Legislature sends Beshear bill decriminalizing medical mistakes; some in vitro fertilization advocates say bill will protect it

By Sarah Ladd
Kentucky Lantern

A bill giving Kentucky’s health-care providers criminal immunity for medical mistakes — which one lawmaker thinks will enshrine protections for in vitro fertilization by default — is on its way to Gov. Andy Beshear’s desk.

House Bill 159, which would decriminalize medical mistakes made by health care providers, passed the House in February by a vote of 94-0. On Friday it cleared the Senate — also without dissent.

The bill follows a 2022 Tennessee case in which a nurse was found guilty after a patient died from a medical mistake. The conviction led to protests and resignations within the health care community, KFF Health News has reported.

The Kentucky Nurses Association says that if medical mistakes are criminalized, providers are less likely to report them.

“I’m all for responsibility for medical errors,” said Sen. Phillip Wheeler, R-Pikeville, who carried the bill to the Senate floor on the 54th day of the 60-day legislative session. “I think that that is an appropriate domain for civil justice and not for the criminal justice system.”

State Sen. Whitney Westerfield

Republican Sen. Whitney Westerfield, who in February filed a bill seeking to protect access to in vitro fertilization in Kentucky, said he believes HB 159 will accomplish his goal by default. His colleague, Sen. Cassie Chambers Armstrong, D-Louisville, filed a similar bill to protect IVF.

“Neither of our bills have advanced,” Westerfield said while voting in favor of HB 159, which he said will cover IVF access because of its “broad” definition of the word “providers.”

The criminal-liability bill, sponsored by Rep. Patrick Flannery, R-Olive Hill, protects “a person providing health services” who is appropriately licensed and/or certified.

Bills to protect access to IVF, which is used to treat infertility and can help other people trying to get pregnant to do so, came this session in response to a ruling from the Alabama Supreme Court stating that frozen embryos are children.

The ruling led to concerns that it could deter people in Alabama from attempting to conceive children via IVF, which sometimes involves freezing embryos for future attempts at insemination. Several clinics in Alabama, including the University of Alabama Birmingham, paused IVF treatments and embryo transfers in response to the ruling.

Westerfield, of Christian County, said House Bill 159 will protect IVF.

“I think this bill accomplishes that and does so without necessary amendments or changes,” Westerfield said. “And so as a proud father of now four IVF children, I’m proud to see this bill make final passage and head to the governor.”

Most Kentucky hospitals in national patient-safety ratings got C grades again; state ranks 36th among states in share of A ratings

By Melissa Patrick
Kentucky Health News

Most of the 60 Kentucky hospitals graded on a nonprofit group's report card for patient safety got a grade of C.

The Leapfrog Group, based in Washington, D.C., rates nearly 3,000 general acute-care hospitals based on how well they protect patients. Most of Kentucky's 126 hospitals are relatively small and are not rated.

The group does not grade small hospitals with "critical access" status because they don't have to report quality measures to the federal government; nor does it grade specialty hospitals, government hospitals, or hospitals that don't have enough publicly reported data.

Leapfrog gave A ratings to 11 Kentucky hospitals, or 18.3% of the 60 it graded; Kentucky ranked 36th among states in the percentage of A grades, about the same as 35th in the last report. It gave Bs to 16 Kentucky hospitals, Cs to 23 and Ds to 10. 

The grades are based on more than 30 measures that indicate how well hospitals protect patients from preventable errors, injuries, accidents and infections, and whether hospitals have systems in place to prevent them. 

A Leapfrog news release notes that this is the 10th anniversary of the Leapfrog Hospital Safety Grade report and that an analysis of data gathered from 2012 to 2022 suggests there has been an improvement in patient safety over time, with a 27% decrease in falls and trauma, and a nearly 29% decrease in objects being unintentionally left in bodies after surgery. Further, it found decreases in infections associated with health care.

"For five of the outcome measures that can be tracked, these improvements saved an estimated more than 16,000 lives over the 10-year period," the release says.

The report uses data from the Centers for Medicare and Medicaid Services, Leapfrog's own survey and other supplemental data sources. Leapfrog says hospitals are only graded if they have submitted adequate data for evaluation. 

The Leapfrog site offers details on a number of measures, under headings titled Infections, Problems with Surgery, Practices to Prevent Errors, Safety Problems, and Doctors, Nurses and Hospital Staff. It also includes an easy-to-read, color-coded scale that indicates how the hospital is performing.

Screenshot of Leapfrog page for AdventHealth Manchester, which moved up  to an A from a C. 

High Scores

Hospitals getting As were: Advent Health Manchester; Baptist Health Lexington; Baptist Health Richmond;  Clark Regional Center in Winchester; Deaconess Henderson Hospital; Louisville's Norton Audubon Hospital, Norton Brownsboro Hospital, Norton Hospital, and Norton Women's & Children's Hospital; St. Elizabeth Healthcare-Ft. Thomas; and Lebanon's Spring View Hospital. 

AdventHealth Manchester moved up from a C on the last report, Clark Regional Center moved up from a B on the last two, and Spring View Hospital got its first A ever. The rest maintained their A grades. 

