Your hospital's medical errors may soon become public knowledge

Trend toward transparency takes a new turn

The general public already can find out what percentile your organization scored in when it comes to quality measures for conditions such as acute myocardial infarction or pneumonia. But what about the number of times surgery was performed on the wrong body part of a patient? Serious medical errors such as these are now public knowledge in Indiana and Minnesota, and other states may soon follow suit.

Public reporting of medical errors is part of a growing trend toward transparency in health care. In 2003, Minnesota became the first state to publicly report data on medical errors, and Indiana followed in 2005, as a result of a gubernatorial order. Indiana's Medical Errors Reporting System now requires all 287 hospitals and surgery centers in the state to track the 27 preventable adverse health events identified by the Washington, DC-based National Quality Forum as "never events." According to Indiana's interim report, 77 serious preventable mistakes were made in 2006, including nine cases of surgery on the wrong body part and four patient deaths associated with falls.

Minnesota's adverse health event reporting requirement has put the issues of error reporting and public transparency "front and center," says Alison Page, MS, MHA, chief safety officer for Fairview Health Services in Minneapolis.

"I think this is a good law. The public has a right to know what happens in hospitals, and hospitals have an obligation to make it public," she says. "As hospitals, we are now able to learn from each other."

Prepare now for reporting

Quality professionals at St. Vincent Health in Indianapolis spent "considerable organizational and community effort" preparing for the release of Indiana's preliminary report, says Jon D. Rahman, MD, system vice president and chief medical officer.

Rahman says that the interim report displayed the results broken down by the number of discharges, which muted the impact somewhat. "We also expect that, in future years, the number of events will increase, as the Minnesota experience tells us," he says. Minnesota has seen its numbers rise steadily each year, from 99 in 2003 to 154 in 2006.

Be proactive to prepare for the possibility of public reporting of medical errors in your state. "Be open with the board, associates, and physicians about what the institution anticipates as far as the number and type of events that may be reported," Rahman advises.

Explain that the number of reported events will most likely rise over time, and also be clear about what has been implemented to prevent further occurrences. "If your organization is already moving toward greater transparency, this should be an easy task," says Rahman.

Since Minnesota's mandated reporting requirement took effect in 2003, most hospitals in that state have had an increase in the numbers of events reported, likely due to better identification of events. For example, as a result of hospitals learning more about the "never event" of foreign objects left in patients after surgery or other invasive procedures, it was determined that reported incidents should include retained sponges during childbirth.

"Working together through this reporting system, hospitals realized this was happening, consulted with the Minnesota Department of Health, and broadened the definition of what was reportable to include sponges and gauze used during delivery," says Lori Johnson, RN, director of improvement services/patient safety officer at Hennepin County Medical Center in Minneapolis.

To prepare for the reporting requirements, quality professionals at Hennepin made sure that there was a clear understanding of the organization's own data and the specific actions taken to improve care. "In preparing for the report, it is also important to keep your board, executives, employees, and physicians informed of its release and anticipate any questions they might have," says Johnson.

To develop a robust reporting process, your organization must promote an environment conducive to improving patient safety though "reporting, learning, fixing, and sharing," says Johnson. "As a quality leader, you must be knowledgeable and participate in any efforts to develop mandated state reporting, so that the process promotes the sharing of event learning and improvement strategies," she says.

Shared strategies

In Minnesota, the report's data are already proving to be a powerful tool for quality professionals. "We can learn more together than we can individually," says Page. "Now we can learn from what happens at 139 hospitals in Minnesota, vs. only learning from what happens in each of our organizations."

Page recommends identifying the top issues at your state's hospitals and forming collaborative work groups to resolve safety issues. For example, pressure ulcers are the No. 1 reported event in Minnesota. The Minnesota Hospital Association has convened a group of experts in skin care, identified best practices to prevent pressure ulcers, developed tools to assist organizations, and put out a "call to action" to all Minnesota hospitals to implement the best practices. "We are setting standards for ourselves and, in doing so, raising the bar state-wide for what hospitals are expected to do to prevent these types of things from happening," says Page.

Quality leaders at Washington, IN-based Daviess Community Hospital intend on using the report as a tool for both risk management and quality improvement opportunities, rather than using it as a "fingerprinting exercise," says Dawn Fritschle, RN, director of quality/risk/case management.

It would be a mistake for the public to jump to conclusions based on one report without looking at the whole picture, she says, adding that patients at Daviess are frequently referred to hospital networks that have reported errors.

"We have no intention of changing our referrals based on the report," says Fritschle. "These hospitals often receive our most critically ill or injured patients. We work closely with them and can easily see their commitment to providing quality care for these complicated patients."

Data useful for QI

Though there are no comparative data available on a state-to-state basis, the report's data have helped quality improvement efforts at Munster, IN-based Community Healthcare System, says Janice Ryba, division director of regulatory and rehabilitative services. For the first-year report, the health care system's three hospital sites had zero reportable events.

"We are proud and grateful. But we are also acutely aware that the best way to acquire consistent excellent performance is by reporting events as they occur, so that we all benefit from the lessons learned and continue to improve," says Ryba. "One single year's report is not a reflection of the total quality care provided by any one hospital or health care system."

To prepare for the mandatory report, the health care system reviewed its policies and procedures already in place to protect patients. The organization is working to eliminate variability in practice, to reduce the likelihood of a serious error.

