TV-6 Investigates: QCA lacks public medical mistake databases

http://kwqc.com/2016/03/21/tv-6-investigates-qca-lacks-public-medical-mistake-databases/

DAVENPORT, Iowa. (KWQC) – Wrong site surgeries are what doctors call never events, they should never happen. But it’s tough for patients in the Q.C.A. to find out if their hospital had any. Earlier this month TV-6 investigates revealed a state inspection citing Genesis Health System for failing to protect patients from wrong site surgeries at its hospitals. Genesis has since submitted a plan of corrections to fix what the inspector found. But patients have no way to find out how common wrong site surgeries are at any Iowa or Illinois hospital.

Half of the states across the country have some type of public reporting system for never events. These systems typically gather data on wrong site surgeries, patients given the wrong medication, and patients with tools left in their body after surgery. Illinois created a reporting system over a decade ago, but it’s still not operational because the state has never funded it. Iowa came close to implementing a system, but a state board never voted on it.

Patient safety expert Dr. David Nash said, “The public deserves complete and thorough transparency and accountability, from the medical system, I’m an absolute strong believer in that and always have been.”

Nash is a patient safety expert and an advocate for public reporting systems. He’s the editor in chief of the American Journal of Medical Quality. He was one of the first to publish a study comparing Philadelphia hospitals against their track records for open heart surgery. He says public data improves care.

“We also have had literally two decades of public reporting, maybe not always about wrong site surgery but certainly about the outcomes of many different types of surgery, so I firmly believe that reporting has contributed mightily to reducing wrong site surgery, reducing post operative infection,” said Nash.

State adverse event reporting systems were created in response to reports studying preventable medical errors. A Health and Human Services Inspector General study measured medical errors in Medicare patients who went to the hospital in October 2008. Of the one million Medicare patients discharged during that month, the HHS Inspector General found one in seven experienced an adverse event.

Nash said, “Medical error, all medical error that is preventable, is the fourth leading cause of death in our country in 2016, is hard to believe.”

The former director of the Iowa Department of Inspections and Appeals, Dean Lerner, tried to create a public adverse event reporting system in the state.

Lerner said, “I thought it would be a really good idea for Iowa to expose to the public in a very scientific and straightforward way one that had been approved by 20 other states, and make those kinds of events transparent.”

The Iowa Department of Inspections and Appeals inspects hospitals. Lerner believed implementing mandatory public reporting would improve health care in Iowa.

Lerner said, “If you ask any Iowan whether having this information would be valuable and important in the scheme of things in terms of their care, they will tell you yes.”

He brought his proposal to the hospital licensing board back in 2010. The minutes of two meetings show the board had a lot of questions. How would this data improve care? What had other states experienced? How would the data be used? The former chairman of the hospital licensing board Bob Miller said those were critical questions.

“It did not appear to us that there was a plan for what to do with the information to be gathered,” said Miller.

He said the board also felt a state-run public reporting system was redundant.

“We felt that there was a lot of reporting going on through the collaborative, required by CMS, and for our relicensure, Joint Commission,” said Miller.

The Iowa Healthcare Collaborative has gathered data voluntarily from all hospitals in the state since 2007. Its CEO, Dr. Tom Evans said the group publishes a report comparing hospital performance across the state.

“The never events are a starting point, they were a very popular thing to start talking about in the early 2000’s but we’ve moved so far beyond that,” said Evans.

He said the Collaborative’s report has flaws. It’s very technical, so patients in the state may not understand what is being compared and why those comparisons are important. He says they’re working on improving it.

“We want consumers to be engaged with meaningful information so we have other things, tracking infection rates and antibiotic usage and falls and pressures sore,” said Evans.

Evans believes focusing on never events like wrong site surgeries is distracting.

“I want consumers engaged, I want them looking at this information, and we want to be transparent, but we’ve got to give consumers meaningful information that they can make good healthcare decisions based upon,” said Evans.

Miller said those concerns were key in the discussion.

“Is it going to improve quality of care of is it going to penalize an error,” said Miller.

Lerner said he needed the board’s support to move forward with a state public reporting system. He planned to answer questions as they came up.

“We didn’t want to jump with both feet before we carefully analyzed everything was to take this one step at a time, and I honestly thought that would help industry to adjust and get comfortable with the change,” said Lerner.

At the meeting back in 2010, chairman Bob Miller twice called for a motion on the proposal to create a public adverse event reporting system. No one on the board made one. The idea died without anyone casting a vote.

Never events at Iowa hospitals continue to remain hidden from public view. Iowa hospitals are not required to publicly report never events to anyone. Patient safety advocate David Nash said adverse events should be public knowledge.

“If we’re going to have consumer engagement in health care and consumers having more skin in the game with higher deductibles, they have every right to be able to connect the dots between what hospital is in my network and what are the outcomes of care for procedures that I may need, or family members may need in those institutions,” said Nash.

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