? Only 23 states have mandatory error-reporting systems, and standards of measurement aren’t consistent. More states need to adopt rigorous reporting systems, and they should publicly release the type and number of patient safety incidents at each hospital. Exposure can spur progress.

That’s what Minnesota has done, and it’s ranked as the nation’s top state for improving patient safety. A unique program there allows fiercely competitive hospitals to work together to share data, highlight best practices and implement tested solutions. As a result, Medicare patients in Minnesota had a nearly 30% lower risk of a safety incident compared with New Jersey, listed as the worst state.

Progress in reducing medical errors has been painfully slow. Speeding improvements requires making safety a top priority, publicly identifying hospitals that miss the grade and rewarding those that exceed it.”