Medical Errors

QUALITY: Medicare Seeks to Add to "Never Event" List

Joanne Kenen — Tue, 15 Apr 2008 15:16:00 -0400

You know those signs in gift shops, "You break, You pay?" Medicare has adopted that philosophy in refusing to pay hospitals for "never events"—things that just shouldn't happen to patients. Now the agency has proposed adding to its list.

Last year Medicare announced it would not pay for certain medical errors and conditions acquired in hospitals. Starting October 1, several private insurers followed suit. Now Medicare wants to add nine more avoidable conditions and complications, if acquired in the hospital. The goal, which we like, is to put some financial teeth in efforts to improve care of patients, including infection control. Hospitals should not be dangerous to our health.

According to the AP, the new list includes deep vein thrombosis, or a blood clot within the vascular system, which occurred in 140,010 cases for the fiscal year ending September 30, ventilator-associated pneumonia, which occurred in 30,867 cases, bloodstream infections with the staph aureus bacteria, 27,737 cases, and Legionnaire's disease, which occurred in 351 cases.

The focus on hospital-acquired infection has been slowly building since the Institute of Medicine in 1999 concluded that medical errors, including hospital-acquired conditions, caused up to 98,000 deaths annually. Congress in 2006 gave the Centers for Medicare and Medicaid Services the ability to deny payment for extra treatment costs arising from preventable conditions during a hospital stay.

Hospitals now have to report on 30 measures designed to assess quality of care. Medicare is proposing to add 43 new measures to the list. Payment increases are linked to quality reports, and the information is also shared with consumers on the Medicare web site. So maybe the slogan should be updated— "You Break, You Pay. We Tell."

QUALITY: The Kids Aren't All Right: Medication Errors and Hospitalized Children

Paul Testa — Tue, 08 Apr 2008 20:33:00 -0400

One pill, two pills? Red pills, blue pills? Each year more than 1.5 million people are injured by preventable medication errors, and, according to a new study in Pediatrics reported by the Associated Press, about one out of every 15 hospitalized children is harmed by a medication error--getting the wrong drug, the wrong dosage, or the wrong reaction.

We wrote about medication errors recently after actor Dennis Quaid related his baby twins' ordeal to the Association of Health Care Journalism conference last month. Quaid is using his celebrity to draw attention to practical ways of reducing medical errors. His newborns nearly died last November after receiving the wrong dosage of the blood thinner Heparin.

Reducing medical errors is an important goal in itself—the Institute of Medicine estimates that as many as 98,000 Americans die each year because of preventable mistakes. But that goal will be most effectively achieved as part of a comprehensive reform which would combine and amplify the incentives for developing health information systems, changing payment incentives and sharing best-practices among all clinicians.

Why, you ask? Improving quality is in many cases a question of realigning incentives. Doctor, patient and payer can all benefit from adoption of new technologies and higher standards.

In many cases, such as the use of beta-blockers after heart attacks, we know what works. We have evidence. But as AHRQ director Carolyn Clancy noted in a recent speech at Research! America, it takes about 17 years to bring much of what we learn and know to the bedside. In other cases we don't have clear evidence-based guidelines for what works best, when, and for whom—as the Boston Globe's Dr. Victoria McEvoy made clear in her recent column, describing the difficulties prescribing medication for children when guidelines are sparse and clinical trials as hard to come by. Fortunately, our colleague Tom Emswiler reports there's hope Congress may pass comparative effectiveness legislation in the coming year.

As we noted last week, Medicare and some private Insurers are taking steps to stop paying for certain preventable errors and "never events." We hope such steps can help move our country to a health system in which insurers focus on creating value rather than cherry picking risks, in which doctors are paid for providing the right outcomes, and where health IT measures are incorporated as both an economic and a medical necessity.

QUALITY: Oops, We're Not Paying Again

Paul Testa — Thu, 03 Apr 2008 19:37:00 -0400

"Oops I did it again," may have made millions as a pop song, but for 11 preventable medical errors, it will no longer get you paid by the Indianapolis-based insurer, WellPoint, according to an article in today's Indianapolis Star.

WellPoint joins a growing number of public and private payers in efforts aimed at promoting quality, reducing errors, and controlling costs in our medical system. WellPoint's new policy adopts the steps taken by the Centers for Medicare and Medicaid Services last fall to no longer pay for preventable medical errors, injuries and infections that occur in hospitals.

Like CMS, WellPoint will make sure that neither it nor its patients pay for three so-called "never events"—surgical mistakes that should never happen under any circumstances. They are:

Surgery on the wrong body part
Surgery on the wrong patient
The wrong surgery performed on a patient.

Additionally the insurer will limit payments for the following events, all of which are highly preventable when evidenced-based guidelines are adhered to:

Object left in the body during surgery: Typically instruments, sponges, or towels.
Air embolism: Occurs when an intravenous line introduces oxygen into the bloodstream which can create potentially life-threatening blockages.
Blood incompatibility: Wrong blood type given to the patient.
Catheter-associated urinary tract infection: Account for 32 percent of health-care associated infections-largely a product of poor hygiene practices.
Decubitus: Bed sores which occur when a patient is not turned frequently enough (about every 2 hours)and cost Medicare on average $40,000 a patient.
Vascular catheter-associated infection: Like catheter-associated UTIs, a product of poor wound and catheter hygiene.
Mediastinitis: Infections inside the wound after coronary artery bypass graft (CABG) surgery.
Hospital-acquired injuries: Fractures, dislocations, intracranial injuries, crushing injuries and burns—preventable with proper supervision and care.

