Patient harm at Maine hospitals going unreported, studies find

Posted July 24, 2012, at 7:07 p.m.
Last modified July 25, 2012, at 11:03 a.m.

Hospitals are failing to report many cases of patients being harmed during medical treatment, even in states such as Maine where reporting is mandatory, according to a new national study.

Half of states have reporting systems for “adverse events,” such as medication errors or surgery on the wrong body part, but few of those incidents are brought to authorities’ attention, according to a July 19 report by the U.S. Health and Human Services’ Office of Inspector General.

Maine counted 163 such events in 2011, largely “unanticipated deaths,” according to a June report that found “serious under-reporting” in the state. The finding was drawn from national health care quality data that estimate adverse event rates based on factors such as hospitals’ sizes, the number of procedures performed and the community’s population, according to Joe Katchick, a registered nurse who monitors the reporting program in the Department of Health and Human Services’ Division of Licensing and Regulatory Services.

The real number of cases of serious patient harm in Maine, or “sentinel events,” as DHHS identifies them, likely was closer to 300 or 400 last year based on those formulas, he said.

Of the 163 events that were reported, 61 involved patients who went to the hospital with an illness or injury that was not life-threatening but died unexpectedly, according to the June report. Injuries from falls and pressure ulcers, or bed sores, were other problem areas.

Twice surgeons operated on the wrong part of a patient’s body. In 16 cases “foreign objects,” such as surgical tools and sponges, were left behind in patients’ bodies.

There also were three assaults, including a sexual assault on a patient, and three patient suicides or attempted suicides resulting in serious disability.

The report doesn’t identify which health care facilities reported adverse events. The program’s aim is to encourage reporting and remedy circumstances that allow patients to be harmed, not to punish a hospital or publicize its mistakes, Katchick said.

“We don’t share facilities’ stats even with other facilities,” he said.

Fear of blame could discourage hospitals from reporting and learning from adverse events, which also are handled through other accountability channels including the licensing process and the courts, said Jeff Austin, a spokesman for the Maine Hospital Association.

“The goal here is improvement, so people need to feel that they are in a quality improvement environment as opposed to a lawsuit or front-page newspaper story environment,” he said.

The Office of Inspector General study found that weak reporting of serious medical mistakes to state systems likely was due to hospitals failing to recognize events as reportable rather than neglecting to report known events.

The study was an update to another Office of Inspector General report that found 27 percent of Medicare beneficiaries hospitalized in October 2008 were harmed during medical treatment.

Maine saw a spike in sentinel events in 2010 that continued into 2011, which the June report attributed to changes to the criteria in 2009 and growing appreciation among health providers for preventing medical errors through better transparency.

Because there’s no national standard for reporting adverse medical events, the 25 states that do have reporting systems, along with the District of Columbia, take different approaches. Maine uses criteria outlined by the National Quality Forum and in state statute.

The reporting system, put in place in 2003, tracks serious, preventable events and errors at hospitals, ambulatory surgical centers, dialysis units, and facilities for people with mental retardation. Adverse events at long-term care facilities are tracked under a separate system.

The sentinel event program operates independently of the licensing division at DHHS, sharing information about medical errors only when there’s an immediate safety risk, Katchick said.

So far in 2012, more than 70 sentinel events have been reported, he said.
Katchick is currently the sole staffer in the program, so he’s reviewing every adverse event report that comes in.

DHHS is currently recruiting a manager for the program.

Hospitals have 24 hours to report a sentinel event to the state or they could be subject to fines. DHHS then does a review, sometimes on site depending on the circumstances and severity of the case. Hospitals have 45 days to determine how the mistake happened and then identify whether any processes need to be changed and develop a plan for adjusting them.

DHHS also conducts audits to be sure hospitals have required systems in place to deal with adverse events, Katchick said.

“If we don’t know they’re not reporting, we have no auspices because we don’t know it’s happening,” he said. “If we do find them, there’s the possibility of a financial penalty if we find that they did not report something that was truly a sentinel event.”

The fine totals up to $10,000 for each event.

While not every sentinel event in Maine is properly identified and reported, hospitals are committed to training staff to recognize them, Austin said.
Maine hospitals perform well nationally in patient safety, but mistakes still happen and need to be reported, he said.

“We need to track this, we need to report it and we most importantly need to fix whatever problem there was, if there was one, so that it doesn’t happen again,” Austin said.

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