Contra Costa Times, Knight Ridder Newspapers September 15, 1999 Font Page

Curing a Culture of its Denial

Part 4 of a four-part series

By Andrea Gerlin

The nation's health-care industry is making small-scale efforts to address medical errors in hospital care.

New training programs, some of which include the use of simulation devices, have been put in place at some medical centers to focus on avoiding errors.

Systems are being developed to encourage medical professionals to report errors.

Information technology has become available to reduce the risk that hospital patients will receive improper medication or treatment.

But these efforts have been limited, and there is no comprehensive initiative by the industry to minimize the occurrence of errors, despite growing data and warnings in recent years that have made the industry more aware of the high frequency of errors.

"I am puzzled that senior clinical leaders and boards of trustees seem not to understand the degree of opportunity for improvement," said Donald Berwick, president and chief executive officer of the Institute for Healthcare Improvement in Boston. "There's such a long list of areas that can be improved that you don't have to think hard."

A major factor in the health-care industry's lack of progress is its carefully guarded system of self-policing, an honor system that even insiders say is ineffective. At its roots is what doctors and researchers describe as a culture built around blame, in which medical professionals face intense pressure to deny or rationalize failure, lest they be ruined.

And little is being done to change that culture.

Though the health-care industry represents one of the largest sectors of the American economy, it has failed to strive for the higher standards required in comparable industries. Health care costs the country an estimated $1.2 trillion a year and accounts for 14 percent of the gross domestic product. In Philadelphia, the industry is one of the largest sources of jobs.

In addition to injuries and deaths, the financial costs of medical errors are enormous. Testimony during a 1997 congressional hearing estimated that hospital mistakes cost the nation $51 billion a year.

Though hospital executives, doctors and nurses complain about the burdens of regulations and licensing, in practice they have enjoyed a long and cherished tradition of autonomy when mistakes occur.

"It's very clear that the medical profession has been loath to police itself," said Jay Krakovitz, a physician and medical director for Aetna U.S. Healthcare's mid-Atlantic region.

"There is absolutely no reason for them to sweat," said Charles Inlander, president of the People's Medical Society, a health-care advocacy group in Allentown.

The result, according to Inlander: "This stuff just grows and grows, and they never correct these problems."

Most experts on medical errors view the prospect of a government crackdown as counterproductive. Punitive action, they say, will drive the problem further underground as hospitals and health-care professionals seek to avoid sanctions and shame by not reporting errors. That, in turn, would make it even harder to obtain information about errors and find solutions.

The focus on patient safety, they argue, should turn to the failure of systems, not individuals. Experts agree that there are incompetent and irresponsible health-care providers who should be held accountable, but they say that incompetent professionals are not the majority of those who make mistakes at patients' expense.

"If we could find a way to deal with error that didn't deal with so much individual accountability, we might do better in the long term in dealing with error," said David Blumenthal, a professor at Harvard Medical School and director of the Institute for Health Policy at Massachusetts General Hospital.

Accreditation visits

rarely come as a surprise

The task of monitoring the quality of hospital care has been led chiefly by a private group, the Joint Commission on Accreditation of Healthcare Organizations. The commission, based in Oakbrook Terrace, Ill., is an arm of five professional groups that also represent the interests of doctors, dentists and hospitals. In many states, hospitals must be accredited by the commission to receive reimbursement from government and private health plans, which gives the commission significant authority.

Joint Commission committees composed of doctors, dentists, nurses, pharmacists and hospital executives visit and survey the commission's 5,000 member hospitals in the nation every three years. Their visits to hospitals rarely come as a surprise.

Hospital administrators spend months readying their staffs for accreditation committee visits, directing them in memos on bulletin boards, meetings, internal newsletters, and on signs posted in corridors to assure optimal conditions when the visitors arrive. In a report issued in July, the inspector general of the federal Department of Health and Human Services harshly criticized the commission's cozy relationship with the hospitals it accredits and its failure to aggressively monitor substandard care and incompetent doctors.

Julie Roberts, a commission spokeswoman, said hospitals are not required at the time of surveys to open their incident report files or inform the committees of medical errors. Rather, when serious incidents occur, she said, "We ask them to self-report. What we're doing is creating a database of errors."

What is in that database? After nearly five years, very little. Since the policy took effect in 1995, the commission has received fewer than 500 incident reports from 5,000 member hospitals. More than that number of errors, experts say, would be expected to occur in one large hospital in that period.

Hospitals do not send state health departments and licensing authorities any more information about errors. In the case of the Medical College of Pennsylvania Hospital, none of the most serious medical errors contained in the hospital's internal insurance report - those that led to death or permanent disability - was included in three years of reports that the health department provided to The Inquirer. No sanctions or fines were levied either.

The MCP internal report was made public in its former owner's Bankruptcy Court proceedings.

A health department spokeswoman said reporting requirements that took effect in June 1998 now require Pennsylvania hospitals to report 14 types of events that seriously jeopardize patient safety or lead to death. Among them are fatal medication errors, wrong-site surgery, and hemolytic reactions following blood transfusions.

She said the department cannot release figures for individual hospitals because the information is considered confidential. However, Philadelphia's 35 acute-care hospitals reported to the department one death and five other incidents during the year ended June 30, 1999.

New York state began requiring hospitals to report similar information to its Department of Health in 1993, in an effort to better understand the causes of errors. For 1995-1996, Montefiore Medical Center in New York City filed 469 patient event reports, and Mount Sinai Medical Center filed 321. In contrast, St. Vincent's Hospital-NY filed two event reports, and Beth Israel Medical Center filed 17.

