Local hospitals report high adverse event counts

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Photo by Sergio Zenisek.


New Haven’s hospitals fared poorly on the Connecticut Department of Public Health’s (DPH) latest Adverse Event Report, which lists the number of “adverse events” reported by the state’s hospitals.

The report, released in October 2011, identified St. Raphael’s Hospital as having the second-highest count of malpractice errors that qualify as adverse events, while Yale-New Haven Hospital reported the highest number of cases in which foreign objects were left in a patient during surgery, based on data between 2004 and 2010. This is the first time Connecticut’s Adverse Event Report has listed the names of the hospitals in the annual report, according to the Department of Public Health.

“[Including names in the report] doesn’t make a difference one way or another,” said Yale-New Haven Hospital associate chief of staff Tom Balcezak. “The purpose of the report is to identify areas of improvement so that institutions can work with one another.”

By federal law since 2002, the state’s hospitals have been required to report to the DPH any malpractice errors that qualify as adverse events, such as surgery performed on the wrong part of the body and sexual assault within hospital premises, along with a corrective action plan stating how the hospital dealt with such matters, according to DPH spokesman William Gerrish. The DPH’s Quality and Healthcare Advisory Committee, in turn, is required to evaluate this information and make suggestions to the hospitals in order to reduce the incidence of adverse events, he added.

At 19.2 incidents per 100,000 inpatient days, St. Raphael’s Hospital had the second-highest rate of adverse events in 2010, calculated with data collected on 100,000 inpatient days. The hospital recorded that the most common adverse event were falls, which Jim Judson, St. Raphael’s director of quality improvement and patient relations, said in a Monday email that this statistic is due to the hospital’s high number of elderly patients. He added that St. Raphael’s has since implemented new practices to reduce this rate, such as hourly nurse rotations on floors with many patients at risk of falling and installing bedroom alarms on all patient beds. He added that in fiscal year 2011 total patient falls fell 8 percent, as measured in number of falls per 1,000 patient days.

In addition to topping the list of acute care hospitals with high rates of foreign objects being left in patients between 2004 and 2010, Yale-New Haven hospital reported one of the highest rates of pressure ulcers and injuries from falls. Balcezak said that they do not shy away from reporting every case, citing pressure ulcers as an example, so even small ulcers in the nose made by oxygen tubing are reported along with larger ones in the arms and legs.

One concern, according to Jean Rexford, executive director of the Connecticut Center for Patient Safety, is that hospitals might underreport adverse events in an effort to lower their rankings.

“Mistakes are happening but what is troublesome is the fact that things get reported and everybody continues with business as usual,” Rexford said. “How could we still be having wrong-side surgery or instruments left in people when there are so many protocols and procedures to prevent that from happening?”

Gerrish said in addition to reporting adverse events, the DPH reviews patient records to verify the no events remained hidden, in which case they proceed with legal action.

Connecticut Hospital Association spokeswoman Michelle Sharp said the state’s hospitals are working together to improve patient safety through the Patient Safety Organization’s multi-hospital collaboratives and participation in the nationwide initiative “Partnership for Patients: Better Care, Lower Costs,” a private-public healthcare partnership that aims to improve healthcare for all Americans.

Overall, 1,637 adverse hospital events that resulted in patient harm were reported to the DPH between May 2004 and May 2011, including 157 cases in which patients died. The most common incidents reported since 2004 were falls that resulted in injury or death.

Comments

  • Catherine08

    Checklists will help.

  • ChrisGreen

    Hospital errors as reported in the(NY Times 1/6 )mostly go unreported. http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html?emc=eta1. By pinning the high number of adverse events on the elderly, St. Raphael’s spokesman does a disservice to consumers. I can’t imagine him blaming any other group of patients for failures in their care. Since the hospital spends more money on advertising and lawyers fees than any amount the state fines, there will be no impetus for change. Falls should counted as hospital mistakes because they are preventable. An old person, frail, confused and unattended in the hospital is an extremely vulnerable position, and what staff may know about them at any given moment may be limited to “bed 2 has pneumonia.” Dementia is also a catch all phrase that actually may be a sign that staff may be overlooking a drug reaction or delirium. Like other groups of patients, such as children, of the mentally ill; elderly patients have their own special needs, any one with an elderly relative in the hospital should not take for granted that they will be well cared for.