The Deadliest Diagnosis: Medical Errors

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A one year old patient named Emily was diagnosed with a yolk sac tumor (the size of a grapefruit) in her abdomen. Her treatment team assured her that it was entirely curable and after testing, surgery and chemo, she was in the clear. Her parents were relieved. They could take their gorgeous daughter with ringlet hair and infectious laughter home. The last night of their stay, she was given her last dose of sodium chloride. She woke up groggy from a nap and immediately started complaining of a headache. After being transferred to the ICU and declared brain dead, she passed away shortly after. It turns out that the pharmacy tech had filled a plastic bag with concentrated sodium chloride of 23.4% rather than the standard prepared sodium chloride solution (with 1% of NaCl).

More patient stories including medical errors (of neurosurgery procedures being done on the wrong hemisphere of the brain, of hospital borne infections treated inaccurately, of surgical equipment left in patients bodies…etc) track common mistakes made by healthcare professionals with patients and their families ultimately paying the price.

Medical errors are defined as: healthcare errors that could have been prevented, such as inaccurate diagnosis, subsequent treatment, injury, hospital borne infections, improper protocol compliance, or other factors that adversely affect care. According to the Institute of Medicine 1999 edition, a range of 44,000 to 98,000 people die in hospitals due to medical errors, making it far deadlier than all deaths combined for MVAs, breast cancer and AIDS (Kohn).

Legislative Background on Medical Errors

This discussion of medical errors began with the Institute of Medicine in June 1998. A large cohesive report was compiled by the Quality of Health Care in America project and it began the conversation of how deep rooted, deadly and complex addressing medical errors really is. After the IM report, US Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced an ‘unanticipated outcome’ policy that demands disclosure of a critical event by the provider or the institution (Kalra). In some states, the federal government has made it mandatory for hospitals to inform patients on adverse effects.

Perhaps the most recent developments with medical errors involve the Affordable Care Act. Obamacare attempted to reduce incentives for poor quality care, while rewarding health systems that provide quality patient care.

Let’s take Medicare for example. It gives less money to health systems if their patients return shortly after discharge. Hospitals are then held accountable for readmission rates, hospital-acquired infections, injury, and medical errors. According to a Huffington Post, a report from the Agency for Healthcare Research and Quality showed a seventeen percent rate decrease of patients of “hospital-acquired conditions” since 2010 which ultimately equates to “87,000 lives saved and $19.8 billion not spent on extra medical care” (Cohn). In other words, when hospitals are held accountable for readmission rates, they tend to go down.

This may be in part due to American Recovery and Reinvestment Act of 2009, specifically the Health Information Technology for Economic and Clinical Health (HITECH) Act, which aims to “promote the adoption and meaningful use of health information technology” (Office for Civil Rights).

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Health systems are adopting advanced electronic medical record systems that are designed to reduce medical error and promote better care. EPIC, for example, requires dual sign off for nurses when administering high-alert medications, such as heparin and insulin. Physicians are given warnings when prescribing medications that have interactions with other drugs, or medical conditions, such as prescribing Corgard and Aspirin together. Additionally, there are order sets built into the system to ensure that providers include appropriate protocols for patients (i.e. prophylaxis protocol for sepsis). There are additional enhancements that alerts providers patients are sepsis, 75% (or more) name similarity to other patients, and built-in alerts when medical records are found from other health systems allowing for a more cohesive, united approach to care. In short, the ACA is pushing health systems to place patient care as a priority, which creates a top-down initiative to eliminate medical errors.

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What if hospitals were required to disclose medical errors?

These medical errors involve a number of stakeholders. Patients, patients’ families, providers, health systems and the greater public are affected by medical errors. If hospitals/providers are required to disclose on medical errors, then these are the proposed benefits. We’ll discuss consequences and possible middle ground afterwards.

Firstly, patients want to know when something goes wrong. Patients prefer to be informed when medical errors are made, thereby allowing them to be active, informed decision-makers in their healthcare plans. According to a survey conducted in 1996, “virtually all patients (98%) desired some acknowledgement of even minor errors” (Witman). If something wrong happened to you, wouldn’t you want to know?

