Incidents of pressure ulcers, wrong-site surgeries and other surgical
errors reported by Connecticut hospitals have increased in the last
five years, despite myriad efforts to curb them, a new state report
shows.
At the same time, state health department investigations of many
hospital adverse events, such as patient injuries from falls,
perforations resulting in disability, and death or serious injury due to
surgery, have been rare, data in the report shows. For example, of 196
cases reported since 2007 in which patients were injured by a
perforation during a colonoscopy or other procedure, the Department of
Public Health (DPH) investigated just 20, or one in 10 cases.
The new Adverse Event Report, prepared by the DPH, marks the
first time that acute-care hospitals and other medical facilities have
been publicly identified by name, as they report errors that caused harm
to patients.
The five hospitals with the highest rate of adverse events in
2010, calculated per 100,000 inpatient days, were: New Milford Hospital
(21.4), the Hospital of St. Raphael in New Haven (19.2), Sharon Hospital
(17.2), Johnson Memorial in Stafford Springs (17), and the William W.
Backus in Norwich (16.2).
Other hospitals had above-average rates of errors over the seven-year period from 2004-2010.
Backus reported eight incidents in 2010, four of them surgical
errors that resulted in death or serious injury. The hospital had the
fifth-highest adverse event rate (16.2 per 100,000 patient days) among
the state's 30 acute-care hospitals. Lawrence & Memorial Hospital in
New London reported seven incidents in 2010, three of them injuries
from falls, with a below-average overall incident rate (9.8).
Because the errors are self-reported, state officials caution
that some of the variation could be due to underreporting. The state
does not conduct audits of medical or death records to validate the self
reports, and national studies have found underreporting is a widespread
problem. One study, published last May, estimated that the system used
in Connecticut and other states - voluntary reporting, based on federal
patient-safety indicators - missed 90 percent of all adverse events.
The DPH reviews all hospital errors but does not investigate
every case. In fact, the report shows, of 1,023 adverse events included
in DPH's database since 2007, the department launched investigations in
only 23 percent of cases. Of 17 cases in which patients died or were
seriously injured during surgery - a newer category added in 2010 - only
six were investigated.
The rate of DPH investigations into reported errors has dropped
over the last five years - from 27 percent in 2007-08, to 20 percent in
2009-11. For cases in which patients acquired painful pressure ulcers
during hospitalization, the investigation rate fell from 36 percent to 8
percent.
DPH officials said they target preventable errors that may
indicate systemic problems or inadequate standards of care. The decision
to investigate also is influenced by how often the type of event has
been investigated before, and whether DPH is satisfied with a corrective
plan that must be submitted by the hospital after an adverse event is
reported.
DPH spokesman Bill Gerrish said the agency "has jurisdiction to
investigate when there appears to be noncompliance with regulations or
professional standards of care. Not all adverse event reports fall into
these categories."
The report notes that DPH used to receive funding for physician
consultants in specialties including surgery, pediatrics and orthopedics
- but as of 2010, "these resources were no longer available" to support
investigations.
Overall, 1,637 adverse hospital events that resulted in patient
harm were reported to the DPH from 2004 through May 2011, including 157
cases in which patients died. The most common incidents were falls that
resulted in injury or death. Hospitals reported 655 falls through May,
33 in which the patient died.
Perforations during open, laparoscopic or endoscopic surgery were
the second most common source of errors reported, with 319 cases,
including 32 deaths. Serious pressure ulcers acquired during
hospitalization represented the third most common event, while foreign
objects left in patients after surgery or other procedures was the
fourth highest incident, with 105 cases reported.
Of 126 surgical incidents reported since 2005, 26 involved
surgeries on the wrong site, 11 were wrong procedures, and two involved
the wrong patients. One of the wrong-patient procedures involved a
needle aspiration of the chest cavity.
A record year
The DPH report notes that there were more cases of wrong-site
surgery in 2010 than in any previous year - seven, as compared to two in
2009 - but the agency cautioned against drawing conclusions.