Baptist Health Lexington has received an A grade for 10 consecutive grading periods, and and Baptist Health Richmond has received an A for five consecutive grading periods.  

This is the seventh straight grading period that all four Norton Healthcare adult-service hospitals in Louisville have received an A.

“By working together and keeping the safety of our patients — and each other — at the center of all they do, Norton Healthcare’s employees consistently do the hard work that is necessary to receive ‘A’ Leapfrog Hospital Safety Grades,” Russell F. Cox, president and CEO of Norton Healthcare, said in a news release. “Seven consecutive ‘A’ grades is no small feat, and I am honored to lead this exceptional team." 

Shifts up and down

After receiving four Cs in a row, preceded by nine Ds, University of Louisville Hospital rose to a B on the latest report.

"Improved data reporting, and other initiatives, implemented since UofL Health’s formation are beginning to show positive direction," UofL Health said in a statement. " As the first hospital in the system, UofL Hospital’s rising grade is an early indicator of more to come. . . . For our other facilities, the grades issued by Leapfrog reflect data that lags by several years and continue to include years of previous ownership groups." 

Other U of L hospitals graded by Leapfrog were UofL Health Shelbyville Hospital (B), UofL Health-Sts. Mary and Elizabeth Hospitals (C), and Jewish Hospital (C). 

Meadowview Regional Medical Center in Maysville moved up to a B after receiving two Cs in a row, as did Saint Joseph Hospital in Lexington, after getting four Cs in a row and Lexington's UK HealthCare Good Samaritan Hospital after getting five Cs in a row. 

Two Kentucky hospitals moved from an A grade on the last report to a C grade: Mercy Health Lourdes in Paducah and Monroe County Medical Center. Baptist Health Corbin moved from an A to a B.  

Baptist Health Paducah moved down to a C from a B, after having received only one C grade since fall 2018, and Owensboro Health moved down to a C after receiving only As and Bs since spring 2018. 

Other hospitals that moved from a B to a C were Frankfort Regional Medical Center and TJ Sampson Community Hospital in Glasgow. 

Five hospitals moved from a C grade down to a D grade. 

Flaget Memorial Hospital in Bardstown moved down to a D from a C, after having received all As and one B since Fall 2019. 

Harlan ARH Hospital moved down to a D after receiving seven Cs in a row, and Hazard ARH Regional Medical Center got a D after getting two Cs in a row. 

Jackson Purchase Medical Center in Mayfield moved down to a D after getting seven Cs in a row. 

The other five hospitals with D grades are Jennie Stuart Health in Hopkinsville, Murray-Calloway County Hospital, Pikeville Medical Center, St. Claire Regional Medical Center in Morehead, and Taylor Regional Hospital in Campbellsville. Each also got a D on the last report. 

Click here for a list of frequently asked questions about the survey. Click here to see if your hospital was graded.

Registration is open for Nov. 3 HealthWatch USA conference in Lexington on health-care transparency and patient safety

Somerset-based HealthWatch USA will hold its annual Healthcare Transparency and Patient Safety conference Nov. 3 in Lexington.

In addition to exploring issues around problems that occur with medical devices and implants, the importance of creating cultures of safety and health-care accountability, this year's conference, "The Setting of Strong Quality Standards and Research Integrity," will include two nationally renowned investigative reporters who will discuss research integrity and how it influences health-care policy.

Deborah Nelson, a Pulitzer Prize-winning investigative reporter and associate professor of investigative journalism at the University of Maryland, will discuss conflicts of interest and how this issue influences infectious disease policy.

Dr. Ivan Oransky, distinguished writer in residence at New York University and co-founder of Retraction Watch, will discuss the characteristics of articles retracted from peer-reviewed academic journals and how research integrity affects health-care policy.

The conference will run from 8:30 a.m. to 4:30 p.m. at the Four Points Sheraton in Lexington and will offer continuing education credits for medical professionals. Click here for more information and a link to register.

Studies: 21% of people with serious conditions are misdiagnosed; most in U.S. will get an incorrect or late diagnosis at some time

More than one in five patients who sought a second opinion at the Mayo Clinic had been misdiagnosed by their primary-care doctors, a study concluded.

The results, published in the Journal of Evaluation in Clinical Practice, "are generally similar to other research on diagnostic error, but provide additional evidence for advocates who say such findings show that the health-care system still has room for improvement," Lenny Bernstein reports for The Washington Post.

Researchers at Mayo, in Rochester, Minn., looked back at 286 patients their primary-care doctors and nurse practitioners saw in 2009 and 2010. Nearly two-thirds were under 65, and most were female. The researchers reported that in 62 cases (21 percent), the second diagnosis was "distinctly different" from the first. In 188 cases, the diagnoses were at least partly correct but were “better defined” by the second opinion, the study said. In 36 cases, the diagnoses were the same.

Mark Graber, a senior fellow at the research institute RTI International and founder of the Society to Improve Diagnosis in Medicine, told Bernstein, “Diagnosis is extremely hard. There are 10,000 diseases and only 200 to 300 symptoms.”