Additionally, when health systems release medical errors, they allow for system-wide investigation, allowing committees to properly diagnose key weaknesses within an institution which will decrease the possibility of future repeated medical errors. For example, after a 2015 superbug outbreak at UCLA Medical Center that caused seven confirmed infections and two deaths, UCLA “removed two contaminated duodenoscopes and implemented a more stringent decontamination process for the remaining devices” (Berdjis) after determining their employees did not violate any protocol.

When medical errors are disclosed, it generates further discussion on root causes of standard protocol and understanding. For example, the 2001 Gisborne Cervical Screening is a compiled of wide ranging recommendations for improvements to the national cervical screening program. It was put together after a patient took her pathologist to court because of her late prognosis. (Gisborne Cervical Smear Inquiry). Such examples and reforms have the potential to tremendously improve population health.

When medical errors are acknowledged and addressed, there is room for improvement in the work environment and demands of providers. For example, on paper, as per ACGME guidelines, first year surgical residents are required to not work more than eighty hours a week. Off the record, however, due to extensive healthcare burden, residents are unwillingly made to work more than one hundred hours a week. When medical errors are disclosed, they call attention to possibly dangerous work environments for their employees which inevitably jeopardizes everyone in healthcare, including patients.

Requiring hospitals to develop a system to proactively acknowledge and address medical errors will inevitably affect financial responsibility two fold. If medical errors consequently reduce, sick patients who stay in the hospital longer, receiving more intensive care, will incur less additional expensive charges to their stay. Out of the $19.5 billion that costs the US of medical errors, roughly “87% or $17 billion were directly associated with additional medical cost, including: ancillary services, prescription drug services and inpatient and outpatient care” (Andel). Health systems, additionally, benefit financially when disclosing medical errors proactively.

University of Medicine and Health Sciences did an assessment after utilizing a disclosure with offer program and found that disclosing medical errors reduced capita costs across the board. According to a UHMHS study on Liability Claims and Costs Before and After Implementation of a Medical Error Discloser Program, “after full implementation of a disclosure-with-offer program, the average monthly rate of new claims, average monthly rate of lawsuits, median time from claim reporting to resolution, average monthly cost rates all decreased.” (Kachalia).

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Conversely, these stakeholders also face backlash if required to report medical errors. Counterarguments to disclosing medical errors include: Physicians face lawsuits, loss of license, trust and reputation. According to a study involving physician focus groups, “physicians felt upset and guilty about harming the patient, disappointed about failing to practice medicine to their own high standards, fearful about a possibly lawsuit, and anxious about the error’s repercussions regarding their reputation” (Gallagher). Understandably, physicians face serious guilty and shame resulting from medical errors. Requiring them to disclose these errors, thereby jeopardizing their career, can exacerbate these issues. For example, “for some physicians, the emotional upheaval following an error led to sleeplessness, difficulty concentrating, and anxiety” (Gallagher).

Furthermore, hospitals loss of reputation affects patient perceptions after bad press. In a Spanish study investigating patient perceptions, “increasing the hospital’s reputation or the positive perception of the treatment results led to a 13 and 15% increase of the safety perception” (Mira) for those patients. Finally, hospitals face loss of Medicare payments. In October 2008, “Medicare will stop paying US hospitals to correct 8 preventable medical errors caused by their negligence” (Brooks).

The question of medical errors begins to show the interplay of these stakeholders and provides great opportunity to improve patient care, population health, per capita costs, public health focuses, institutional reform, and interpersonal relationships between providers. If hospital systems were required to release medical errors to the public, then health systems would be more inclined to reduce them.

Limitations

Limitations to requiring health systems rest inherently within the system. Requiring that health providers release medical errors depends solely on the health providers’ ability and willingness to acknowledge an error. Roughly, “86% of medical errors go unreported” (Mullin) according to an investigation.

Alternative Approaches

Alternative approaches to requiring health providers to disclose medical errors would be to implement external departmental reviews on patient safety, utilize an anonymous physician reporting system that protect physician autonomy, or creating/revamping quality improvement committees within the hospital to self-regulate areas of weaknesses.

Utilizing an external federal department to perform quality checks with health systems has some benefits. It mimics a “secret shopper” infrastructure that performs a baseline investigation on problem areas within hospitals, such as ICU areas or surgical procedure mistakes. This governmental agency can then give a grade — similar to the health grades on restaurants that ensure food is safe for human consumption. Limitations to this approach lie deep within the changing world of medicine — it is difficult to stay atop of a dynamic field that constantly introduces new strains of bacteria, infection and procedures as a standardized, timeless approach is not practical. Catching the mistake before it happens or attempting to stay ahead of the “game” is difficult with medicine.