"As the reported number is influenced both by the number of
events and the awareness of and willingness to report events, nothing
can be concluded about frequency of errors based only upon the number of
reports," the DPH said. But "regardless of whether the increase in 2010
is statistically significant, any event of this sort is a serious
concern."
Under the state's "adverse event" reporting law, hospitals have
been required since 2002 to inform the DPH whenever patients suffer
certain serious unintended harm. The legislation was intended to compel
hospitals to improve care and to help patients assess the quality of
care. But after the first reports became public, hospitals persuaded
lawmakers to rewrite the statute in 2004, limiting the kinds of adverse
events that must be divulged and keeping reports secret unless they led
to an investigation.
In 2010, the law was revised again, this time requiring public
reporting of errors and infection rates. While the new system is an
improvement, patient-safety advocates say it still doesn't go far
enough.
"We don't know how to deal with under-reporting," said Jean
Rexford, director of the Connecticut Center for Patient Safety. "We know
it happens, but what are we doing about it?" She said it was alarming
that three out of four reported events were closed without an
investigation.
Ten of the state's 30 acute-care hospitals reported at least one
death or serious injury due to surgery mistakes in 2010. Backus Hospital
reported four such incidents and Hartford Hospital reported three, with
those seven cases accounting for nearly half of the 15 cases logged in
2010.
The report indicates that while some hospitals have made headway
in reducing common medical errors over the last seven years, others
haven't. Overall among acute-care hospitals, the rate of reported
surgical errors rose from .97 per 100,000 inpatient days in 2006, to
1.31 in 2010. The rate of post-admission pressure sores and other
care-management problems rose from 1.70 in 2006, to 2.24 in 2010,
despite increased attention nationally to the problem.
Hospitals in the state, through the Connecticut Hospital
Association, have taken action. "There are new strategies in place to
standardize the process of care" and prevent ulcers, falls and other
adverse events, said CHA spokeswoman Michele Sharp.
The report indicates that both large and small facilities wrestle
with common adverse events. Yale-New Haven and Hartford Hospital
reported the highest numbers of incidents of foreign objects from 2004
through 2010; the Connecticut Children's Medical Center, Bridgeport
Hospital and the Hospital of Central Connecticut also were among the top
five.
In numbers of reports of pressure sores, Yale and Hartford
hospitals again were in the highest five. Some hospitals reported
multiple perforations resulting in disability.
The highest overall adverse-event rate over the seven years was
reported by Sharon Hospital - 24.4 per 100,000 patient days. Day Kimball
Healthcare in Putnam had the third-highest rate.
In comments included in the report, most hospitals with high
error rates described initiatives being undertaken to reduce adverse
events. Yale-New Haven Health System, which includes Yale-New Haven,
Bridgeport and Greenwich hospitals, said it encourages and expects the
reporting of "all unexpected and adverse outcomes."
Backus Hospital officials said they had put an "extensive focus"
on preventing falls, pressure ulcers, blood clots, hospital-acquired
infections and medical errors. Hartford Hospital credited its
patient-safety initiatives with reducing reportable falls by 45 percent
from 2009 to 2010, and reducing pressure ulcers by 55 percent.
Among ambulatory surgical centers, the Middlesex Endoscopy Center
in Middletownreported the highest rate of adverse events in 2010. DPH
officials again cautioned that no conclusions should be drawn about
quality based on the self-reporting.
Rexford and other advocates said in terms of making information
available to citizens, Connecticut lags behind other states, such as
Minnesota, which provides the public with a searchable database of
adverse events.
In the report, DPH officials said they hope to improve the
adverse event reporting program in ways that will promote patient-safety
interventions. While they said the report alone should not be used as a
gauge for a hospital's quality of care, the department "encourages
citizens, using this report, to ask their hospital or physician what is
being done to prevent these types of events from occurring."
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