Wrong-patient errors are underreported

Two recent studies suggest that risk managers should take a closer look at how they measure errors in their organizations. One study suggests you should beware of using patient charts to track medical errors because doctors are so inconsistent in how they assess the same charts. Another study indicates that there may be many more "wrong-patient" errors than commonly believed.

In the first study, the researchers found that physicians who were asked to make conclusions based on patient charts were wrong about one-third of the time, says Eric J. Thomas, MD, of the University of Texas-Houston Medical Center and lead researcher on the project. Using multiple reviewers improved the chance of getting an accurate analysis of the charts, but there still were enough errors to warrant caution. Thomas says the findings are particularly relevant because the 2000 Institute of Medicine Report To Err is Human relied on physicians reading patient charts.

The University of Texas study involved charts for patients hospitalized in Utah and Colorado in 1992 (Ann Intern Med 2002; 136:812-816). After three independent reviews of 500 medical records, the following were measured: reliability and the effect of varying criteria for reviewer confidence in and reviewer agreement about the presence of adverse events.

For agreements in judgments of adverse events among the three sets of reviews, the statistics ranged from 0.4 to 0.41 for adverse events and from 0.19 to 0.23 for negligent adverse events. Rates for adverse events and for negligent adverse events varied substantially depending on the degree of agreement and the level of confidence that was required among reviewers.

Thomas and his colleagues conclude that "estimates of adverse-event rates from medical record review, including those reported by the Institute of Medicine in its 2000 report on medical errors, are highly sensitive to the degree of consensus and confidence among reviewers."

In another study, Mark R. Chassin, MD, MPP, MPH; and Elise C. Becher, MD, MA, of the Mount Sinai School of Medicine in Los Angeles, say hospitals seriously underreport the number of patients undergoing medical procedures intended for someone else (Ann Intern Med 2002; 136: 826-833).

"Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them," they wrote.

The article by Chassin and Becher examines the case of a patient who was mistakenly taken for another patient’s invasive electrophysiology procedure. After reviewing the case and the results of the institution’s root-cause analysis, they discovered at least 17 distinct errors, no single one of which could have caused the adverse event by itself. They determined that those specific "active" errors interacted with a few underlying system weaknesses to cause harm. The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.

The researchers point out that the Joint Commission on Accreditation of Healthcare Organizations maintains a national database of sentinel events, which include errors such as this one. But reporting the incidents to the Joint Commission is voluntary and the database contains 17 reports of an invasive procedure done on the wrong patient over the past seven years. Additional information about adverse events is compiled by individual states, at least 15 of which maintain their own error-reporting systems. New York state has received reports of 27 "incorrect patient/invasive procedure" incidents from April 1998 through December 2001.

"The marked disparity in the number of events chronicled by these two databases — one voluntary, one mandatory — suggests that the voluntary Joint Commission database is incomplete," the researchers wrote. "But even mandatory state reporting systems may underestimate the true incidence of wrong-patient’ procedures. All error-reporting systems depend on hospitals’ internal incident reports as sources for their data, and research has shown that clinicians file incident reports for only a small percentage of actual errors."

A recent analysis of the New York system, for example, determined that for one of the adverse events for which reporting is required (deaths within 48 hours of surgery), only 16% of cases were reported in 1999, Chassin and Becher report.