Graber, who was not involved in the Mayo research, "estimates that the rate of misdiagnosis, although difficult to determine, occurs in 10 percent to 20 percent of cases," Bernstein reports. The new study cites previous research that found diagnostic errors "contribute to approximately 10 percent of patient deaths" and "account for 6 to 17 percent of adverse events in hospitals."

"In 2015, the National Academy of Medicine reported that most people will receive an incorrect or late diagnosis at least once in their lives, sometimes with serious consequences," Bernstein writes. "It cited one estimate that 12 million people — about 5 percent of adults who seek outpatient care — are misdiagnosed annually. The report also noted that diagnostic error is a relatively under-measured and understudied aspect of patient safety."

James Naessens, a policy researcher at Mayo, said in a press release: "Effective and efficient treatment depends on the right diagnosis. Knowing that more than one out of every five referral patients may be completely [and] incorrectly diagnosed is troubling — not only because of the safety risks for these patients prior to correct diagnosis, but also because of the patients we assume are not being referred at all."

Ideas for patient safety: collaboration, transparency, more nurses in hospitals and nursing homes, surgical patients' risk awareness

By Melissa Patrick
Kentucky Health News

Patient safety was the topic at the 2016 HealthWatch USA conference this month in Lexington, with health advocates calling for a more collaborative and transparent health-care system to better prevent medical errors, improved nurse-to-patient ratios and a call for patients to become their own advocates to improve their safety in the operating room.

Former surgeon general Joycelyn Elders, professor emeritus of pediatric endocrinology at the University of Arkansas, said preventable medical errors are the third leading cause of death in the U.S., behind heart disease and cancer, and the errors cost the nation "billions of dollars each year." The latest study says between 200,000 and 400,000 Americans die each year from preventable medical errors, she said.

"You will find very few death certificates that will have medical error on them," she said. "That is not the culture that we have. . . . but we've got to change the culture."

Elders said to increase patient safety in hospitals, we have to create a culture of transparency and open reporting; that hospitals need to create systems of collaboration that allow for transparency; and that these systems must be "consistent and persistent" in these efforts.

Daniel Saman, research scientist at the Essentia Institute of Rural Health in Minnesota, talked about the rising cost of care, noting that while the U.S. pays more for care than most developed nations, its life expectancy is lower, its infant mortality rate is higher, the number of people over 65 with two or more chronic conditions is higher, and its obesity rates are higher than those countries'.

Saman, chief epidemiologist for HealthWatch USA, said the increased cost of care in the U.S. is largely driven by high administrative costs, high drug prices and increased use of medical technology, rather than more frequent doctor visits or hospital admissions.

Said Abusalem, an assistant professor in the School of Nursing at the University of Louisville, talked about building a culture of safety in health care, especially in nursing homes, through appropriate staffing, improved communication systems, non-punitive responses to mistakes and effective leadership.

"You cannot talk about patient safety without talking about the culture of safety," he said.

He noted that most adverse events in nursing homes are related to falls and pressure ulcers. He said 6 to 25 percent of nursing-home patients have pressure ulcers, and the annual rate of falls in the homes is 1.7 per bed, with 10 to 25 percent of the people who fall sustaining serious injuries resulting in death.

Abusalem discussed his study, "In an Era of Reform: The Culture of Safety in Long-Term Care Facilities." He found nursing homes that reported good teamwork had fewer pressure ulcers and fewer falls; nursing homes with better communication systems had fewer falls; and those that staffed more hours with registered nurses had fewer pressure ulcers.

As the number of RNs plus licensed-practical-nurse staff hours per resident per day increased, the rate of falls decreased by 79 percent, he said, noting "This is a very significant finding."

He added: "As the culture of safety scores increased, the risk of falls decreased 26 percent, UTIs [urinary tract infections] decreased 20 percent and the short-stay ulcers decreased 7 percent. So the more culture of safety, the less the adverse risk for our residents in nursing homes."

He said his study shows the need to build a strong culture of safety in nursing homes to promote employee retention and the value in hiring RNs to improve safety.

Nurse-to-patient ratios can be critical

Texas RN Deena Sowa McCollum said a series of delays in her father's care, despite her strong advocacy, contributed to his death in 2015.

McCollum said she had worked in leadership positions for 11 years and thought she was in tune with the needs of her nurses, but after her father died, she had to return to bedside nursing to try to figure out the shortcomings in the system. "I needed a better understanding of why so many things could go wrong for one person," she said.

McCollum said she had no idea that higher rates of errors were associated with nurse-to-patient ratios above 1:5. Now she knows that for every patient above five assigned to a nurse, there is a 7 percent increase in error.

"When I have six patients, I know my patient. I know their medications and their diagnosis. I may know a family member, but probably not. And I will have to be very deliberate at making sure that I catch subtle changes because we are so easily disrupted with tasks," she said.

