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Hospitals say there is no change in 'never events' tally

New Hampshire Sunday News

October 12. 2013 11:56PM

Seventeen New Hampshire hospitals and one ambulatory surgery center reported 42 "adverse events" happened in 2012, including surgery on the wrong body part and foreign objects left in patients. It's the same total that hospitals reported in each of the previous two years.

But while health care providers admit frustration that the numbers have not declined despite their efforts to improve quality and patient safety, they say it also means that hospitals here take their obligation to report very seriously.

Since 2010, hospitals and ambulatory surgical centers in the state have been required by law to tell the state Health Department when certain "adverse health care events" occur. The list includes surgery on the wrong body part or patient, wrong procedure, foreign objects left inside a patient, severe pressure ulcers (bedsores), medication errors, burns and falls.

Reporting rules

When such an event does occur, a facility must report it to the state within 15 days; it then has 60 days to provide a "root cause analysis" of what happened and a "corrective action plan" to fix it.

The state's largest hospital, Mary Hitchcock Memorial, part of Dartmouth-Hitchcock Medical Center, reported the most adverse events last year, a total of 10. They included three surgeries on the wrong body part, one wrong procedure, one foreign object left in a patient, one medication error, two serious pressure ulcers, one burn and one fall.

A DHMC spokesman said no one was available to discuss the report last week.

Michael Fleming is chief of the Bureau of Health Facilities Certification at the Department of Health and Human Services, which compiles the annual list.

If a hospital reports similar errors year after year, Fleming said, state inspectors will check during periodic "surveys" to make sure the facility has complied with its own corrective action plan. "We're basically confirming that the facilities are doing what they say they're doing," he said.

Publishing the list allows hospitals to learn from each others' mistakes, Fleming said. "The whole idea of this entire process is to create a proactive mechanism so that (when) unfortunate mistakes ... happen, everybody can improve their systems by looking at where a system failed," he said.

Anne Diefendorf is vice president for quality and patient safety at the nonprofit Foundation for Healthy Communities, which is affiliated with the New Hampshire Hospital Association.

She said representatives of all hospitals and surgical centers serve on the New Hampshire Healthcare Quality Assurance Commission, which meets five times a year to share information confidentially. Even before adverse events are made public, these hospitals have shared their stories with each other so they can learn from others, she said.

The commission met last Friday and reviewed the latest adverse events report. Diefendorf said members asked the same question the public and lawmakers ask about such events: "Why is this still occurring?"

"As health care professionals, I would say we're equally as alarmed as we would expect the general public to be," she said.

They used to be called "never events" - mistakes that are never supposed to happen, she said. Now they're called serious reportable events instead "because we know these events are going to occur."

It's the surgical mistakes that are most concerning, she said. In 2009, hospitals and other medical facilities here adopted a "surgical safety checklist" created by the World Health Organization to reduce patient harm.

And two years ago, the Foundation for Healthy Communities joined a national initiative called Partnership for Patients that brings in experts and educational resources aimed at improving quality.

Given all that, Diefendorf said, "we're frustrated in the sense of we all feel like we should be better by now."

However, she said, the number of adverse events reported thus far in 2013 does seem to be lower than in the previous three years. "It's my hope and my very strong belief that the numbers will be different next year with all this work," she said.

Added to list

The Legislature tweaked the reporting law earlier this year, adding to the list of events the exposure of a patient to a blood-borne pathogen by a health care worker's "intentional, unsafe act."

That came after 32 patients at Exeter Hospital contracted hepatitis C in 2012 from a medical technician who stole narcotics meant for patients and replaced them with used syringes contaminated with his infected blood.

The new requirement took effect July 15. Had it been in place last year, Exeter Hospital would have had to report each of the 32 cases as adverse events, Fleming said.

Exeter Hospital did report three adverse events in 2012: a foreign object left during surgery, one fall and one serious case of bedsores.

Wentworth-Douglass Hospital in Dover, which is licensed for 178 beds, reported three adverse events: a wrong surgical procedure performed; a foreign object left during surgery; and one case of serious bedsores.

Noreen Biehl, vice president of community relations at Wentworth-Douglass, said the hospital takes the issue "very seriously."

When an adverse event occurs, the hospital's "sentinel events task force" interviews all staff involved, she said. "It's a real investigation of what went wrong, not so much to penalize people, but the purpose is to learn from that experience, to avoid ever doing whatever it is again.

"It could involve a change in ... a process that we have, it could be some equipment problems, there could be staff training, there could be a new procedure developed or a new way to do something."

Donna Fitts is vice president of quality at Portsmouth Regional Hospital, which reported three falls and three cases of serious pressure ulcers in 2012.

Fitts said while hospitals have been working for years to reduce patient harm in both those categories, in some cases such events are not entirely within a hospital's control.

Hospitals today often see sicker patients who come in with chronic conditions that may not have been properly managed, she said. It's "virtually impossible" to prevent all pressure ulcers in such populations, she said.

Likewise, she said, all the safeguards in the world may not prevent falls if a patient doesn't call for a nurse before getting out of bed.

Following the law

Fitts said she's proud of how hospitals in New Hampshire have handled the mandatory reporting.

In some states, she said, "they went from events happening, and then legislators passed mandatory reporting and, amazingly, no hospital had any events happening."

That didn't happen here, and Fitts said, "I take pride in the integrity of the hospitals in New Hampshire."

She said she hopes publishing the annual adverse-events list also helps make people more informed consumers of health care.

"In no way am I suggesting this burden is theirs," she said. "The burden is the hospitals'.

"But as a consumer, these reports to me always represent an opportunity for the public to come along with us on this journey and really become more savvy around safety practices," she said.

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