Reforms for patient safety listed as critical

THE BALTIMORE SUN

For all the focus on reducing medical errors in recent years, the cultural changes that institutions must make to keep patients safe have been slow to develop.

The gravity of the problem was highlighted this week in the case of a 17-year-old girl who was given a heart and lungs from an organ donor of the wrong blood type at Duke University Hospital.

More than three years after the Institute of Medicine released a headline-grabbing report on the frequency of errors and a plan for reducing them, some medical experts say progress has been limited.

"It galvanized public awareness for safety, but the reality is actually very little has been done nationally to improve safety since then," said Dr. Peter J. Pronovost, co-chairman of the Patient Safety Committee at Johns Hopkins Hospital. "Now we're aware, but now we've got to act."

The 1999 report, "To Err is Human," estimated that 44,000 to 98,000 Americans die each year because of medical errors. Some have argued that the number is inflated, while others have said it is not high enough because the report considered only fatal mistakes made at hospitals and not at other medical settings.

Patient-safety advocates agree that fixing the problem will require understanding why the mistakes happen and creating systems with multiple safeguards. The difficulty is that information about mistakes - whether a surgery performed on the wrong side of a patient or a medication given to the wrong person - is not widely available: In most states, disclosure of errors is voluntary, making oversight limited.

The Joint Commission on Accreditation of Healthcare Organizations made it mandatory, beginning in 2001, for medical institutions to tell patients if they are harmed during treatment. But it is unclear how many hospitals are fully complying. Only in recent months have some hospitals started training staff members on what to say when a medical mistake happens and how to say it.

"My sense is [patient disclosure] is not yet routine," said Dr. Daniel Stryer, acting director at the Center for Quality Improvement and Patient Safety at the federal Agency for Healthcare Research and Quality. "A hospital can say, 'This is what we want you to do,' but until you've changed the culture, it's very hard to change what individuals actually do."

Only three states - Nevada, Pennsylvania and Tennessee - require the reporting of adverse events to patients or families, according to the joint commission.

In Maryland, proposed regulations that could go into effect this fall would require hospitals to report all errors that cause death or serious injury. Hospitals would have to submit an analysis of what went wrong and a plan to prevent future occurrences; they also would be required to tell patients or their families about mistakes that cause significant injury.

The underlying assumption in the patient-safety movement is this: Individuals don't fail, "systems" do, meaning that mistakes typically happen when a series of vulnerabilities align in an incredibly complex health care system that is, by definition, imperfect.

"You have to build your systems to anticipate that you are going to have errors and figure out where you have to have safeguards - and safeguards on top of safeguards," said Margaret VanAmringe, vice president for external relations at the joint commission, which last month instituted a new set of "patient safety goals" highlighting six of the most common preventable problems.

Maryland initiatives

Maryland hospitals are phasing in initiatives ranging from anonymous error-reporting systems to computerized prescription-ordering systems. At the University of Maryland Medical Center, a robot nicknamed "Rosie" dispenses at least 90 percent of inpatient medications, which improves accuracy and reduces delivery time.

Dr. David G. Rorison, the hospital's senior vice president for medical affairs, said that improving technology is critical to making care safer. "Each patient is different, may have a different set of circumstances on a different set of medications," he said. "It's for all of those reasons that we probably need to depend more and more on technology. But it's not as easy as just using your ATM card and getting money out of the bank."

Johns Hopkins is overseeing a new Web-based reporting system that is tracking mistakes in the intensive care units of 30 hospitals. Pronovost, the project's principal investigator, said an analysis of the first 350 cases showed that about 60 percent of the errors were the result of communication problems, while about 40 percent stemmed from workload.

In one case, a Hopkins ICU patient with a known allergy to penicillin was mistakenly given a derivative of the antibiotic and suffered a fatal heart attack, Pronovost said. The mistake by the person who prescribed the medicine might have been caught by the pharmacy, but the order never made it that far because a nurse borrowed the drug from another patient to save time.

After the death of an 18- month-old girl at the Hopkins Children's Center two years ago, hospital officials launched the Josie King Patient Safety Program last fall. Josie, who had been hospitalized for the treatment of first- and second-degree burns, died of dehydration because of a series of mistakes, hospital officials have said.

Josie's parents, Sorrel and Tony King, pushed Hopkins to create the program - funded in part with money from a settlement with the hospital - to help prevent other children from being harmed. They hope it will become a model for medical institutions nationwide.

"My picture is that this Josie King program works, that Hopkins makes it work because there's pressure," said Sorrel King, 37. "They need help. ... It's not going to change unless parents and families get involved."

Teams of Hopkins doctors, nurses, pharmacists and other staff members meet every few weeks to address potential safety problems and come up with practical ways of preventing them. Some are auditing patient charts for medication errors. To decrease hospital-acquired infections, the Children's Center has launched a hand-washing campaign in which parents are urged to wear buttons that ask: "Have You Washed Your Hands?"

"It really starts to breed a culture of safety among the providers," said Dr. Marlene R. Miller, director of quality and safety initiatives there.

Dr. Gerald B. Hickson, vice chairman of pediatrics at Vanderbilt University Medical Center, has been holding seminars across the nation for years to advise medical providers on disclosing errors. Many are hesitant to tell patients about mistakes for fear they will be sued, he said, even though studies have shown that people are less likely to file a lawsuit if they feel their doctor has been open and honest.

'Less resistance'

Hickson thinks hospitals are getting safer - albeit in small steps. "We are finding less and less resistance, and finding people more and more interested," he said. "Changing a culture occurs very slowly."

In the case of Jesica Santillan, who nearly died at Duke after the transplant mix-up, the family reportedly was told immediately about the mistake. In the rush to transplant the organs, the surgical team apparently failed to confirm compatibility. Santillan was in critical condition yesterday after undergoing a second transplant operation at the hospital with new, matching organs.

"My expectation is that no child should die from a preventable cause in the Children's Center or in any hospital," said Dr. George J. Dover, head of the Hopkins Children's Center. "I think, really, how complex medicine has become [and] I don't think we'll ever approach perfection, but that ought to be our goal."

Sun staff writer Jonathan Bor contributed to this article.

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