"When I have seven or eight patients, which is the norm -- 90 percent of the time I have seven or eight patients on a med-surg kind of floor-- they all start looking alike. I spend a great deal of my time prioritizing who is the sickest and who is the most unstable and what do I need to do for them. I don't always remember why they are in the hospital or what medications they are on. I often know them by room number and that is embarrassing to say. I am going to miss subtle changes and I am going to make medication errors. The patient that is going home that needs a lot of discharge instructions, I am barely going to see them."

McCollum cited research from California that found the difference between a 1:4 and a 1:8 nurse-to-patient ratio is approximately 1,000 deaths a year. She added that adding one patient to a nurse's workload increases the odds to readmission for heart attack by 9 percent, heart failure by 7 percent and pneumonia by 6 percent. Patients on an understaffed unit have a 6 percent higher mortality rate.

She said legislation to establish a safe nurse-to-patient ratio is in the works and that though some states have instituted such practices, they are not well-monitored. She noted that nurses will gather in Washington, D.C., May 4-5 in support of legislation for better nurse-to-patient ratios.

A Massachusetts Nurses Association survey from 2015 found that 50 percent of the nurses in the survey reported injury and harm to patients due to understaffing; 61 percent reported medication errors due to unsafe patient assignment; 61 percent reported complications for patients due to unsafe staffing assignments; 81 percent report RNs don't have enough time to educate patients and provide adequate discharge planning and 86 percent report RNs don't have time to properly comfort and care for patients and families due to unsafe staffing assignments.

Operating room safety

Dr. Mark S. Davis, an operating room safety consultant and author of Irresponsible: What Surgeons Won't Tell You and How to Protect Yourself, said there are hidden risks to surgeries that put you at risk of contracting HIV or hepatitis C because many surgeons don't adhere to basic safety standards.

"This risk does not appear on a surgical consent form and is not discussed pre-operatively with the patients," he said.

He said surgeons and assistants are "injured with needles, scalpels and other sharp objects at an astonishing 1,000 times a day" and are exposed to the blood of potentially infected patients because many people are infected with HIV or hepatitis C and don't know it.

Davis said that surgeons usually fail to report their injuries and that this puts their future patients at risk because if they are infected and don't know it (and might not know it for years), they can then transmit the infection to a healthy surgical patient during a procedure if they cut themselves and then bleed into the patient.

Davis said most exposures are preventable if physicians would use safety devices to prevent sharps injuries, like safety designed injection equipment, safety scalpels and blunt tipped suture needles. Federal law requires surgeons to use them, but there is a clause in the law that says surgeons may chose to not use them if "in their opinion, they interfere with patient care."

"Well the truth is, they rarely interfere with patient care. I have a lot of experience with them, yet only 5 to 10 percent of surgeons use these devices," Davis said.

He said surgeons don't use them because of the poor enforcement of the federal regulations that requires them; because facilities don't enforce their use; and a general resistant to change.

"The only solution left in my mind is consumer pressure," he said.

Davis stressed the importance of bringing someone with you to your appointments to ask questions and assure understanding and said there are some questions that "you can and must ask" the surgeon before you schedule any surgery to protect you from this hidden risk:

1. Do you use blunt tipped suture needles to close your incisions?
2. Do you use a neutral zone for passing sharps?
3. Do you double glove?
4. Do you and your team all use protective eyewear?
5. Do you use safety scalpels?

"As a consumer of health care, you have the power to protect yourself and you must use that power," he said.

Common blood thinner Coumadin is causing deaths and injuries in nursing homes, prompting calls for more regulation

From 2011 to 2014, at least 165 nursing-home residents were hospitalized or died after errors involving blood thinner Coumadin or its generic version, warfarin, according to a ProPublica analysis of government inspection reports, Charles Ornstein reports for the nonprofit news organization.

The analysis only includes Coumadin injuries that are reported, but "studies suggest there are thousands more injuries every year that are never investigated by the government," Ornstein writes.

Coumadin is a popular preventer of heart attacks, strokes and blood clots, but patients who use it must be carefully monitored. "Too much, and you can bleed uncontrollably; too little, and you can develop life-threatening clots," Ornstein warns.

Graphics by The Washington Post

It is one of the most used drugs in Medicare's prescription-drug program, with one in six of the nation's 1.3 million nursing-home residents taking an anticoagulant, mostly Coumadin or its generic, Ornstein reports.

Improper administration and poor monitoring of patients who use Coumadin can cause serious harm or even death. Ornstein tells of several such nursing-home cases, each stemming from a different type of error:

"Dolores Huss, an 89-year-old grandmother of eight, died from internal bleeding after a San Diego facility gave her an antibiotic that multiplies the effects of Coumadin, then didn’t alert her physician that she needed additional blood tests to measure how long it was taking her blood to clot."

"Shirley Reim, recovering from hip surgery, was hospitalized with blood clots in her legs after a Minnesota nursing home failed to give her Coumadin for 50 days in a row and also didn’t perform the blood test ordered by her doctor. She suffered permanent damage."

"Loren Peters arrived in the emergency room in October 2013, bruises covered his frail body, and blood oozed from his gums. The 85-year-old had not been in a fight or fallen down." Instead, he had been given too much Coumadin and "no one at the nursing home conducted the blood test needed to see the effect Coumadin was having, even as bruises spread across his body over a two-week period."