The CDC estimates that about 1.7 million infections are acquired each year in hospitals and other health-care facilities.That translates into roughly 90,000 deaths and $4.5 billion in extra costs. Preventing errors and injuries listed above represent the tip of the iceberg in terms of improving quality and reducing costs (CMS estimated the new payment policies would produce yearly savings in the millions).

But the approaches taken by CMS, WellPoint and others to such problems are both innovative and important: Doctors, nurses, and hospitals already should be doing the things that prevent these errors. Designing payment systems that reflects evidence-based standards of care can help ensure that they do. And paying for performance is something we can all sing "Gimme More" to.

QUALITY: In Good Company: Dennis Quaid and Preventing Medical Errors

Joanne Kenen — Mon, 31 Mar 2008 22:12:00 -0400

Imagine if your newborn twins, already hospitalized with an infection likely acquired at another hospital, were given two potentially fatal overdoses of a blood thinner. Imagine if your pediatrician (now your former pediatrician) did not call to tell you. Imagine if the night nurse told you everything was fine when you phoned to check on the babies. Imagine if you learned the truth when you arrived at the hospital at 6 a.m. to see your kids and were met by Risk Management.

That's what happened to Dennis Quaid last winter. His babies survived. His story has been told. But Quaid hasn't forgotten the 41-hour ordeal, when his tiny children nearly bled to death, their blood "squirting on the walls." He has joined the ranks of "cause celebrities," knowing that his fame can bring national attention to medical errors that usually occur in isolation. He has set up a new foundation to address patient safety, particularly regarding medication errors.

Quaid told the Association of Health Care Journalists' annual convention that he used to think of hospitals as safe places. Now, he said, "I would never let a friend or family member ever be in the hospital alone." Not because the doctors or nurses are incompetent or uncaring, because by and large they are not, he said. But they are human. They make mistakes. And the safeguards aren't in place--or aren't consistently used--to prevent those mistakes. Lawmakers have been grappling with how to address quality and errors without spurring more malpractice litigation; so far they have not agreed on answers.

As a movie star, Quaid doesn't profess to have all the answers, or even to have the policy expertise to ask all the questions. But he said he doesn't understand why hospitals can't adopt some of the same technology--like bar codes on medications to prevent errors--that are commonplace in supermarkets. A licensed pilot, he said he doesn't understand why medical errors aren't studied the way aviation errors are, to prevent a repeat catastrophe. He doesn't understand why it took a week and a half to get his kids' medical records, 300 pages each, only to find three pages missing, covering the critical nine hours when the errors were made.

Only one event in the whole long nightmare didn't surprise him: the hospital never sent a bill.

The policies Quaid calls for are not only reasonable; they're starting to be implemented.

The Institute of Medicine found in its 1999 report, "To Err Is Human," that as many as 98,000 Americans die each year from medical errors. Since then, the Institute for Healthcare Improvement launched its "100,000 Lives" campaign aimed at promoting hospital safety around the country (and in 2006, after initial success, they expanded their goal to 5 million lives). Leading edge systems like Geisinger in Pennsylvania and the Mayo Clinic in Minnesota have adopted a "Never Event" policy of not taking reimbursement for extremely serious and preventable errors that occur in their systems. Similarly, Medicare recently announced that it will no longer pay for a number of specific preventable medical errors.

These efforts would be made more effective by comprehensive reform which would combine and amplify the incentives for developing health information systems, providing payment incentives and sharing best-practices among all clinicians.

QUALITY: Hospitals Combat High-Risk Medication Errors

Joanne Kenen — Wed, 05 Mar 2008 14:28:00 -0500

Remember that scary Institute of Medicine report a few years back about the 98,000 fatal medical errors in hospitals each year? And the conclusion that it wasn't the fault of a few "bad apple" or incompetent doctors and nurses, but layers of unnecessary hazards built into the system? The problems range from confusing packaging to the "hurry up and rush" culture of hospitals. Today's Wall Street Journal has an interesting article on how hospitals are rethinking how they use the riskiest drugs--the eight medications which studies have shown account for nearly one-third of the drug errors that harm patients.

[slideshow]The Journal reports that hospitals are "working with drug makers to redesign confusing packages and eliminating multiple concentrations of the same drug from supply cabinets. They are also investing in bar coding and systems that let staffers check the accuracy of medication orders at patients' bedsides and see other information, such as allergies, that could cause adverse reactions. In perhaps the most challenging step, hospitals are tackling the "grab and go" culture in busy hospitals that evidence increasingly shows causes dangerous errors."

One simple tool is making two people check prescriptions. I saw this in practice last year when I was doing some reporting at the pain clinic at Virginia Commonwealth University's medical center. They use heavy-duty narcotics for patients with metastatic cancer or severe back pain, and I watched as the nurses whipped out their calculators and double-checked each other's decimal points....