First Do No Harm

Last year there wasn’t a single fatal airline accident in the developed world.
So why is the U.S. health care system still accidently killing hundreds of thousands?
The answer is a lack of transparency.

By Marshall Allen

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Photo: IStockPhoto.com

 eorgeanne Mumm’s surgeon emerged from the operating room with welcome news for her worried family. He had removed her cancerous kidney, he said, and her outlook looked good.

The surgeon failed to mention, however, that he also had accidentally removed part of her pancreas, having mistaken it for a tumor. Nor did he mention that he had in-advertently cut the blood flow to her spleen, damaging it irrevocably. Only an emergency operation by another doctor the next day kept Georgeanne from dying right then and there.

Now the fifty-six-year-old Mumm sits alone in her trailer in rural Nevada. She is unable to work due to her disability but is still on the hook for about $300,000 in medical expenses related to her disastrous contact with the U.S. health care system.

Why do we keep hearing stories like this? Twelve years ago, the Institute of Medicine issued a landmark report showing that medical errors in U.S. hospitals kill up to 98,000 Americans a year. In 2000, another estimate, published in the Journal of the American Medical Association, which included fatalities resulting from unnecessary surgery, hospital-acquired infections, and other instances of harmful medical practice, put the total annual death toll at 250,000.

By that figure, contact with the U.S. health care system was the third leading cause of death in the United States, just behind all heart disease and all cancer. People responded to the alarm. Task forces were convened, congressional investigations launched, op-eds written. Yet as hard as it may be to believe, American medicine is, if anything, even more dangerous today.

In November 2010, the U.S. Department of Health and Human Services issued a study that covered just the 15 percent of the U.S. population enrolled in Medicare. It found that each month one out of seven Medicare hospital patients is injured—and an estimated 15,000 are killed—by harmful medical practice. Treating the consequences of medical errors cost Medicare a full $324 million in October 2008 alone, or 3.5 percent of all Medicare expenditures for inpatient care. Another recent study looked at the incidence of avoidable medical errors across the entire population and concluded that they affected 1.5 million people and cost the U.S. economy $19.5 billion in 2008. The Centers for Disease Control and Prevention have estimated that almost 100,000 Americans now die from hospital-acquired infections alone, and that most of these are preventable.

People like Carole LaRocca are the human face of this travesty. One day recently I sat at the seventy-four-year-old’s kitchen table as she broke down in tears. She was weeping not because of the hospital-acquired infection that almost took her life, but because of the $3,676 bill she faced for the antibiotics she needed to treat the harm done to her by her hospital stay. Every month she pays $25 of her meager fixed income toward the debt, and is still hounded by bill collectors.

A cynic might say it’s no surprise that American medicine fails to put safety first, since doctors and hospitals often make money by treating those they injure. There is, however, also a deeper and more systematic reason for the continuing toll of injury and death caused by the U.S. health care system: we don’t know who’s failing and who’s succeeding. Plenty of U.S. hospitals have dramatically improved their safety performance. The best have virtually eliminated the deadliest hospital-acquired infections, even as lethal microbes have evolved to become more contagious and resistant to treatment. If every health care provider adhered to the highest standards of patient safety and evidence-based medicine, hundreds of thousands of lives could be saved, to say nothing of the billions of dollars spent on treating complications—but good luck discovering for yourself which hospitals are safe and effective and which aren’t.

That’s because the public, the payers, and the providers themselves typically lack access to the data necessary to make such a life-and-death determination. In the airline industry, if a pilot so much as accidentally makes a wrong turn moving away from the gate, anywhere in the world, the event is instantly recorded in global databases and scrutinized by government agencies and the industry itself. The knowledge gained from this continuous process leads to big and little changes in aviation protocol, equipment, and personnel. As a result, there was not a single airline fatality anywhere in the developed world last year.

In health care, by contrast, patient safety experts often remark that the death toll from medical errors in U.S. hospitals is equivalent to three jumbo jets falling out of the sky and killing all the passengers on board every forty-eight hours. But even the most egregious errors go largely unreported, and when they are reported, they are often buried and ignored. For the most part, all the public gets to hear about are industry-wide estimates and statistical averages of the kind presented above. Because we lack specific knowledge of where these injuries are occurring and under what circumstances, we can’t know precisely what to do about the ongoing catastrophe or whom to reward when specific solutions are found.


 ortunately, there is much that can be done—even by mere journalists willing to submerge themselves in some data. Not long ago, my colleague at the Las Vegas Sun, Alex Richards, and I set out to identify these cases of preventable harm and publish them. In Nevada, regulators require hospitals to submit a record of every inpatient stay, a policy originally intended to monitor costs. Based on billing records, each file provides a patient’s age, gender, and race, as well as the conditions diagnosed and the procedures received during his or her hospital visit. And in 2008, the federal government started asking hospitals nationwide for one additional piece of data. Stung by the money it was paying under Medicare to treat injured patients, hospitals were required to report with a “yes” or a “no” whether each medical condition was present when the patient was admitted. This makes it possible to identify how may patients acquired preventable injuries while at the hospital—problems like severe bedsores, bloodstream infections caused by central-line catheters, and falls that resulted in a broken bone.

