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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.
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.
Because 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.”