For example, the process to avoid the wrong surgical procedure performed on a patient was reviewed by a multidisciplinary team consisting of surgery directors, physician leaders, and quality managers. "After the policy was determined, staff and physicians were educated. But it certainly does not stop there," says Ryba. "The final and most important phase of process change involves monitoring to be sure the policy is effective."

Through direct observation and review of documentation in the medical record, the surgery department and quality management team determine compliance by staff and physicians. "The true outcome or goal is certainly zero wrong-site surgical events. Thus far, we have been successful in achieving this goal," says Ryba.

At Daviess, a Failure Mode and Effects Analysis (FMEA) is being done based on the two most common reported errors — correct site verification and hospital-acquired wound prevention. "The data clearly point out that these areas are high-risk areas for all hospitals, not just the hospitals that had reportable errors," says Fritschle. "We are grateful that we can take this information from the report and use it proactively to help us reduce the chances for errors in the same areas."

The FMEA process will identify any weaknesses in the hospital's current procedures for correct site verification, says Fritschle. "We'll do another FMEA on our screening process for identifying patients at high risk for developing a decubitus ulcer while they are in our hospital," she says.

If the patient is admitted with bedsores or is assessed as high risk for development of bedsores, specific protocols are initiated by the physician and nursing staff to prevent the escalation of the degree of bedsores. "Frequent rounding by bedside caregivers, with attention to the unique care required for particular patients is paramount," Fritschle says.

Quality managers at Daviess now are looking at whether the hospital had any incidents or near-misses that weren't reportable incidents, and are examining incidents reported by other hospitals to see exactly where breakdowns in the process occurred.

"The hospitals we've talked to have been very open with us, and have willingly shared information," says Fritschle. "By combining all the information gathered both internally and externally, we will be able to drill down quickly to areas in our own processes that could potentially cause us to have errors."

At Hennepin County, the state's report has augmented internal efforts to promote transparency, improve care systems, and reduce adverse events. "This reporting process provides a new avenue of learning, improvement and networking opportunities for the quality professional that otherwise may not exist," says Johnson.

This year, the Minnesota Hospital Association is hosting four "call to action" campaigns to reduce adverse events in the top four statewide events: pressure ulcers, falls, retained foreign objects, and wrong body-part surgery. "This is an opportunity for all hospitals to hear from national and local experts, share what we have learned, and implement action plans to reduce these specific types of adverse events," says Johnson.

If each hospital were examining just their own events, valuable information would be lost, adds Johnson. "This type of reporting system provides a unique opportunity to gather the collective experiences from all hospitals and share what is learned, to the ultimate benefit of patients across the state," she says.

Long-term impact

Indiana's mandatory requirement in January 2005 set the stage for other patient safety initiatives in the state, such as the July 2006 launch of the Indiana Patient Safety Center. "The formation of the center provides an opportunity to go beyond mandatory reporting, and explore the role of voluntary reporting outside of that list," says Betsy Lee, RN, MSPH, director. The center is currently working with hospital-based quality leaders on many different initiatives, including pressure ulcers and preventing harm from high-alert medications. Topics for future initiatives include wrong-site surgery and retained foreign objects.

"The important thing is that clinical staff and quality professionals at hospitals are coming together to talk across typically competitive lines about ways to improve safety," says Lee.

The new requirements are part of a national movement toward public disclosure when things go wrong, and the jury is still out on whether this will increase the number of malpractice lawsuits filed. For the state reports, only the category of event is known, with no dates or patient or practitioner names released. "So, in that sense there is protection. However, due to the nature of many of these events, the fact that one occurred may already be known within a community," says Lee.

Regardless of the transparency trend, front-line staff may still be fearful of liability or other repercussions. "We have worked for many years with different rules of behavior around adverse medical events, so there will be a time of trust building during this period of change," says Lee. "I don't think we have that level of trust from the front line yet. We have a ways to go to improve the culture of safety, but hospitals are moving in the right direction."

Increased public awareness of medical mistakes could result in more of a tendency to sue health care providers, or it could wind up having the opposite effect. "I don't think we can predict with any degree of certainty which way it will go," says Lee. "Will the patients and families involved have a different threshold for seeking legal action? That might be true, but then again, it might go in the other direction."

After the Indiana report's release, two family members of patients that had been harmed contacted Lee and both asked, "How can I help?"

"I believe that the public's reaction may not always be what we predict," she says. "There are people who have been personally impacted who are now committed to improving the system. I believe we have some untapped partners in this process."

[For more information, contact:

Lori Johnson, RN, Director of Improvement Services/Patient Safety Officer, Hennepin County Medical Center, Minneapolis, MN 55415. Phone: (612) 873-4552. E-mail:

Betsy Lee, RN, MSPH, Director, Indiana Patient Safety Center. Phone: (317) 423-7795. E-mail:

A lison Page, MHA, Fairview Health Services, 2450 Riverside Avenue, Minneapolis, MN 55454. Phone: (612) 672-6396. Fax: (612) 672-6060. E-mail:

Jon D. Rahman, MD, System VP & Chief Medical Officer, St. Vincent Health, 8425 Harcourt Rd., Indianapolis, IN 46260. Phone: (317) 338-7057. Fax: (317) 338-4715. E-mail:

Janice Ryba, Division Director, Regulatory and Rehabilitative Services, Community Healthcare System, 901 MacArthur Boulevard, Munster, IN 46321. Phone: (219) 836-3465. E-mail:]