Shaking the data out of Nevada’s state government wasn’t easy, and crunching through 2.9 million inpatient billing records was also involved, as well as interviews with more than 250 nurses, doctors, hospital administrators, and injured patients to make sense of it all—but we eventually prevailed and launched a five-part series based on what we discovered. (The entire series is available at www.lasvegassun.com/hospital-care.) Not surprisingly, given the picture that health care quality experts paint of the U.S. health care system as a whole, we found that the safety performance of Las Vegas hospitals was alarming. In 2008 and 2009, for example, we identified 3,689 Las Vegas patients who suffered preventable harm, including 2,010 who became infected by one of two nearly untreatable and often fatal bugs: methicillin-resistant Staphylococcus aureus—better known as MRSA—and Clostridium difficile. In 354 of the total cases, the patient died in the facility. With the help of other public documents, we established that only about one in ten of these and other preventable errors was ever brought to the attention of authorities, as is required by state law, much less analyzed for lessons learned.

The real power in our reporting, however, came from the transparency and accountability it imposed on the local health care system. We published the total number of injuries and infections and their rates for each hospital in Las Vegas. Under pressure from hospital lobbyists, the Nevada state government had long refused to do this, as is common in other states as well. But we saw good reasons for naming names. So, for example, we posted a tool on the Sun’s website that allows users to compare the rates of MRSA and Clostridium difficile infections in different Las Vegas hospitals. As it turns out, the MRSA infection rates range from 24 per 1,000 discharges at Desert Springs Medical Center, to a “mere” 7.6 at Spring Valley Hospital, eight miles down the road.

To put this more-than-threefold difference into context for our readers, we published a series of accompanying stories pointing out that infection control is hardly rocket science. According to Dr. Peter Pronovost, a professor at Johns Hopkins School of Medicine and a national patient safety leader, prevention of central-line catheter infections involves little more than a simple five-step checklist:

  • Wash hands.

  • Wear sterile gloves, hat, mask,
    and gown and completely cover
    the patient with sterile drapes.

  • If possible, do not place the catheter
    in a patient’s groin, where it can
    more easily become infected.

  • Clean the catheter insertion site
    on the patient’s skin with
    chlorhexidine antiseptic solution.

  • Remove catheters when they are
    no longer needed.

After Pronovost partnered with Michigan hospitals to study the effectiveness of the checklist, the reduction in infection rates saved an estimate $100 million and 1,500 lives over just an eighteen-month period. In 2002, Dr. Rajiv Jain of the Pittsburgh Department of Veterans Affairs Medical Center introduced a commonsense method used throughout Europe to drive down the number of hospital-acquired MRSA infections: swab the noses of patients before they are admitted, and if they test positive for MRSA, isolate them from other patients. This simple protocol has reduced hospital-acquired MRSA infections by 59 percent at both the Pittsburgh VA and other hospitals that have followed its example. At some VA hospitals, MRSA infection rates have been lowered to almost zero.

It’s still too early to tell how the market share or quality of care at different Las Vegas hospitals may be affected by exposure to our bit of sunshine, but we’ve already seen the leaders of at least two institutions publicly reporting the errors and infections that take place in their hospitals and vowing to make improvements. Meanwhile, insurance companies can see the same broad disparities in patient safety, and some now use our data to pressure hospitals to improve quality. State regulators responded to the revelations by using our methods to verify our findings in the same billing records, and then launching investigations of the individual cases of patient harm. Transparency is a potent antidote for complacency.


 ecause of the lack of national standards for measuring and reporting harm to patients, we were unable to show definitively, with a few exceptions, that care in Las Vegas is any more dangerous than anywhere else. It’s telling that some leaders of the local medical establishment jumped on this point. “You’re looking at the problems in Las Vegas and saying there are problems here, no one is denying that,” said Dr. Ron Kline, president of the Nevada State Medical Association. “But the argument would be that those similar problems exist in other places. To some degree you can’t eliminate them.”

Unfortunately, this attitude is typical among health care leaders. When I showed our data about accidental surgical injuries to Dr. Jim Christensen, an allergist who also oversees quality improvement at Spring Valley Hospital in Las Vegas, he was nonplussed. “I see these all the time,” he told me. Asked if he had become inured to the problem, he said that surgery is “like working on the car with the engine going. Sometimes something slips, but they recognize the injury right away and repair it. As long as that doesn’t go beyond the published error rate, I’m fine.”

