Most Adverse Events at Hospitals Still Go Unreported

The Hospitalist Perspective

Greg Maynard, MD, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science (CIIS) and senior vice president of SHM’s Center for Healthcare Improvement and Innovation, says hospitalists face multiple barriers to regular reporting. Some errors, he says, are so pervasive that they are “considered routine” and “happen all the time.”

“Hypoglycemic events, for example, don’t always get entered into adverse-event reporting systems because they’re so common,” he explains, “even though you should be entering and examining them all.”

Improper coding is another hospitalist-centric issue. Since Oct. 1, 2008, the Centers for Medicare & Medicaid Services (CMS) has reduced payment for acute-care inpatient cases when designated hospital-acquired conditions are not present on admission and the condition would have increased the reimbursement.

“CMS went to a lot of trouble to implement codes that could help them identify, in the coding process, patients who had an iatrogenic event,” Dr. Maynard says. “But those codes simply aren’t being used properly, and administrative coding is always a problem with regard to accuracy.”

Hospitalists can be particularly vulnerable to errors due to the nature of their work—multiple tasks, multiple team members, multiple interruptions. “[Hospitalists] are prone to the type of errors that are related to the hectic nature of being a doctor and an air traffic controller at the same time,” Dr. Maynard says. “You’re in the middle of admitting someone and get two urgent calls on two other patients, so you have to switch out of what you’re doing on that patient, issue orders on the other two, and immediately switch back. It’s hard to keep your focus when dealing with many complex patients, many of whom you’re seeing for the first time, and try to remember all the things you should not omit.”

One area that has, in recent years, become more important to hospitalists in terms of error prevention—and reporting—is discharge planning.

“When you’re sending your patient out of the hospital, they may have started on new medications or changed medications while an inpatient,” says Dan Budnitz, MD, MPH, director of the Medication Safety Program at the Centers for Disease Control and Prevention. “A recent report in the New England Journal of Medicine looked at drug-only causes of emergency hospitalizations, and the most common drugs involved are blood thinners, insulin, and some diabetes pills. The implication for the hospitalist is clear: If you start a patient on these medications in the hospital, or change them, you need to pay particular attention, because they’re two of the top drugs that may put your patient back in the hospital.”

National Models

One institution that is far ahead of the curve in error reporting is the University of Michigan Health System. In 2001, just two years after To Err is Human was published, the health system adopted a process of full disclosure of medical errors. The process involves multiple components, including an online incident reporting system, a multidisciplinary claims review committee, open and honest communication with patients and families, and quality-improvement (QI) initiatives guided by reported errors.

“They’ll get 7,000 or 8,000 reports a year from staff,” Gibson says. “That’s what you want. Most of them are minor or near-misses, and you want to know about those so you can learn from them and prevent the larger errors. But you have to create a space where it’s safe for people to report.”