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Health care facilites keep track of 'adverse events'

New Hampshire Sunday News

April 21. 2013 12:04AM

Hospitals in New Hampshire reported 84 incidents of harm to patients due to falls, bedsores, surgery on the wrong body part or wrong patient, foreign objects left inside a patient, and other adverse events during the first two years state law mandated they do so.

Mike Fleming, bureau chief of Health Facilities Certification, said hospitals appear to be reporting as required, although there is no way to know for sure.

"The whole reason for reporting is to increase transparency as a whole and improve outcomes and patient care," Fleming said.

There were 42 reports in each of 2010 and 2011, according to the Department of Health and Human Services. The 2012 incidents are being compiled.

Hospitals, which are identified by name and number of specific events, are also required to investigate the root cause of the incident and follow through on a corrective action plan.

Two hospitals have been fined $2,000 apiece for failing to report in a timely manner. Those cases were discovered through consumer complaints.

Over the two-year period, there were 28 falls reported; 23 serious bedsores; 12 foreign objects left inside patients after surgery; nine surgeries on the wrong body part; four medication errors, three involving air injected into veins and arteries; two wrong procedures; one surgery on the wrong patient; one burned patient; and one injured by being restrained.

Some of the events could have caused patients to die, but the law doesn't allow that information to be made public. The names of the patients and the remedial plans are also confidential.

To be reportable, some events - such as falls, medication errors, restraints and bedsores - must have caused serious impairment for at least seven days or death. Others, such as surgery errors, must automatically be reported.

"Some are worse than others," Fleming said. "But the outcomes for any can be death."

Patients are told when they are involved in an adverse event, also called "never events,'' Fleming said. In cases where a patient dies, the survivors are told of the event.

"These are things that shouldn't happen, but because they involve human beings, they do happen, and we need to find out how to decrease the numbers," Fleming said.

"The whole idea isn't to place blame, but to develop the root cause and correct the reason why it happened," Fleming said.

Dartmouth-Hitchcock Medical Center in Lebanon, the state's largest hospital and sole academic teaching hospital, accounted for 20 percent of the adverse events during the two years.

In 2010, Dartmouth-Hitchcock reported one wrong surgical procedure, three foreign objects left inside a patient, two serious bedsores and one fall. In 2011, DHMC reported two surgeries on the wrong body part, one wrong procedure, one foreign object left inside a patient, one medication error and five serious bedsores.

Dr. George T. Blike, the chief quality and value officer at Dartmouth-Hitchcock Medical Center, said the hospital had more reports because it treats more patients, does the most surgeries and serves the sickest patients.

Sometimes higher numbers make it look like a problem is getting worse, he said.

"That is not always the case," Blike said, adding he supports the reporting system.

"This is where counting can be a trap. We can have a lot more volume. On a rate basis, the one that looks worse is really better," he said. (See related chart.)

DHMC has been aggressively working to eliminate adverse events for many years, not just since the mandated reporting, he said.

"It's the right thing to do," Blike said.

Fleming said his office is working to create more detailed reports that will take into consideration patient volume and other factors that will put the numbers into perspective.

"Human error is what causes a lot of systems to fail, and sometimes there isn't a proper system in place, although that is less frequent. Sometimes, the cause is manufacturer's defect," Fleming said.

Besides New Hampshire, 25 other states and the District of Columbia have systems for reporting adverse events. It is impossible to make comparisons between states because each state determines what events will be reported and what information will be made public and the numbers are too small, experts say.

Maine hospitals reported 163 adverse events in 2011, up slightly from 150 in 2010, according to the state's website. Unanticipated deaths were reported in the majority of cases at 61 (37 percent), a category that doesn't exist separately in New Hampshire.

The names of the hospitals and most other details in Maine are confidential.

New Hampshire is expected to pass legislation that would automatically update its list of 28 reportable events any time the National Quality Forum does. The proposed changes would also add a new listing to require hospitals to also report whether an employee has transmitted a blood-borne pathogen to a patient by "an intentional unsafe act."

Sponsor Rep. Cindy Rosenwald, D-Nashua, also sponsored the initial reporting law.

"Everybody is looking for the same thing: how to keep our health care system as good as it can be," Rosenwald said.

Dr. Stephanie Wolf-Rosenblum, chief medical officer at Southern New Hampshire Medical Center, said there is more going on in New Hampshire hospitals working toward improved care.

"This is not about individual numbers," Wolf-Rosenblum said. "This is about commitment to a process where we examine any opportunity to raise the bar on the care that we give."

Anne Diefendorf, vice president for patient safety and quality at the Foundation for Healthy Communities, praised the reporting law.

"It's been great in terms of hospitals' ability to share information with each other. People are more comfortable to share what they have learned," Diefendorf said.

Adverse events chart

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