What these and many other like-minded health care professionals are saying can be put another way: Never mind that errors committed by individual hospitals might be leading to hundreds or thousands of annual deaths and injuries, or that safety measures put in place by other hospitals show that most of these casualties are avoidable; as long as the rate of medical error or infection at any given hospital is in line with the national average, that is good enough.

Kerry O’Connell, a fifty-four-year-old construction executive from Colorado, scoffs at this mind set. Several years ago he became infected with potentially lethal bacteria during surgery to repair a broken elbow. O’Connell says that it took weeks of procedures to flush out his wound, and months of infusions with potent antibiotics to kill the resistant bug, yet doctors and hospital administrators refused to accept responsibility for the infection. Meanwhile, they charged O’Connell and his insurance company $65,000 for the treatment. Galvanized by the injustice, O’Connell became a patient safety advocate and has adopted a clever prop to get his big point across. When he attends conferences on patient safety, he wears a name tag that says, “The Numerator.”

When people inevitably ask him what that means, he launches into the explanation. It’s easy to forget, he says, that even in hospitals where medical error rates are no worse than average, the numerator in that ratio—the number of actual people victimized—remains large and unacceptable. “I call infection rates sedatives for health care workers so they can sleep at night,” O’Connell said. “They keep tracking these rates and comparing to each other and saying ‘We’re not so bad.’ But the only thing that counts in the end is how many people got infected.”

If the airline industry and its regulators had clung to the same attitude, the average rate of airline fatalities would likely be little better than it was in the 1950s, when flying was at least three times as dangerous, on average, as it is today. It’s only human nature to call average good enough, particularly when what you are doing is difficult. Moreover, when people are engaged in inherently dangerous activities that they believe bring great benefit to society—whether it is serving their country in combat, or moving passengers at 600 miles an hour in and out of the wild blue yonder—it’s understandable that they tend to overlook or dismiss any avoidable harm caused by their actions. Dr. Thomas Lee, an associate editor at the New England Journal of Medicine and a professor at the Harvard School for Public Health, notes how this same process of moral disengagement affects doctors and hospital administrators. They are reticent to acknowledge patient harm, he says, because they’re too busy highlighting the diseases cured and lives saved.

To overcome this natural tendency toward moral disengagement—or what safety experts in other fields call “normalized deviance”—we need in health care what the airline and many other industries already have: a process for systematically recording specific errors and near misses and for making them widely known so that everyone can learn from them. Dr. Peter Pronovost, the safety expert from Johns Hopkins, recommends creating a similarly robust, nationwide system for spotting, measuring, and reporting instances or harbingers of harmful care, with spot audits of medical records to assure compliance. This was also a recommendation of the ground-breaking 1999 “To Err Is Human” report. Following the example of the aviation industry (and of the VA health system, incidentally), this system should also include a process that allows people who witness or commit errors and near misses to report them anonymously.

Public reporting will be bolstered, to a limited degree, under the fine print of Obama’s Affordable Care Act. The new law says that certain injuries and infections that take place in hospitals will be published on Medicare’s Hospital Compare website. Hospitals will also be rewarded or penalized according to how certain readmission rates and hospital-acquired injuries compare to national averages. (As this story was going to press, the Centers for Medicare and Medicaid Services were formulating regulations that go further than any previous efforts, using both carrots and sticks to get hospitals to make care safer.) But here again, the mind set is not zero tolerance of error, but merely a focus on how different hospitals compare to the mediocre safety performance that pervades the industry. Moreover, the new law applies only to acute care hospitals, leaving out nursing homes and other long-term care facilities. It will only include harm to Medicare patients, a subset of the overall population. And the system will not be able to capture some of the most common types of injuries to patients, such as those caused by medication errors.

The provisions of the Affordable Care Act are a step in the right direction, but they don’t go far enough. Implementing and operating a nationwide system that captures all harm to patients also requires that the U.S. health care system at last move out of the nineteenth century and replace paper records with open-source, truly integrated information technology of the kind the VA has pioneered. Electronic medical records, if they are written in compatible, open-source computer languages, have the potential to form vast databases that researchers, regulators, and practitioners themselves can easily mine to spot dangerous or ineffective practice patterns. Unfortunately, though many health care providers are busy installing health IT using federal stimulus dollars, most are installing propriety software that will leave data locked in “black boxes” and that have limited value in promoting transparency. (For more information on this subject, see Phillip Longman, “Code Red,” July/August 2009.)

