A Plea to Candidates

[P.J. Lurvey]

The New York Times reported that hospital employees recognize and report only one out of seven errors that harm Medicare patients while they are hospitalized based on a newly released federal report.  Yet even after hospitals investigate preventable injuries and infections that have been accounted, they rarely change their practices to prevent repetition.  Such mistakes include, but are not limited to, medication errors, severe bedsores, hospital acquired infections (HAIs) and excessive bleeding linked to improper use of blood thinners.

As a future Medicare patient, and daughter and granddaughter of Medicare patients, this is hard to believe and frankly, unacceptable because these effects are easily avoidable.

 

Take HAIs: 76,000 Americans will develop a catheter-related blood stream infections, according to the CDC in the ICU per year.  However, CRBSIs are preventable by hand washing. Shockingly, compliance for hand washing is 60% -- that means 40% of physicians are not washing their hands before patient care. 

 

So, six out of seven Medicare patient errors are unreported, and 40% of physicians are not washing their hands. Sickening (pun intended).

 

In October 2009, Medicare began cutting payments to hospitals that did not lower rates of CRBSIs and other HAIs.  According to a government report, following the implementation of the new Medicare rules, the total cost savings calculated between October 2009 - September 2010 was $21,450,095. Only .3% of that was associated with CRBSIs. Not only were the cost savings trivial, but HAIs still affect one in 20 patients.  

 

The irony lies in the data: during the same period of time, hospitals have not accurately reported the number of HAIs while Medicare cut payments to hospitals that did not lower HAIs… Maybe this is in fact, not a coincidence at all.  

 

Let’s not blame Medicare. They’ve taken enough heat. Same with hospitals, because as the Times reports, they certainly are not solely responsible for the unreported errors and failure to implement new policies.  Daniel Levinson, inspector general of the Department of Health and Human Services said the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported. Yes, this is a problem…

But what about inspection agencies who oversee the reported errors and monitor the recurrence rate? We can’t let them off the hook. The federal investigators reviewed the 293 cases in which patients were harmed: forty were reported to hospital managers, 28 were investigated by hospitals, but only five led to changes in hospital policy or practice.

 

The Obama administration has placed a high priority on reducing medical errors (tangent: the fact that this is now a priority and not already a best practice astounds me).  So as the 2012 presidential election kicks into high gear, candidates need to go back to the basics. Push for a reform—no, not that healthcare reform we’ve been talking about for years—but a root reform. Educate nurses, doctors, administration to accurately identify a problem, react, treat, report, and then implement best practices to ensure patient safety for the future. Further, inspection agencies must be educated to scrutinize, track medical errors, monitor hospitals and doctors who have a recurring issue, and most importantly, force hospitals to implement best practices that puts patients first.

 

[Palmer Reuther]

great post, PJ. It's unfortunate that all too often the needs of patients are overshadowed by political discourse.