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Full Table of Contents
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Abbreviated
Table of Contents
Home Page
Patient Safety
Silence vs
Safety
Silenced
White wall
of Silence
Silencing
Conflict Of
Interest
Psychology of
Providers
Subjectivity
Blacklisting
Nurse survey
Loyalty
Mobbing and
bullying
Trust Us
Defensive
documenting
Report Rate
Risk
managemnt
SOAP
Management
Hospitals
Crime in
medicine
Sexual Abuse
Liability
Limitations
Free Speech
for Patients
Exploitation
OSMB Medical
Boards
Mammography
solutions
Medical errors
Medical Complaints
One number
Links
Injured patients who want to help and be heard,
click here.
Thomas Jefferson said that given the choice between
government without newspapers and newspapers without government, he would choose
newspapers.
In medicine we have government without newspapers. Patients
cannot find out what they need to know to make informed choices. No one in
medicine records or reports the information patients need to know the most. So
patients will have to do it.
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Rate of Reporting Adverse Events
in Medicine
"Read power begins where secrecy begins."
- Hannah Arendt
The "disinclination to believe the monstrous is constantly
strengthened by [he/she] . . who makes sure that no reliable statistics, no
controllable facts and figures are ever published, so that there are only
subjective, uncontrollable, and unreliable reports . . . "
- Hannah Arendt
The determination of healthcare professionals to cover up
their sins and errors at all costs is born out by the scholarly journal articles and studies
below, from
everyone from AHRQ to HHS to the Annals of Internal Medicine, showing how little
accurate reporting there is in medicine. The rate at which adverse events are
reported accurately can be referred to as 2% or 3%. Injured patients have known
this for decades. Healthcare professionals almost universally are in denial
about it. In our experience, when this information is pointed out to them, they
prove to be impervious to evidence. Their self-interested subjectivity overwhelms their beliefs to a degree
that is unappreciated and, in the end, lethal for patients.
1.5% report rate of adverse events
This fact is cited in:
Making Health Care Safer
A Critical Analysis of Patient Safety Practices
Prepared for: Agency for Healthcare Research and Quality, Contract No.
290-97-0013
Prepared by: University of California at San Francisco (UCSF)-Stanford
University Evidence-based Practice Center
The full report is available on line at:
http://www.ahrq.gov/clinic/ptsafety/chap4.htm
Chapter 4. Incident Reporting
Heidi Wald, M.D., University of Pennsylvania School of Medicine
Kaveh G. Shojania, M.D., University of California, San Francisco School of
Medicine
"Most hospitals' incident reporting systems fail to capture the majority of
errors and near misses. Studies of medical services suggest that only 1.5% of
all adverse events result in an incident report and only 6% of adverse drug
events are identified through traditional incident reporting or a telephone
hotline. The American College of Surgeons estimates that incident reports
generally capture only 5-30% of adverse events. A study of a general surgery
service showed that only 20% of complications on a surgical service ever
resulted in discussion at Morbidity and Mortality rounds."
2% report rate in this study
HHS Report for March 2010
found that
reviewed hospitals reported accurate
information on adverse events only 2% of the time.
The summary is at this link: Reporting
Never Events
A pdf of the
full report is at this link:
http://tiny.cc/hhsNeverEvent
0% of adverse were events reported in this study
Among 228 patients admitted to the medical unit of a Boston teaching hospital,
the patient-reported adverse event rate was nearly 9 per 100 admissions. Serious
injuries were uncommon, but two thirds were judged preventable. In addition, 4%
of patients experienced near misses. Few patient-reported incidents were
identified in the medical record, and
none were submitted by clinicians to
the hospital's incident-reporting system.
The conclusion of the article was that inpatients can identify adverse
events affecting their care. Many patient-identified events are not captured by
the hospital incident reporting system or recorded in the medical record.
Engaging hospitalized patients as partners in identifying medical errors and
injuries is a potentially promising approach for enhancing patient safety.
All 19 nurse respondents endorsed the statement that medical inpatients can
identify problems such as errors and injuries, and that they should continue to
be asked about problems, injuries, and errors experienced in the hospital.
A significant limitation of most studies is the ascertainment of adverse events
based on chart review alone. Many adverse events are not recorded in the medical
record, a finding attributed to variable standards for documentation, clinician
unawareness or oversight, and concern about liability exposure.
A study in ambulatory care showed that chart review detected fewer than 11% of
adverse drug events. . . patient contact represents an important detection
approach.
