Laurie Tewinkle, Attorney at law.

Address: 821 state street. Erie, Pennsylvania 16501. Phone: (814) 454-1100



Hospital errors cause 15,000 deaths per month

A major federal study released yesterday suggests that state regulators aren't getting the full story from California hospitals when it comes to reporting serious lapses in care. And if the results of the nationwide probe apply here, hospitals could be withholding reports of as many as 20,000 incidents.

The federal study [PDF] found that one in seven Medicare patients are harmed while in a U.S. hospital, and 15,000 die each month as a result of lapses by hospitals and their employees.

The report by the Health and Human Services Inspector General’s Office found that 44 percent of the errors were preventable and spurred declarations of a crisis.

The report is based on the findings of a team of doctors who reviewed the records of 780 Medicare patients who were in a U.S. hospital during October of 2008. The report findings are considered reliable enough to draw conclusions about all Medicare patients who received care in a hospital.

If their conclusions hold in California, then the implications are serious.

In the fine print of the report [PDF], you can see that a tiny fraction of the medical errors are so-called "never events," [PDF] as defined by the National Quality Forum. (They're now called "serious reportable events," but I'll use the shorter designation for now.)

Those include leaving a sponge inside a patient after surgery, operating on the wrong patient and two dozen other mishaps that California now requires hospitals to report [PDF].

In the 780 cases that doctors examined, they found only five such cases, representing 0.64 percent of the total and including serious medical errors and major bedsores.

Multiply that by the million cases during the study period, and the report authors estimate that such incidents befall just over 6,300 Medicare patients in a month.

Ever curious, I wondered, if these worst-case scenarios happen in 0.64 percent of hospital stays nationwide, what do the numbers look like in California?

Here’s what I found. According to OSHPD, there were about 3.73 million hospital discharges [PDF] in California in 2008. Assuming that the rate of disasters affecting Medicare patients nationwide also applies to patients in California, you’d expect a total of 23,757 “never events,” like medication-related deaths or serious bedsores.

The report estimates that the percentage rate of 0.64 serious errors could actually be as low as 0.27 percent or as high as 1.53 percent, putting California’s expected number of errors as low as 10,000 or as high as 57,000.

Let’s compare that with the number of such events that California hospitals reported in 2008. According to the Department of Public Health, hospitals reported 1,509 such incidents in the 2008-09 fiscal year.

The state also fined hospitals that year for failing to report 153 events on time, typically nabbing hospitals when they file a report after the legal timeframe.

That leaves, by my count, roughly 20,000 incidents that may have occurred but were never reported.

Certainly, there could be problems with the study that make it risky to draw such a conclusion. For one, the inspector general only looked at cases in October, and it could be argued that doctors and nurses were particularly absent-minded that month. The study also looked at patients who were mostly 65 and older, which could be a group that is more prone than the general California population to get bedsores or experience falls and other “never events." And the fact that only 5 of the 780 cases involved "never events" could raise questions about drawing any major conclusions.

Still, as I wrote a couple weeks ago, state authorities already told Sen. Elaine Alquist, an architect of the adverse event disclosure laws, that they are pressing hospitals to disclose adverse events.

Public health officials wrote to the chief executives of 80 hospitals that never reported a single serious lapse, calling on them to report such incidents or certify that none happened.

Whether reports about 20,000 medical errors come in – that remains to be seen.

Read the Original Article from California Watch here.


   

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