Done right, a fully digitalized and integrated medical record system would also by itself prevent many serious errors, such as the thousands that occur every year when pharmacists misread a doctor’s scribbled prescription. Lest you think such matters are no big deal, the Institute of Medicine estimates that the average hospital patient in the U.S. is subject to at least one medication error per day (wrong med, wrong dose, wrong time, wrong patient), and that the financial cost of treating the harm done by these errors conservatively comes to $3.5 billion a year. An integrated digital records system would also make it much easier to monitor and curb the overuse of treatments that are both costly and dangerous. For example, Americans are exposed to so many CT scans, many of them redundant, that, according to the New England Journal of Medicine,the resulting radiation exposure may be responsible for as much as 2 percent of all cancer deaths in the country.

With such a robust, data-driven system of safety promotion at last brought to bear in health care, average performance will no longer seem good enough. Health care providers, employers choosing health care for their workers, and patients seeking the best care will all demand more. The benchmark for any given hospital to meet would thus become what it should have been all along: the refusal to tolerate even one case of preventable harm to a patient. Without such demonstrable standards of performance, there is little hope that the quality of health care can improve—whether the system is “socialized,” “market driven,” or any combination thereof.


 ome doctors and hospital administrators will object on principle. When O’Connell, aka “The Numerator,” asked his surgeon about the moral implications of billing patients for treatments made necessary by sloppy medical practice, the response he reports receiving was disheartening: “We’re like lawyers,” O’Connell recalls the surgeon saying. “We just provide services by the hour and sometimes it works and sometimes it doesn’t.”

Other medical providers live by a higher standard than this, yet many will still raise all kinds of methodological objections. They will say that their patients tend to be much sicker or older than those treated in other hospitals. Or that the reason their hospital has such high infection rates is that many of their patients come from nursing homes, where lethal bacteria are rampant. (In the case of our investigation, I always pointed out that we were reporting the infections that their own employees had marked as not present at the time the patient arrived, meaning they were acquired in the hospital itself.) And to be sure, certain risk adjustments do need to be made in comparing the performance of one hospital with another.

But these are adjustments that can be made, and made all the more fairly and definitively the more data we have about just who is receiving what treatments and with what results. In no other realm—certainly not any as inherently dangerous as health care—do we accept the argument that meaningful comparisons of results are impossible just because those being compared face somewhat different circumstances. Some airports have shorter runways and are more congested than others; some have to deal with frequent snow or thunderstorms, nearby mountain ranges, or lakes and rivers that attract unusual numbers of flocking birds. No two are exactly the same. Yet we don’t therefore conclude that there is no point in comparing the safety record of one airport versus another, much less say that it is acceptable for a certain number of people to be routinely killed on approach or takeoff. We demand that all airports, and everyone else involved in aviation, do what it takes to get accidents to as close to zero as possible, and that they use reams of performance data to make that happen.

Moreover, it’s not just the outputs of different health care providers we are concerned with, but their inputs as well. You say many of your infected patients are coming from nursing homes? Why not hold them to higher standards? Why are you not doing what the Pittsburgh VA is doing and testing all your patients for infection before they get out on the wards? Why don’t you have sensors in hospital rooms, as some hospitals now do, that sound an alarm if anyone exits the door without having first washed his or her hands? For that matter, why not take up the suggestion of Paul O’Neill, the former treasury secretary who pioneered industrial safety as CEO of Alcoa and is now a leading voice on patient safety: have a big sign posted at the front door of the hospital, as nearly all factories and construction sites do, that reminds workers as they come on each shift just how many days it has been since the last medical error or hospital-acquired infection? In short, just exactly what have you done to promote a culture of safety?

Experience has shown that when hospitals and doctors can answer that question forthrightly, and when they are open and honest about their mistakes and show they are taking steps to fix them, they are much less likely to face malpractice suits. In 2004 the University of Illinois Medical Center in Chicago began flagging cases of harm and unsafe conditions that could cause injuries—up to 7,000 reports a year. It also began admitting and apologizing for its mistakes, conducting investigations of harmful incidents that are open to patients and their families, and even offering financial compensation when necessary. The program has lowered the number of malpractice claims and the amount of payouts, while increasing trust and leading to hundreds of patient safety improvements. The hospital’s methods boil down to what any one of us would instruct a child to do when he makes a mistake: stop making excuses, and take responsibility. The facility is now considered a national patient safety pioneer, and its methods are being expanded through a federal grant to nine other hospitals in the Chicago area.

This is what current best practices in patient safety look like. They could be even better if consumers and medical experts had the data they need to determine each hospital’s progress in promoting safety. We know this works in other inherently dangerous industries. Why should health care be an exception?

We all understand that medicine is increasingly complicated and that hospitals are increasingly filled with patients who would have died years ago were it not for the wonders of modern medicine. But the Hippocratic oath says, “First do no harm.” Precisely because health care is becoming more and more complex, and therefore inherently dangerous, it will continue to cause more and more and more deaths and injuries until we put safety first.
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Marshall Allen is a health care reporter for the Las Vegas Sun.  
 
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