From an article called "What Can Hospitalized Patients Tell Us About Adverse
Events? Learning from Patient-Reported Incidents"
by Saul N. Weingart, MD, PhD, Odelya Pagovich, BA , Daniel Z. Sands, MD,
MPH, Joseph M. Li, MD, Mark D. Aronson, MD, Roger B. Davis, ScD, David W. Bates,
MD, MSc and Russell S. Phillips, MD
in the Journal of General Internal Medicine, Volume 20, Issue 9, 2005,
pages 830-836
The abstract can be viewed at:
http://www3.interscience.wiley.com/cgi-bin/fulltext/118700875/HTMLSTART
Eight Years After IOM Report: Patient Reports are more Reliable than
Hospitals
Daniel R Longo, ScD, Virginia Commonwealth University School of Medicine
says that any study that does not take patient reporting into account is
severely underestimating the extent of problems in the nation’s hospitals.
http://www.annals.org/cgi/eletters/149/2/100#97449
Janet Corrigan says that based on the research and knowledge that has
accumulated since 1999 regarding root causes and systemic breakdowns, the IOM's
initial estimate is “probably quite low.” She is president and CEO of the
National Quality Forum and helped to author the Institute of Medicine report.
The Silence
by Michael L. Millenson
in Health Affairs, 22, no. 2 (2003): 103-112
http://content.healthaffairs.org/cgi/content/abstract/22/2/103
He says that there
remains within healthcare a refusal to confront providers’ responsibility for
the problems. He suggests initiating emergency
corrective-action comparable to Flexner’s crusade against charlatan medical
schools.
See also:
Patients Identify Undocumented Adverse Events
Telephone interviews with 201 patients after ED discharge identified 10 adverse
events that had not been reported in their medical records. That is 5% of
patients suffering adverse events of which no record was made at all.
— Kristi L. Koenig, MD, FACEP in Journal Watch Emergency Medicine September 26,
2008
http://emergency-medicine.jwatch.org/cgi/content/citation/2008/926/4
The reliability of medical record review for estimating adverse event
rates
According to this article, when negligence is involved, an adverse event is
much less likely to be reported.
Journal Title:
Annals of internal medicine ISSN 0003-4819, 2002, vol. 136, no11, pp. 812-816
(16 ref.)
Published by American College of Physicians, Philadelphia, PA,
http://cat.inist.fr/?aModele=afficheN&cpsidt=13705597
Authors: THOMAS Eric J. ; STUDDERT David M. ; BRENNAN Troyen A. ;
Authors Affiliations:
Brigham and Women's Hospital and Harvard School of Public Health, Harvard
University, Boston, Massachusetts, Medical University of South Carolina,
Charleston, South Carolina, University of TexasHouston Medical School, Houston,
Texas,
Abstract
Background: The data used by the U.S. Institute of Medicine to estimate deaths
from medical errors come from a study that relied on nurse and physician reviews
of medical records to detect the errors. Objective: To measure the reliability
of medical record review for detecting adverse events and negligent adverse
events. Design: Medical record review. Setting: Hospitalizations in Utah and
Colorado in 1992. Measurements: After three independent reviews of 500 medical
records, the following were measured: reliability and the effect of varying
criteria for reviewer confidence in and reviewer agreement about the presence of
adverse events. Results: For agreements in judgments of adverse events among the
three sets of reviews, the K statistics ranged from 0.40 to 0.41 (95% CIs ranged
from 0.30 to 0.51) for adverse events and from 0.19 to 0.23 (CIs, 0.05 to 0.37)
for negligent adverse events. Rates for adverse events and for negligent adverse
events varied substantially depending on the degree of agreement and the level
of confidence that was required among reviewers. Conclusion: Estimates of
adverse event rates from medical record review, including those reported by the
Institute of Medicine in its 2000 report on medical errors, are highly sensitive
to the degree of consensus and confidence among reviewers.
See also:
"Disclosing unanticipated outcome to patients: The art and
practice"
by Thomas Gallagher, Lucian Leape and others
Journal of Patient Safety, September 2007
". . . available evidence suggests that open communication of unanticipated
outcomes occurs infrequently."
The federal Agency for Healthcare Research and Quality reported that
the rate of adverse events—a key measure of patient safety defined as unintended
harm during medical care—has risen by about 1% in each of the past six years, in
part because of a rise in hospital infections. Other studies show that one in
seven hospitalized Medicare patients experience one or more adverse events. One
in 15 hospitalized children are harmed by medication errors. And those are just
the ones that get recorded.
For a personal story about this see:
The aftermath of a 'never event'
A child's unexplained death and a system seemingly designed to thwart justice
By: Dale Ann Micalizzi
Modern Healthcare March 3, 2008
"The immediate silence from the physicians, nurses and the hospital's chief
executive officer was deafening. I felt connected with the staff, having worked
for an HMO in the area for a number of years. Now, all I was seeing was a
classic pattern of denial and defense."
In the same breath that healthcare professionals insist that they and their
colleagues report everything, they say that "of course you have to protect
yourself from lawsuits" - which is done by not reporting anything.
In Justin's Hope Dale Ann Micalizzi said:
http://www.taskforce.org/justinhope.asp
"I never wanted lawyers involved. I never wanted to question a physician's
judgment or a hospital's care. There was no other option available to us. . . "
". . . it isn't worth a lawyer's time to accept such a case unless the
evidence is overwhelming and an easy settlement attainable."
