Hospital Adverse Event Reporting – No Federal Requirement

There is currently no federal requirement for reporting adverse events which occur during US hospital care.  Twenty-six states have some type of reporting requirement, but both the scope of data that must be reported, and the potential penalties for non-reporting, vary greatly.

In December, 2008 the Office of Inspector General (OIG) issued a report outlining its findings in this regard: Adverse Events in Hospitals, State Reporting Systems.   

The OIG document notes that because state tracking is so disparate, national data cannot be aggregated in any meaningful way.  Also noted is the Centers for Medicare and Medicaid Services (CMS) recommendation that an amendment to the Patient Safety Act be made to make reporting of well-defined adverse events mandatory.

States with Hospital Adverse Event Reporting Requirements: 

  • California
  • Colorado
  • Connecticut
  • District of Columbia
  • Florida
  • Georgia
  • Indiana
  • Kansas
  • Maine
  • Maryland
  • Massachusetts
  • Minnesota
  • New Jersey
  • Nevada
  • New York
  • Ohio
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Utah
  • Vermont
  • Washington
  • Wyoming

Grand Rounds 5.47 is up at Invisible Illness Week

Invisible Illness Week is our host for this week’s edition of Grand Rounds, with a Back-to-School theme. 

Also noted, National Invisible Chronic Illness Awareness Week is coming up on September 14-20. 2009. About 133 million people, nearly 1 in 2 in the USA live with a chronic condition and most of these are not visible.  Seems like a good statistic to remember the next time we want to scowl at someone with a handicapped parking sticker who “doesn’t look sick.”

Stop on over for a review of this week’s best of the medical blogosphere.

Grand Rounds

CACTUS and Quantros Announce Strategic Alliance

CACTUS Credentialing Software and Quantros data management solutions for safety, quality, and compliance, have announced a strategic alliance. 

The two organizations state that the relationship will expand and simplify the ability of healthcare providers to more effectively capture and evaluate physician performance data, including the Joint Commission requirements for OPPE (Ongoing Provider Performance Evaluation) and FPPE (Focused Provider Performance Evaluation).

Quantros currently supports more than 2,000 healthcare organizations; CACTUS Software supports more than 1,400.

Top Ten US Health Systems According to Thompson Reuters

According to a leading national news and information source, if you have to be sick Ohio is a pretty good place to be. Thompson Reuters has released their pick for the Top 10 health systems in the US based on quality and efficiency benchmarks. Five of the top ten are in Ohio.

Out of a pool of 252 health systems, the final 10 were selected based the two most recent years of data to assess the clinical quality and efficiency of the hospitals within a system.

Thompson Reuters states “the top health systems are providing higher quality care, with fewer mortalities and patient complications and better adherence to patient safety standards and core measures of care. They are also treating patients more efficiently, with substantially shorter patient stays.”

“Based on the results of this study, we estimate that if all Medicare inpatients received the same level of care as those in the 100 Top Health Systems-winning hospitals:

  • More than 47,000 additional patients would survive each year.
  • Nearly 92,000 patient complications would be avoided annually.
  • The average patient stay would decrease by more than half a day.”

Congratulations to the Top Ten Health Systems for making patient safety a top priority!

Kentucky Case Highlights Need for Disclosure Training; Dangers of Temporary Privileges

Imagine waiting anxiously near a hospital OR to hear word on how your mother’s surgery is going.  You suspect problems because the procedure is taking longer than expected. 

The surgeon finally appears, but he reports that the surgery didn’t go well.  He begins to relate details, then suddenly falls to his knees, covers his face with his hands, and says “This isn’t your fault, it’s my fault,” she’s in the hands of a higher power.”

That’s the recollection of the daughter of Bertie Lang, a patient who died two days after surgery, and whose family is now suing Meadowview Regional Medical Center in Maysview, Kentucky, and Dr. John Christian Gunn.

The case, which is currently being heard in Kentucky, is noteworthy for a couple of reasons.  For one, the issue of potential negligent credentialing is under consideration.  The accusation relates directly to the decision by leadership of Meadowview Regional Medical Center to grant temporary clinical privileges to Dr. Gunn.  

If you’re not familiar with temporary privileges, they are often granted after a streamlined review of a physician’s credentials and background in order to allow him/her to begin practicing in the hospital quickly.  A full credentials and background review takes time.  There are occasions when temporary privileges are quite appropriate, but at times they are granted without a thorough understanding of the risks to both patients and the organization. 

The second matter this trial brings to the forefront, is disclosure.  Physicians and other caregivers make mistakes, systems break down, and when that happens disclosure needs to be made to the patient and/or family.  However, reading the way the disclosure was apparently handled in this case gives me reason to feel sympathy, not just for the family of Bertie Lang, but also for Dr. Gunn.  His guilt and anguish are obvious, and his attempt to appropriately disclose painful, both for the family and for himself.  Add to that, the hospital’s additional exposure to legal liability and potential loss based on the words uttered at that stressful time. 

This case strongly reinforces the need for caregivers to be taught how to appropriately disclose unanticipated outcomes.  That education also takes time, and with privileges quickly granted there is less opportunity for Risk Management to offer that education. 

There are two important take-aways from this case, regardless of the court’s final judgment.  Hospital leadership must be extremely judicious in granting temporary privileges, and risk management must work proactively to educate and assist caregivers regarding appropriate disclosure of unanticipated or undesirable outcomes. 

Patients first.
Related stories: 

Malpractice Case Focuses on Doctor With Temporary Privileges – CRC Blog

8/16/09 Update – Out of Court Settlement Reached

8/18/09 - Physician now serving a prison sentence for 2008 armed robbery.

Infamous Malpractice – The Other Side of the Scalpel

Stop over at Kevin M.D. for a reminder that there are always two sides to a story.  Robert Ricketson relates his side of the infamous 2003 “screwdriver” medical malpractice case, and the overwhelming impact it has had on his life.

If nothing else, his account strongly supports the need for an accurate surgical time-out, assuring that all the needed equipment is present at the start of a case.

It’s good to remember that there are humans on both sides of the scalpel.

Dead by Mistake – The Hearst Report

Phil Bronstein, Editor-at-Large of Hearst Newspapers and the San Francisco Chronicle writes this about the compilation of articles he and a group of Hearst reporters put together entitled “Dead by Mistake.”  

Dead by mistake, the comprehensive story you see on this web site, is the result of two things converging: a team of skilled and dedicated journalists from across Hearst newspapers and television stations, and a critical and neglected health care issue that dramatically affects hundreds of thousands of Americans every year.

The idea for the story first came in an informal discussion among reporters and editors from several papers; we were looking at topics to investigate that would have a significant impact on people’s lives. We decided that focusing on the plague of fatal but preventable hospital errors would be a public service.