Reporting medical errors critical to patient safety

By Bonnie Pisarik and Garth Bowen

----

Despite more than a decade of national focus on patient safety, research indicates that medical errors and other adverse events still occur in one-third of hospital admissions.

That finding is reported in the April issue of Health Affairs and based on a study conducted by David Chassen of the University of Utah and co-authors at the Institute for Healthcare Improvement.

The Chassen study is one of several recent articles that address persistent challenges facing the U.S. health care system with respect to closing the gaps in quality and safety of care - challenges identified as far back as 2001.

Late last year, the Office of Inspector General for the U.S. Department of Health and Human Services said 180,000 Medicare recipients die each year from hospital mistakes. This is equivalent to a 747 jet crashing each day of the year.

Public reporting of hospital and other health care providers' quality and patient safety is essential. It is important for consumers, patients and families to be aware of the quality record of health care providers. Transparency of this information also has proved to be an important catalyst for improvement in health care.

What will it take to motivate health care providers to make health care higher in quality and safety? Dr. Lucian Leape, with the Harvard School of Public Health, recently published an article on the three major approaches: 1) regulation/accreditation, 2) financial incentives and 3) public reporting of performance. Of the three, public reporting held the most promise for improving patient safety, according to Leape.

The Iowa Health Buyers Alliance is leading the greater Iowa Leapfrog Group regional rollout effort to encourage hospitals to publicly report their quality and patient safety. Letters were recently sent to more than 40 Iowa hospital CEOs - including those at Cedar Rapids, Iowa City and Waterloo hospitals - requesting them to complete the Leapfrog annual hospital survey.

The Leapfrog Group is a non-profit organization led by employers and other purchasers alerting America's health industry that big leaps in health care safety, quality and efficiency will be recognized and rewarded. For results from the most recent survey and other information, go to www.leapfroggroup.org.

Reporting on medical errors in hospitals are included in the annual Leapfrog hospital survey. These cover a range of practices that, if used, would reduce the risk of harm. They include “never events.”

Never events are 28 occurrences on a list of inexcusable outcomes in a health care setting. They are adverse events that are serious, largely preventable and of concern to both the public and health care providers.

The Leapfrog Group advises these industry standards following a never event: 1) apologize to the patient 2) report the event 3) perform a root cause analysis and 4) waive costs directly related to the event.

We hope all Iowa hospitals will join their peers in other states, now numbering more than 1,200, and voluntarily report annually to the Leapfrog Group. Mandatory reporting of medical errors would be the next step absent voluntary reporting.

Bonnie Pisarik and Garth Bowen are co-chairs, Iowa Health Buyers Alliance, an association of health care consumers and purchasers working for a patient-centered health system, improved quality, wellness and transparency. For more information, visit www.ihbaonline.org. Comments: contact@

ihbaonline.org