Utilizing an anonymous system that protects providers is an alternative to requiring providers to release medical errors. The Patient Safety and Quality Improvement Act signed into law in 2005 allowed for medical professionals to confidentially report on events that could adversely affect patients (Kalra). This act also prompted the creation of NPSD which acts as a resource for evidence-based management techniques. By allowing providers to anonymously report areas where medical errors are most likely to occur (or have occurred) alleviates their anxiety about career damage. These concerns can then be addressed as a whole for health systems allowing them to introduce changes.

These changes should be reviewed and executed by internal health committees. Most hospitals have internal quality improvement committees. An alternative to requiring health systems to disclose errors to the general public is to disclose errors to these quality committees that can then take proactive actions to do “in-house” cleaning. Limitations to this can include negligence among both reporting errors by providers and also by health systems that fail to address them.

Bottom line:

Medical errors are too great of a public health concern involving various stake holders to be addressed with one simplified approach. Requiring health systems to report medical errors and actively work to address root causes through quality improvement committees while protecting physician reputation is quite possibly the greatest recommendation. It protects the careers of physicians while allowing a health system to take responsibility for patient safety. By requiring health systems to disclose medical errors, it provides transparency and accountability toward reducing medical errors thereby improving patient care, population health, reducing costs per capita patient among various other public health benefits.

Bibliography:

Andel, C., Davidow, S., Hollander, M. & Moreno, D. (2012). The economics of health care quality and medical errors. Retrieved from http://wolterskluwerlb.com/health/resource-center/articles/2012/10/economics-health-care-quality-and-medical-errors

Berdjis, Noushin (2015). “Superbug” Outbreak at UCLA Medical Center. The Disease Daily. Retrieved from http://www.healthmap.org/site/diseasedaily/article/%E2%80%9Csuperbug%E2%80%9D-outbreak-ucla-medical-center-22715

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs,27(3), 759–769. doi:10.1377/hlthaff.27.3.759

Brooks, J. (2007). US medicare will stop paying for preventable errors. CMAJ : Canadian Medical Association Journal, 177(8), 841–842. doi:10.1503/cmaj.071347

Cohn, J. (2015, -12–01T19:36:13Z). Fewer patients have been dying from hospital errors since obamacare started. Huffington Post Retrieved from http://www.huffingtonpost.com/entry/patient-safety-obamacare_us_565dcb8ce4b072e9d1c34a57

Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients’ and physicians’ attitudes regarding the disclosure of medical errors. Jama, 289(8), 1001–1007. doi:10.1001/jama.289.8.1001

Gisborne cervical smear inquiry | women’s health action.. Retrieved from http://www.womens-health.org.nz/consumer-rights/gisborne-cervical-smear-inquiry/

Kachalia, A., Kaufman, S. R., Boothman, R., Anderson, S., Welch, K., Saint, S., & Rogers, M. A. M. (2010). Liability claims and costs before and after implementation of a medical error disclosure program.Annals of Internal Medicine, 153(4), 213–221. doi:10.7326/0003–4819–153–4–201008170–00002

Kalra, J. (2011). Medical errors and patient safety, strategies to reduce and disclose medical errors and improve patient safety. Berlin, Boston: De Gruyter. doi:10.1515/9783110249507

Kohn, L.T, Corrigan, J.M, Donaldson, M.S. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press. doi:10.17226/9728

Mira, J.J., Lorenzo, S, Navarro, I (2014). Hospital Reputation and Perceptions of Patient Safety. Madrid, Spain. Medical Principales and Practice. Doi:10.1159/000353152

Mullin, Emily (2014) 86% of Medical Errors Go Unreported, as Hospital Costs SoarI. Dorland Health. Retrieved from: http://www.dorlandhealth.com/dorland-health-articles/86-of-medical-errors-go-unreported-as-hospital-costs-soar

(OCR), Office for Civil Rights. (2009). HITECH act enforcement interim final rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/index.html

Witman, A. B., Park, D. M., & Hardin, S. B. (1996). How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Archives of Internal Medicine, 156(22), 2565–2569.

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