Ornstein cites other sources that have also found that Coumadin errors are common, with one study in The American Journal of Medicine estimating "that nursing home residents suffer 34,000 fatal, life-threatening or serious events related to the drug each year."

Despite this evidence, Ornstein writes, the Centers for Medicare and Medicaid Services, the federal agency that regulates nursing homes, and the American HealthCare Association, the main lobby for nursing homes, have not focused on the deaths and hospitalizations caused by Coumadin medication errors.

Instead, individual cases are investigated as they come to the attention of CMS and depending on the circumstances, "CMS will issue "immediate jeopardy" citations, fine them or threaten to cut off federal funding if quick action isn't taken," Ornstein writes."More commonly, though, homes are not fined and are simply asked to correct the problems and put policies in place to keep them from happening again," according to the analysis.

"Last year, the Department of Health and Human Services identified Coumadin and other anticoagulants as one of the drug categories most frequently implicated in “adverse drug events,” calling on government agencies to work on solutions," Ornstein reports. In a statement, CMS, which is part of HHS, said "it is raising awareness of such events, training its inspectors to do a better job at identifying them and working with nursing homes to prevent them."

There are newer anticoagulants, like Eliquis, Pradaxa and Xarelto, that don't require regular blood tests and don't have to avoid certain foods, but they come with their own risk, like gastrointestinal bleeding,which makes doctors reluctant to use them on seniors.

Coumadin requires the coordination of doctors, nurses, pharmacists and laboratories, which makes nursing homes the “perfect setup for bad things happening,” Jerry Gurwitz, chief of geriatric medicine at the University of Massachusetts Medical School, told Ornstein.

Gurwitz wrote about this problem in the 1990s and says since, "very little, unfortunately, has changed."

Ornstein notes that "federal inspection reports repeatedly cite the same types of problems: patients not getting the drug as ordered, or given the wrong doses, or given without a doctor’s order."

Increased training doesn't seem to make any difference, prompting some to call for federal regulations.

"A report published last year in The Consultant Pharmacist journal found that 12 New York nursing homes given tools to improve how they handled patients on Coumadin — including staff education programs — largely failed to improve their management of the drug," Ornstein writes.“Improvements were not seen despite active intervention,” the report’s authors wrote. “If long-term care facilities are unable to voluntarily implement necessary improvements, then regulatory changes may be necessary to assure patient safety regarding anticoagulant use.”

David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, told Ornstein that "Coumadin errors can’t be viewed in isolation." and said that the association has introduced a quality initiative that covers all types of errors, including those involving medications.

Some long-term care associations say CMS should work with the industry to change its practices including looking their current policy of reviewing each case individually and its discipline policies, Ornstein reports.

Another concern is not to discourage doctors from prescribing Coumadin.

“It may be distorting a little bit to look at the immediate jeopardy outcomes [cited by regulators] without looking at the overall population that’s on it and needs to be on it,” Cheryl Phillips, senior vice president of public policy and advocacy at LeadingAge, an association of nonprofit senior service organizations, told Ornstein. “In fact, to not put people on blood thinners is a huge risk and in many cases malpractice.”

Click on ProPublica's Nursing Home Inspect tool to compare more than 60,000 nursing-home inspection reports.

Health care's culture doesn't encourage doctors to report medical errors of colleagues; article says patients should come first

By Melissa Patrick
Kentucky Health News

Doctors are often aware of their colleagues' medical errors, but fail to report them because of a culture that does not support or encourage such actions, Marshall Allen writes for ProPublica, a non-profit, non-partisan journalism organization.

Medical errors are estimated to kill 400,000 people in U.S. hospitals each year according to an online article by John T. James in the Journal of Patient Safety, causing some to say that medical errors are one of the nation's leading causes of death, Allen reports.

According to a report from the U.S. Department of Health and Human Services, most health-care providers employ a philosophy of "deny and defend" when confronted with issues related to medical errors. Providers fear full disclosure will lead to more lawsuits, higher jury awards, higher insurance premiums, and the loss of reputation or coverage for the provider, the opposite is true, the HHS report says. It says honest and open communication helps to lessen malpractice costs.

The Department of Veterans Affairs Medical Center in Lexington has led the way in the move toward health-provider transparency. It has worked under a philosophy of full transparency and disclosure since 1987, requiring prompt reporting and investigation of medical errors and near misses, full investigation, full disclosure of investigation results to the patients and families who have been injured because of accidents and medical negligence, and expressions of apology and  fair remedy, including compensation for injuries, according to the HHS report.

Several years ago, Allen contacted a Las Vegas surgeon to follow up on hospital data that showed peers of this surgeon that had high rates of surgical injuries. Allen reported that before he could reveal the list of peers to the surgeon and request his services in the investigation, the surgeon shared stories of the many surgeries he and his partners did to "clean up" the mistakes of "the worst surgeons in town" and said "he did not need a database to tell him which surgeons made the most mistakes."

An article in the New England Journal of Medicine, “Talking With Patients About Other Clinicians’ Errors,” says that although there is a common belief that there is an ethical duty to inform patients who have been harmed by medical errors, physicians often do not.

