ARTICLE: Human toll from medical mistakes - State tallies incidents disclosed by hospitals

Friday, January 18, 2008
Star-Ledger

Forty-two patients lost their lives.  Ten lost some body function or part.  Many others required surgery or left the hospital with a mental or physical impairment.

The causes -- and human cost -- of medical errors at New Jersey hospitals in 2006 are outlined in the second Patient Safety Initiative, a state report released yesterday.

The report looks only at the very worst medical errors, in which clear-cut mistakes caused serious injury or death to hospital patients.

The report provides a statistical look at the mistakes, but does not name the institutions where the mistakes took place. Hospitals are required by law to examine their own errors.

"What this means is that patient care is getting safer because hospitals are working with us to identify adverse events," said Heather Howard, the state's health commissioner. "The hospitals have to analyze and correct the underlying causes of the mistake."

The 2006 Patient Safety Initiative is only the second report created from a 2004 law that requires hospitals to report serious mistakes to the state Department of Health and Senior Services. The aim is to share the lessons learned from the mistakes to prevent future errors.

In 2005, hospitals reported 376 mistakes, but did not disclose the number of deaths. The total number of mistakes in 2006 was 450, with 42 deaths. State officials credit better reporting for the rise in reported mistakes.

About one in three injuries in 2006 were from falls, mostly involving elderly patients who fell in their rooms. Eight died from their injuries. The next most frequent problem -- 29 percent -- was serious pressure ulcers, or bedsores, with one patient dying. Good hospital care can prevent most serious pressure ulcers.

Other mistakes took place in the operating room, where foreign objects were left in patients, or the surgeon operated on the wrong body part, or the wrong patient. Nine patients went into comas, and seven of them died, during or right after surgery.

The report also looked at patients who got the wrong medication, or the wrong dose of medication, as well as patients harmed by burns or some kind of mismanaged hospital care.

"Some of these things are very avoidable, no doubt about it," said Donald E. Casey, vice president of quality and chief medical officer for Atlantic Health, which operates Morristown Memorial Hospital and Overlook Hospital in Summit. He also sits on a committee that advises the state on health quality.

"Others show more difficult problems. Take falls. They occur at every hospital in the U.S., and risk of falls is rising because the population is aging."

He supports reporting of errors.

"But it's still unclear whether just reporting errors means we are figuring out how to improve things," he added.

Some are calling for more openness and want the names of institutions -- not the names of patients or hospital workers -- to be public.

"We want to tear down the wall of silence and give meaningful information about the very worst of the worst mistakes," said Patricia Kelmar, associate state director for AARP New Jersey.

She said more open reports would spark discussions between hospitals and the communities around them. "Hospitals could talk about what they are doing to prevent these mistakes," she said, citing a Minnesota law that gives the public the names of institutions where serious mistakes took place.

Howard disagreed, saying the confidentiality promotes reporting. "I want to make sure we don't have the chilling effect that public disclosure could create," she said.

As part of the act, the state sends out alerts, such as one that examined the problem of foreign objects left inside surgical patients. Another looked at medication mistakes. One alerted hospitals about metal in sandbags used in magnetic resonance imaging machines (MRIs), a potential hazard.

David Knowlton, president of the New Jersey Health Care Quality Institute, a nonprofit advocacy group, said the safety report fails to examine patterns, such as if one hospital has far more patients fall than a similar hospital.

"There is no analysis, even without naming the facility," he said.

State health officials said the department does flag patterns that indicate problems at a hospital, and has launched several investigations in response.

Ten hospitals reported no medical mistakes at all, and many critics find it highly unlikely that no mistakes took place in those facilities, which are not named in the state report.

"That's impossible," Knowlton said. "The health care delivery system today is so sophisticated that it's dangerous."

New Jersey hospitals in 2006 treated 1.5 million patients.

Howard said the new regulations being created will give the department enforcement power to fine hospitals that do not comply with the law.

"We will look more aggressively at hospitals that don't report, when these new rules are in effect," she said.

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