"The ones that report the most are just the most honest," said Bertrand Bell, a professor at Albert Einstein College of Medicine in New York.

A health-care issue,

and a money issue, too

That the health-care industry and its regulators have failed to take action to prevent errors is not lost on health insurers.

Who pays for costs stemming from errors?

"We do," said Krakovitz of Aetna, which insures more than 21 million Americans.

The costs eventually are passed to employers and patients.

"It's remarkable that people are blindly writing checks for crappy quality," said David Nash, associate dean and director of the Office of Health Policy and Clinical Outcomes at Thomas Jefferson University.

A study conducted at Brigham and Women's Hospital and Massachusetts General Hospital, published in 1997 in the Journal of the American Medical Association, calculated total additional hospital costs from preventable drug errors to be $2.8 million a year at the 700-bed teaching hospitals, or $4,685 for each error.

Employers, who pay for health insurance for 152 million American workers, so far have not used their purchasing power to pressure hospitals and doctors to reduce medical errors. Though they would have unequaled clout, they are struggling to determine their appropriate role.

"It's an area that a lot of us are concerned about as we take a look at the data," said Bruce Bradley, medical director of managed-care plans for General Motors Corp., which provides health insurance to 1.5 million workers, retirees and their dependents. "We're trying to figure out if it makes sense for us to incorporate patient-safety considerations in our purchasing decisions."

Health-care industry lags

in error-reduction efforts

Commercial aviation, to which the health-care industry is most often compared in terms of safety, has reduced airplane crash deaths to one of every two million passengers, a tenth of the rate of 20 years ago. Along with the nuclear power industry, which suffered heavy criticism in the aftermath of the Three Mile Island accident in 1979, aviation has improved safety by developing extensive training and simulation requirements, reporting "near misses," and harnessing technology.

Such efforts may or may not be as effective in health care, given the uncertainties and variation among patients. And people are obviously different from computer chips and airplane parts. But hospitals and health care are far behind in even attempting the types of initiatives that have reduced errors in aviation and other high-risk industries. Their efforts so far have been on a small scale.

Training and simulation are high on the list of necessary changes, experts say. Robert Helmreich, a professor of psychology at the University of Texas at Austin, has studied the behavior of aviation and aerospace crews and medical teams. He said that though operating rooms may be more complex environments than cockpits, aviation and medicine have much in common, such as a need for clear communication.

"The range of things that can go wrong is probably no greater than the things that can go wrong in an airplane at 40,000 feet," Helmreich said.

Helmreich advocates overhauling medicine's culture, which he describes as seriously flawed. In surveys, he has found that pilots and doctors hold markedly different attitudes about their own capabilities. Roughly 60 percent of surgeons and anesthesiologists responded that they perform effectively when fatigued, compared with 30 percent of pilots.

"They deny overwhelmingly the influence of fatigue," Helmreich said. "There's a certain climate in which the surgeon can say, 'I'm the surgeon and I'm infallible.' "

The perfectionism that drives many in medicine can also render them vulnerable to overconfidence that escalates into arrogance and reinforces competitiveness. "I'd start working on that in the first year of medical school," Helmreich said.

The University of Colorado School of Medicine has been developing a virtual-reality spinal tap and surgery simulation. Harvard-affiliated Beth Israel Deaconess Medical Center has designed computer programs for diagnosing numerous medical conditions, on which medical students are required to practice.

Medical error experts also advocate more extensive reporting systems, similar to the Federal Aviation Administration's Aviation Safety Reporting System. Airline crew members file thousands of confidential reports of unsafe conditions and near misses to the system every year. The data are centralized and made available publicly, and safety problems are addressed in efforts to avoid accidents.

Researchers in the Department of Anaesthesia at the University of Basel in Switzerland have developed an anonymous, international Critical Incident Reporting System on the World Wide Web to distribute information about anesthesia accidents. Modeled on an Australian system, it allows doctors to send online reports, which are then posted on the Web site without identifying information about the patient or the person who reported the accident. Visitors to the site respond with their analyses.

Doctors responding to some recent reports wrote: "Reading some of these comments, I can't believe patients trust us with their lives," and "There but for the grace of God go I."

In one of the most ambitious efforts of its type, the U.S. Department of Veterans Affairs will launch a Patient Safety Reporting System pilot project at 22 of its health facilities in Minnesota, Wisconsin and upstate New York next year. "If we are able to do it at all successfully, it's going to spark a lot of interest," said Ron Goldman, a research analyst at the VA's Office of Performance and Quality in Washington.

Information technology is another area that the industry has yet to fully utilize. The health-care industry spends an estimated 2.5 percent of its revenues on information technology, much of it for billing systems, compared with an average of 12 percent to 15 percent in other industries.

Computerized physician-order entry systems on hospital wards eliminate penmanship errors and sound alarms about excessive doses, drug interactions and drug allergies. Children's Hospital of Philadelphia and the Hospital of the University of Pennsylvania are among the local hospitals that have computerized physician-order entry systems on their floors.

Using a highly sophisticated system of this type, Brigham and Women's Hospital in Boston cut its number of errors and lowered costs by reducing hospital stays. The hospital spent $1.4 million on software and $500,000 to maintain it, said David Bates, chief of internal medicine.

Bates estimated that Brigham and Women's has saved $5 million to $10 million a year since it installed the system.

"Not only would paying attention to this improve quality, but it would reduce costs," he said. "It will pay for itself, and in short order."