The existing guidelines emphasize ethical duties related to self reporting when physicians make  errors, says the report, but offers little guidance about what to do when they discover someone else's mistake.

In a survey separate from the New England Journal of Medicine report, but led by the same main author, more than half of doctors said that in the previous year they had identified at least one error by a colleague.  Gallagher told Allen that the survey did not ask what the doctors did about it.

For the New England Journal report, Dr. Thomas Gallagher, an internist and professor at the University of Washington, led a team of 15 experts who identified possible reasons doctors stay silent about errors by their peers. One reason is the system of referrals on which doctors depend, Allen reports; if a physician "becomes known as a tattler" he or she will lose referrals, and thus suffer financially.

The report lists other reasons for not reporting colleagues' medical errors, such as lack of time to investigate, a culture that promotes loyalty and solidarity, concerns about harming one's institution or becoming involved in a medical malpractice case,  concerns about causing a colleague to face legal issues,risk of acquiring an unfavorable reputation with colleagues and issues related to cultural differences, gender, race and seniority.

The bottom line, Gallagher told Allen, is that "physicians are not learning from their errors and patients are not getting the information they need to receive proper treatment or compensation when the outcome is harmful."

Dr. Brant Mittler, a cardiologist who works as a medical malpractice attorney in Texas, told Allen that in almost four decades in medicine he often saw errors and stayed quiet because "there would have been hostility" if he had reported them. “There’s not a culture where people care about feedback,” Mittler said. “You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you."

Gallagher told Allen, "The result of this culture is too much leniency toward mistakes."

The New England Journal article said that despite the challenges of disclosure, the patient comes first, and doctors should "explore, not ignore" a colleague's error, Allen notes.

Once an error is suspected, the report suggests, the doctor recognizing the error should find the facts, starting with a direct conversation with the physician who made the error so together they can decide how to inform the patient. The article also suggests that hospitals and other health-care institutions lead by supporting transparency.

Dr. David Mayer, vice president of quality and safety at Medstar Health, which runs 10 hospitals in Maryland and Washington, D.C., told Allen that "reporting of medical errors (and near misses) is a top priority at the organization so everyone can learn from mistakes, saying that each month there are about 1,400 reported safety events."

The safety events are analyzed for trends, Mayer told Allen.  If a patient is harmed, an investigation is conducted and the information is disclosed to the patient and family, an apology can be made and compensation can be offered.

Dr. Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, which provides guidance for how state boards regulate doctors, told Allen that doctors and other providers should be more assertive about reporting errors. "Failing to tell a patient about another doctor's mistake undermines the doctor-patient relationship," Chaudhry told Allen. "It makes patients wonder if they can trust their own physicians and the profession of medicine."

Speakers at conference discuss impacts and possible solutions for deadly mistakes and near misses in hospitals

By Melissa Patrick
Kentucky Health News

Medical mistakes made in hospitals cause 98,000 deaths per year. Or four times that many?

That is the widely accepted number based on a 1999 Institute of Medicine report, but a study published in the Journal of Patient Safety says that as many as 210,000 to 440,000 Americans die each year in the hospital because of a preventable harm, Marshall Allen of ProPublica reports on NPR. But the current culture in health care does not support the reporting of mistakes or near misses, said speakers at the Health Watch USA 2013 Conference on Nov. 1 in Lexington.

Keith Widmeier, training officer for the Wayne County Emergency Medical Service, talked about the importance of reporting medical errors: "How are we supposed to fix things if we don't address the near misses?" he asked. "We must look at patterns and address them, learn from the data. Reliable data helps promote systemic change. The current system creates a system of not reporting."

Helen Haskell, president of the grassroots patient-safety organization Mothers Against Medical Error, said there are many contributing factors to this culture, and suggested that there is much to be learned from patient stories.

She told story after tragic story of young patients who had died because of medical error, including the story of her son, Lewis Blackman.

Lewis was a healthy 15-year-old who developed severe upper abdominal pain while on a non-steroidal anti-inflammatory drug and a narcotic following an elective surgery. Nurses and residents failed to act upon increasing signs of instability, including 24 hours with no urine output and four hours with no blood pressure. Haskell asked repeatedly for an attending physician. Four days after the operation, her son died. The autopsy showed a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity. He had been bleeding internally.

It is the responsibility of our health care system to become more transparent, listen to people's stories and put systems in place to decrease the chance of medical errors, Haskell said. Health care must improve in the areas that errors most commonly occur, she said, such as true informed consent, unnecessary surgeries, medication and diagnostic error, failure to rescue, and communication errors.

To decrease medical errors, Haskell suggested that the system use technology as the driver of improvement, providing continuous feedback between everyone involved in the care of a patient and involve the community and government.

Nurse burnout and job dissatisfaction also lead to medical error in hospitals.