Only 3% of injured patients can get a lawyer (see
Studdert). And even those 3% sign
gag agreements. So the patient community does not learn where most injuries are
incurred. Neither does the medical community. They do not share their failures
with each other except in rare circumstances. An inept clinician easily can
define his/her experiences in a way that prevents even his/her own recognition
of having a poor success rate. No one is keeping track.
--------------------
According to Diane Suchetka in The Cleveland Plain Dealer, May 11, 2010, some
medical safety experts say public announcement of errors is the best way to
prevent them.
Judith Hibbard, a professor of health policy at the University of Oregon, says,
"We've done some research on this. And making it public makes a big difference."
Her research found that hospitals improved safety more when their mistakes were
made public than when they were just reported back to the hospital or not
reported at all. "The hospitals were primarily motivated to improve because of
their public image and reputation," she said. "Just knowing that they're not
doing great isn't enough. Unless there's something at stake, they're not
motivated to change."
Lisa McGiffert, director of the Safe Patient Project of Consumers Union, is
another advocate of public reporting of errors. She said, "Reporting is a form
of accountability. And hospitals should be accountable to the public they serve.
. . And that should include reliable information about how safe their hospital
is, how safe their care is."
--------------------
A possible solution
From Slate, "The Wrong Stuff," By
Kathryn Schulz,
Monday, June 28, 2010
http://www.slate.com/blogs/blogs/thewrongstuff/archive/2010/06/28/risky-business-james-bagian-nasa-astronaut-turned-patient-safety-expert-on-being-wrong.aspx
According to James Bagian, director of the Veteran
Administration's National Center for Patient Safety, people
report only when they feel it's in their interest to do so.
Since you
can't fix problems you don't know about, it is important to get
reports that reveal was has gone wrong. So how do you get them
to report?
In 1998 they did a survey and found that the
chief reason people don't report is embarrassment and
humiliation. In response, the VA devised a definition of
"blameworthy acts," which must include either assault, rape, or
larceny, or being drunk or on illicit drugs, or purposely doing
something unsafe. In the ten months after implementing that
definition he says reporting went up 3000 percent.
One must be encouraged by anything that
appears to increase reporting, but one also must wonder how much
was actually accomplished. Their definition suggests that the
only things about which people should or would be embarrassed
are, for the most part, crimes, as though there is no reason to
be embarrassed about indifference or incompetence or ignorance
or anger or jealousy or declining coordination or prejudice or
any number of other things. And 3000% of exactly what? If the
rate of reporting at the beginning was low enough, they might
still be reporting only a single digit percentage of what needs
to be reported. (See above the report that found
that none of the adverse events reported by patients had been
submitted by clinicians to the hospital's incident-reporting
system in "What Can Hospitalized Patients Tell Us About Adverse
Events? Learning from Patient-Reported Incidents" in the Journal of General Internal Medicine, Volume 20, Issue 9, 2005,
pages 830-836)
On top of that, what has been left off the
table in this effort might be the first and most important
things that should be addressed: assault and rape and all the
other criminal acts that some think should be the absolute least
a patients should be able to expect to be protected from.
Mr. Bagian continued saying that the only reason to have reporting is to identify vulnerabilities, not to count
the number of incidents. Reports are never good for determining incidence or
prevalence, because they're essentially voluntary. Even if you say "You must
report," people will report only when they feel it's in their interest to
do so.
So he is saying that the reports on which he bases his 3000% number are not
reliable for determining numbers like his 3000% number. Any increase in
reporting is encouraging, but it would be nice to get a second opinion on just
what happened, and how much of it happened, as a result of whatever management
practices were implemented at the VA.
In addition to being director
of the Veteran Administration's National Center for Patient
Safety, James Bagian is, among other things, an engineer, an
anesthesiologist, a NASA astronaut, and a mountain rescue
instructor.
--------------------
A knee-jerk response from many, if not most, patient safety advocates is to call
for getting things back to the way they used to be, back when patients could
trust their caregivers to report and put the interests of patients ahead of
their own. The assumption that there ever was such a time is counter productive.
A little knowledge of history shows that getting things back to the way they
were only gets us back to a time when things were no better and probably worse,
especially with regard to reporting. For a historical example from more than 200
years ago see
Dr. Benjamin Rush.
This is not new. What is new is that for the first time in history there is a
practical way to gather from patients the information that people in medicine
never have, and probably never will, report. For instance, does someone really
think a pedophile or other sex abuser is going to file a report him or herself?
If you think their colleagues will report them, you haven't been a victim.
"The reason why the totalitarian regimes can get so far toward realizing a
fictitious, topsy-turvy world is that the outside nontotalitarian world . . .
indulges also in wishful thinking and shirks reality. . ."
- Hannah Arendt |