High rate of un­re­ported ad­verse events not sur­pris­ing: safety ex­perts

Modern Healthcare - - NEWS - Mau­reen McK­in­ney

High rate of un­re­ported ad­verse events called un­sur­pris­ing by ex­perts

Pa­tient-safety ex­perts say they’re not sur­prised or even par­tic­u­larly alarmed by a seem­ingly trou­bling find­ing that hos­pi­tals’ vol­un­tary reporting sys­tems cap­ture few ad­verse events. “It’s well-known in the safety world that vol­un­tary reporting sys­tems are nei­ther ac­cu­rate nor can be be­cause peo­ple tend not to see the er­rors around them as they be­come nor­mal­ized,” Dr. Don­ald Berwick, former CMS ad­min­is­tra­tor, said in an in­ter­view.

Hos­pi­tal in­ci­dent-reporting sys­tems cap­tured only 14% of ad­verse events, such as med­i­ca­tion er­rors and falls, leav­ing 86% of events un­re­ported by staff, HHS’ in­spec­tor gen­eral’s of­fice con- cluded in a re­port re­leased Jan. 6. Such reporting sys­tems are a con­di­tion of par­tic­i­pa­tion for the govern­ment’s Medi­care pro­gram, but hos­pi­tals’ reporting re­quire­ments and def­i­ni­tions of pa­tient harm are of­ten un­clear to em­ploy­ees, HHS’ in­spec­tor gen­eral’s of­fice said in the re­port.

“For ex­am­ple, staff re­ported only one of 17 sam­ple events re­lated to catheter us­age (e.g., in­fec­tion and uri­nary re­ten­tion), a com­mon cause of harm to Medi­care ben­e­fi­cia­ries,” the re­port said.

Other types of events that went un­re­ported in­cluded as­pi­ra­tion, pres­sure ul­cers and al­ler­gic re­ac­tions.

In­ci­dent-reporting sys­tems do serve an im­por­tant pur­pose in hos­pi­tals, Berwick said, but he ar­gued that they should be viewed as a cul­tural as­set that pro­motes team­work and trans­parency in­stead of a sta­tis­ti­cal tool.

“Un­der­stand that even in the most de­vel­oped safety cul­ture, vol­un­tary reporting is go­ing to be a weak tool for mea­sure­ment,” Berwick added. “It’s never go­ing to be a main­stay.”

Other meth­ods show much more prom­ise for re­li­ably mea­sur­ing ad­verse events, Berwick said, in­clud­ing the In­sti­tute for Health­care Im­prove­ment’s Global Trig­ger Tool, which uses chart re­view to iden­tify in­ci­dents of pa­tient harm. And fur­ther adop­tion of elec­tronic health records will bring other mea­sure­ment tools that are even eas­ier to use, he said.

“In or­der to make health­care safe, there has to be a whole suite of ac­tiv­i­ties to en­cour­age iden­ti­fi­ca­tion of pa­tient in­juries,” Berwick said.

While the in­spec­tor gen­eral’s re­port does il­lus­trate in­ci­dent-reporting sys­tems’ low cap­ture rate, it’s also use­ful be­cause it lists the types of events that staff most of­ten failed to rec­og­nize as pa­tient harm, Berwick said. He pointed to sev­eral cat­e­gories of ad­verse events that ranked among the least re­ported by staff, in­clud­ing IV fluid over­load, ex­ces­sive bleed­ing and delir­ium.

Only seven out of 29, or 24%, of delir­ium events were cap­tured dur­ing the study pe­riod. And staff only re­ported two of 15 inci-

dents in­volv­ing ex­ces­sive bleed­ing. Those are good places for hos­pi­tals to fo­cus qual­ity im­prove­ment ef­forts, Berwick said.

Mar­garet Vanam­ringe, vice pres­i­dent for pub­lic pol­icy and govern­ment re­la­tions for the Oak­brook Ter­race, Ill.-based Joint Com­mis­sion, praised the in­spec­tor gen­eral’s re­cent se­ries of re­ports fo­cused on ad­verse events, in­clud­ing one re­leased in Oc­to­ber 2011 that ex­am­ined the way the CMS re­sponds to al­leged se­ri­ous pa­tient-harm events.

But Vanam­ringe did ex­press con­cern about the data in this lat­est re­port. The in­spec­tor gen­eral’s of­fice used sur­vey data from a sam­ple of 189 hos­pi­tals about events cap­tured in Oc­to­ber 2008.

“A lot has hap­pened since then,” she said, cit­ing less pu­ni­tive en­vi­ron­ments in many or­ga­ni­za­tions and a greater push to­ward reporting by the govern­ment and groups such as the Joint Com­mis­sion. “Staff in hos­pi­tals are now see­ing the value of reporting these events.”

Hos­pi­tals can use the data in the in­spec­tor gen­eral’s re­port to iden­tify ways to im­prove their own in­ci­dent reporting sys­tems, said Nancy Foster, vice pres­i­dent of qual­ity and pa­tient-safety pol­icy for the Amer­i­can Hos­pi­tal As­so­ci­a­tion. Foster ac­knowl­edged that many types of events, such as near misses, are dif­fi­cult for staff to rec­og­nize and con­sis­tently cap­ture in the sys­tem.

“Some­times peo­ple don’t re­port things be­cause they see them as nat­u­ral oc­cur­rences in the hos­pi­tal,” Foster said. That re­quires ed­u­ca­tion and guid­ance from man­age­ment, she added. “Help­ing em­ploy­ees of all kinds to see how the in­for­ma­tion will be used is the most ef­fec­tive strat­egy to en­cour­age them to re­port more.”

But boost­ing em­ploy­ees’ reporting rates may be the wrong di­rec­tion to go in, said Dr. Robert Wachter, pa­tient-safety ad­vo­cate and pro­fes­sor and chief of the divi­sion of hos­pi­tal medicine at the Univer­sity of Cal­i­for­nia at San Fran­cisco.

“What wor­ries me is not the 14%,” he said, re­fer­ring to the cap­ture rate cited in the re­port. “My worry is that num­ber will prompt more in­ci­dent reporting and I’m not sure that’s a good idea.”

In a 2009 blog post ti­tled “Hos­pi­tal in­ci­dent reporting sys­tems: Time to slay the beast,” Wachter ar­gued that such sys­tems are a drain on clin­i­cians’ time and good­will. Not much has changed since then, he said.

“There are so many types of harm and er­rors that re­ly­ing on vol­un­tary reporting by front­line care­givers is sim­ply not the right way,” Wachter said. In­ci­dent-reporting sys­tems are nec­es­sary, he con­tin­ued, but they can be bur­den­some and should be lim­ited to a very nar­row list of se­ri­ous events. For gaug­ing other types of pa­tient harm, Wachter says trig­ger tools are ef­fec­tive, as are EHRS, in­creas­ingly.

“I have no ob­jec­tions to re­quir­ing hos­pi­tals to have in­ci­dent-reporting sys­tems in place,” Wachter said. “Let’s not throw the baby out with the bath­wa­ter, but we have to be much more thought­ful about them and that means pay­ing more at­ten­tion to the time and en­ergy of care­givers. Ask­ing a nurse to take 15 min­utes to re­port ev­ery event does more harm than good and can re­ally con­tam­i­nate the way she thinks about the pa­tient-safety agenda. ”

Some pa­tient-safety ex­perts say it’s too bur­den­some to ask front­line care­givers to re­port a wide ar­ray of ad­verse events.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.