"We cannot expect high quality health care with burnout," said Jeannie Cimiotte, a Ph.D., RN and associate professor at the Rutgers University College of Nursing and executive director of the New Jersey Collaborating Center for Nursing.
Cimiotte cited a Pennsylvania study that found the implications of increases in nurse workload are burnout and job dissatisfaction, missing important changes in patient conditions and failing to report important patient information at shift change. She said the study also found high nurse burnout appears to be a possible explanation for the association between nurse staffing and infection, jeopardizing patient safety resulting in hospital-acquired conditions and poor health care outcomes.

A culture of change and transparency has been implemented and is working at the Department of Veterans Affairs hospitals in Lexington since 1987, said Dr. Steve Kraman, who was chief of staff and chairman of the Risk Management Committee of the hospitals from 1986 to 2003. They not only require the reporting of medical errors and near misses, but provide full disclosure to patients who have been injured because of accidents or medical negligence, and offer fair compensation for injuries, Kraman said.

The VA has used this model since 1987 and has had "encouragingly moderate liability payments," said Kraman. In 2010, the University of Michigan reported remarkable decreases in suits, costs, trials and time to resolution. They also linked the openness of such a program with patient safety benefits due to reduced need for secrecy surrounding errors. The University of Illinois reports no increase in either number or suits or payouts since participating in this model of care, according to Kraman.

Kraman asked the participants: Is full accountability and transparency the way we should do health care? The answer was a resounding yes.

"This is a decision based on how we behave in society.  We should behave in a stand-up manner," Kraman said.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website.

Kentucky and online audiences hear discussion of proposed system for patients to report medical errors; comments due July 8

By Molly Burchett
Kentucky Health News

The Obama administration is creating a new system for patients to report medical mistakes because existing systems fail to do so, and if all goes as planned, the pilot program will launch this fall, a federal official told a Health Watch USA meeting in Kentucky and online Wednesday night.

Research suggests that many adverse medical events go unreported in current systems that don't allow patients to provide input about their care, said James Battles, Ph.D., of the Agency for Healthcare Research and Quality. To fix this problem, AHRQ has funded the development of a prototype patient reporting system through a contract with RAND Corp.

Called the Consumer Reporting System for Patient Safety, the project is designed to collect information from patients "about medical errors that resulted or nearly resulted in harm or injury” and can also secure reports from family members, said Battles. The data will be available for use by providers and health systems that wish to create or enhance their own local reporting systems.

Here's how the system will work: When a patient recognizes a medical error, an intake form will ask what happened, including questions about the details of the event and the health care provider(s). Providers and patient safety officers are expected to follow up with the patient, which AHRQ estimates would add 28 hours to the provider's annual work load. The collected data will be analyzed to produce estimates about the patient safety events, which will be shared with health institutions.

There is concern about how the project findings will be used and that "frivolous" patient reports may lead to increased medical malpractice liability for providers. Despite apprehension that findings could possibly be linked to financial or legal penalties for poor performance, hospitals say they are receptive to the idea, Robert Pear of the New York Times reported last fall when project was first posted in the Federal Register.

"The question then would become, frivolous to whom?" Battles said when asked what he would say to concerned providers. Patient input is critical to gaining a full understanding of an adverse event, he said, and the overall project will include public awareness campaigns to let patients know their care experience is valued: "The purpose of the system is to improve patient safety, develop ways to prevent future harm and inform policy."

Patients, physicians, hospitals and other health care providers have until July 8 to comment on revisions to the government proposal, says the notice published in the Federal Register. (Click here for more information.) Battles said AHRQ has made substantial changes to the proposed reporting system's data collection tools, based on comments received last fall when the project was originally outlined.

After approval from the federal Office of Management and Budget, Battles said, a pilot program will be launched this fall near Philadelphia, then the system will be tested on a regional basis while considering reports from providers and patients.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website. The organization's next meeting will be held July 31 at 5 p.m. and will feature Dr. Patrick Conway, chief medical officer for the federal Center for Medicare and Medicaid Services.

Hospitals are not reporting cases of harm to patients; electronic health records may be key to solving the problem

By Tara Kaprowy
Kentucky Health News

Hospitals aren't reporting cases in which medical care harmed a patient, making it difficult for providers to identify problems and fix them, according to a report to be released by the U.S. Department of Health and Human Services.

The report indicates many hospitals are ignoring state regulations by not reporting preventable problems. In Kentucky, there are no mandatory public reporting requirements for hospitals. They must only inform the state Department of Public Health about infectious outbreaks, but the definition of an outbreak varies from facility to facility, based on the number of patients seen in a specific period of time.

Dr. Kevin Kavanagh, a retired physician and chairman of Health Watch USA, said the report points to "the need for greater health care transparency and state government engagement."

The study's lead researcher, Lee Adler, is looking to electronic health records to set things right since "we may be able to prevent events, we may be able to ameliorate events, and (electronic records) may become your surveillance system," he said.

The software can be designed to "catch triggers for potential errors," Kelly Kennedy reports for USA Today. One example could involve a patient that is given an antidote after a medication overdose. The fact that the antidote was used would trigger an alert to a hospital quality control officer, who would them follow up in turn. (Read more)

About half of doctors are using EHRs nationwide, the latest survey from the Department of Health and Human Services shows. "That's a pretty high number, historically speaking," reports Sarah Kliff for The Washington Post. "As recently as 2005, just about a quarter of doctors' offices had gone digital."

