Errors

Medical mistakes often unreported

About 3,500 patients die — and no one has to know

By Sarah A. Webster / The Detroit News

    Twenty states require hospitals to report serious mistakes, but Michigan isn’t among them.

Morris Richardson II/ The Detroit News Colleen Chapman of Dearborn was overcome with emotion in a Wayne County court in December. She is suing a local hospital to learn what diseases she may have been exposed to because of a mistake in sterilizing an instrument used on her during surgery.

    As a result, it’s impossible to say exactly how many people are maimed or killed by hospital foul-ups. But based on a recent report by the Institute of Medicine, which estimates 36 error-related hospital deaths per 100,000 people, 3,534 Michiganians died last year due to medical mistakes.

    Patients reported 2,027 complaints about health care organizations to the state, but Tom Lindsay, director of the Michigan Bureau of Health Services, said those likely represent just a fraction of the mistakes.

    “I can’t tell you how many deaths or injuries result from medical mistakes,” Lindsay said.

    Several institute members said mandatory reporting of serious mistakes is the first step to reducing the errors. It is asking Congress to establish a nationwide mandatory reporting system for medical errors that cause injury or death.

    “As soon as we’re able to start that, I think we’ll find that medical errors get corrected,” said Gail Warden, president and chief executive officer of Henry Ford Health System in Detroit and a co-author of the institute report.

    By collecting those statistics, ways to prevent mistakes can be developed. Less serious mistakes — those resulting in close calls or lesser injuries — should be reported voluntarily, the institute says, so recurring problems can be caught before the results are more serious.

    Victims of mistakes were shocked such measures weren’t already taken.

    “There’s no place keeping records? They should absolutely be doing that,” said senior citizen Mary Graham of Detroit. A botched colonoscopy left her sick and hospitalized for a month. The doctor apologized for the mistake and the case was settled for an undisclosed amount of money.

    “I’m very apprehensive of doctors now,” she said.

Secrecy questioned

    Due to the threat of litigation, getting health professionals to report errors will be complicated — even if it’s mandatory.

    That’s why calls are mounting for cloaking in secret some reports of mistakes. Most states, including Michigan, protect information from public disclosure if it is used in a “professional review.” But institutions can lose confidentiality when they share the information with outside groups.

Alan Lessig / The Detroit News Mary L. Graham works out several times a week at the William Clay Ford Athletic Center in Ford Hospital. Patients should demand excellence in health care, experts say.

    Dennis O’Leary, president of the Joint Commission on Accreditation of Health Care Organizations, knowns firsthand that error reporting won’t work without protections.

    “We are the prototype of the failed voluntary reporting system,” he said of the commission.

    For five years, it has asked the 19,500 health care institutions it accredits — including 717 in Michigan — to report errors that result in patient injury or death. But just 709 incidents nationwide were reported to the commission since 1995.

    “We are just getting a pathetically small number, probably about 0.3 percent of what’s out there,” O’Leary said. “It’s a failure.”

    The reason: “Hospitals tell us that they are reluctant because if they share the information with us, then they waive their confidentiality protections.”

    Southfield Attorney Michael Cunningham, who specializes in medical malpractice cases, agreed that some confidentiality might be necessary. But he fears hospitals will abuse it.

    “Where do you draw the line?” he said. “I think they should have to report it, and I think the public has a right to know.”

Liability concerns

    Fear of litigation, coupled with the fear of questioning established procedure, is so great that errors are not even being reported within hospitals, O’Leary said. That leaves executives clueless about how to fix hazards.

    William Richardson, chief executive officer of the Kellogg Foundation in Battle Creek and chairman of the Institute of Medicine committee that wrote the report, said workers don’t report even harmless mistakes because it could be used as evidence in a lawsuit to establish a pattern.

    Intravenous nurse Barry Adams’s experience is a glaring example of what can go wrong when a worker reports patient safety problems.

    In 1996, Adams began noticing safety problems at the Boston-area health care center where he worked. One day, for example, he caught a young nurse who was about to inject a lethal dosage of a medicine into a man’s intravenous line.

    So he did what his job description required him to do: He reported it.

    His supervisor tried to get him to keep quiet, but he refused. In October 1996, he was fired. That month, a patient died of an accidental morphine overdose.

    As a result of Adams’ experience, Massachusetts enacted a whistleblower law protecting nurses who report patient safety problems, and his firing was reversed by the National Labor Relations Board. But the case remains mired in appeals, and the decision to report has dragged Adams down a long, emotional road.

    “It’s been horrible,” he said. “We have to be free to speak without fear.”

Patient need

    Requiring health care providers to report serious mistakes could be a patient boon.

    A recent survey by the MEDSTAT Group, a medical research firm, found 81 percent of southeast Michigan residents want objective information about how their doctors and hospitals perform.

    But that’s not the information they usually get. Usually patients rely on customer satisfaction surveys, doctors’ resumes, or guides of the number of procedures the doctor performs.

    For example, a Cardiac Services Information Guide, produced by the Greater Detroit Area Health Council, tells the number of heart-related procedures performed by local doctors. It doesn’t reveal their successfulness.

    Michigan’s Consumer and Industry Services department will provide a list of doctors they have disciplined upon request or on their Web site. Yet a database managed by the federal government, which tracks medical malpractice awards against doctors and criminal convictions, is not even available to the general public.

    Robert Krughoff, president of the Center for the Study of Services, which compiles a guide to doctors, said only New York state publishes bypass surgery statistics that include death rates.

    Krughoff said “surveys are the only way at this point” to compile physician ratings.

    But mandatory reporting of serious medical mistakes, coupled with information about the caseload could begin to give patients the objective information they desire.

    “There’s an enormous appetite for it,” Krughoff said. “It’s the most important and fixable problem in health care. I think patients absolutely need it.”