In February, Health and Human Services Secretary Kathleen Sebelius said the percentage of hospitals using electronic health records has doubled in two years, Medical News Today reports. The shift at doctors' offices and hospitals stems from a provision in the federal health-care reform law, which gives financial incentives to facilities that switch over to EHRs.

In Kentucky, 723 eligible professionals and 15 hospitals have already been paid their incentives, which totaled more than $155 million as of May. In February, Sebelius said almost 2,000 hospitals and more than 41,000 doctors had received more than $3 billion in incentive payments to use health information technology. The proportion of hospitals that now use EHRs went up from 16 percent in 2009 to 35 percent in 2011. More than 80 percent of hospitals said they intend to advantage of the incentives by 2015.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Revealing patient safety issues and medical errors are goals of Facebook page set up by ProPublica

Photo by iStockphoto.com/selimaksan

Interested in creating a venue for those who have been harmed while undergoing medical treatments, ProPublica, the nonprofit, investigative news organization, has set up a Facebook page on the issue.

"Group members have already shared stories of personal disability or the death of a loved one due to surgical mistakes, becoming infected with deadly drug-resistant bacteria and dental mishaps — including cases they claim were not properly addressed by health care providers," Daniel Victor and Marshall Allen report. The page will be moderated by Victor and Olga Pierce.

The page is also open to doctors, nurses, regulators, health-care executives and others interested in discussing medical errors, their causes and solutions. Question-and-answer sessions with experts will be posted, along with links to the latest reports and policy proposals. (Read more)

Hospital employees report only 1 of 7 medical errors, study finds

In keeping with other studies on the subject, a new report shows hospital employees only report and recognize one out of every seven medical errors, accidents or other events that harm Medicare patients. "Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the 'adverse events'," reports Robert Pear of The New York Times.

While hospitals serving Medicare patients are supposed to track and analyze the cause of medical errors and most hospitals do have a system in place to inform administrators about adverse events, "Hospital staff did not report most events that harmed Medicare beneficiaries," said Daniel R. Levinson, inspector general of the Department of Health and Human Services and author of the report.

Levinson said more than 130,000 beneficiaries were subject to one or more adverse events in hospitals in one month. An adverse event includes medical errors, severe bedsores, hospital-acquired infections, delirium as a result from too many painkillers, or excessive bleeding because blood thinners were used improperly.

The study involved the input of independent doctors, who reviewed 293 cases in which patients had been harmed. Forty of the cases were reported to hospital managers and 28 were investigated by hospitals, "but only five led to changes in policies or practices," Pear reports.

One of the major issues is that hospital employees don't recognize when a patient is harmed, Levinson said. In some incidents, "employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported," Pear reports. In other cases, employees thought an event was so unusual it wouldn't be likely to recur.

In answer, Medicare officials said they will come up with a list of "reportable events" for hospitals and employees to use. Hospitals, in turn, should give detailed instructions to employees about what kinds of events should be reported. (Read more)

A culture of silence remains about medical errors, but things are slowly improving, physician-activist says

There has been a culture of silence when it comes to talking about medical errors, but things are slowly changing, writes Dr. Kevin Kavanagh, right, in an op-ed piece in the Lexington Herald-Leader.

Kavanagh, who is chairman of Health Watch USA, recalls an incident in which a patient came to be treated for a severe sinus infection. Upon being rushed to surgery, Kavanagh discovered "an old smelly gauze pack" had been left in the sinus from a previous operation. When an assistant asked Kavanagh what he should tell the patient, "I answered, 'The truth'," for which he was disciplined by a senior surgeon.

"Years have passed, and things are starting to change in medicine," Kavanagh writes. "Telling patients that something went wrong is slowly being accepted — a revolutionary idea to medicine."

Studies have shown that hospitals with full-disclosure policies actually have lower patient death rates, which Kavanagh just called "common sense." "If preventable patient harm occurs on a ward and the patient is not told, almost all of the employees on the ward will know about the cover-up," he writes. "How then will the administration garner the respect to effectively oversee the functioning of personnel? If hospital staff are not performing adequately, how do you discharge them when there are skeletons in the closet?"

Full disclosure also lowers malpractice expenses, Kavanagh contends. Stanford University hospitals had a 36 percent drop in malpractice claims and has saved $3.2 million since it adopted a full-disclosure policy in 2007. University of Michigan had a 40 percent drop in new claims and saves $2 million each year.

But full disclosure is not common in Kentucky, despite the Veterans Affairs hospitals in Lexington being the first to implement full disclosure in the country. "Instead of this practice spreading throughout Kentucky, the next health-care system to implement it was the University of Michigan," Kavanagh writes.

Things need to change, especially in the face of superbugs like MRSA. As he looked back at the incident involving the botched sinus surgery, "I am most bothered that I apologized for my actions," Kavanagh writes. "Now I would reserve the words, 'I'm sorry' for the patients who have been harmed." (Read more)