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Jordan Margolis
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Safety First: How Dedicated Are Chicagoland Hospitals to Intercepting Preventable Injuries?

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Healthgrades Seventh Annual Patient Safety In American Hospitals Study of March 2010 provided us with an updated report on patient safety incidence rates among Medicare patients at nearly all 5,000 nonfederal hospitals across the nation. The 2010 study examined trends in important patient saftey issues, provided state specific incidence rates, identified "best-performing hospitals to establish a benchmark against which other hospitals can be evaluated" and more. This leading independent healthcare ratings organization can only provide as current and accurate of information about preventable patient injuries to the public as our nation’s hospitals are willing to provide. Unfortunately, hospitals have a history of "hiding behind legal barriers of their own making", rather than touting a full-disclosure policy on reporting patient safety incidence information.

It’s about time for hospitals to start publicly sharing updated information and error report data on preventable injuries that occur within their walls. In doing so, other hospitals, clinics, and individual physicians can help prevent the preventable and save more lives. The general public deserves better, as do the individual patients who put their trust, and their lives, into healthcare professionals’ hands.

According to Chicagobusiness.com, on March 18, the Cook County medical examiner’s office ruled that the death of James Tyree, a prominent Chicago figure as chairman and CEO of Mesirow Financial Holdings Inc., was an accident. This "mishap" involved an air embolism in Tyree’s dialysis catheter which, many of us do not know, is a preventable occurrence. According to healthcare consultant Michael M. Millenson of the Chicago Tribune, many of us also don’t know the statistics regarding how likely it is for an average-Joe like ourselves to get injured once admitted to a Chicagoland hospital. This is because few deaths due to preventable medical mistakes make the news. Tyree’s did because he was a public Chicago figure whose family allowed the release of the Medical Examiner’s results.

Millenson proffers that "if national figures apply to our area, at least 10 people die from preventable medical mistakes in local hospitals every day and another 100 are injured." This reporter uncovered information on preventing medical mistakes in our community at whynotthebest.org. This website is sponsored by Commonwealth Fund, an entity dedicated to "motivate and enable hospitals to improve care". Here’s an overview of what Millenson discovered:

  • "All eight hospitals (Lutheran General, the academic medical centers of Loyola, Northwestern, Rush, the U. of C. and the University of Illinois, and Stroger, Cook County’s public hospital) reported data for three serious safety problems that were part of a ‘bundle’ of standardized safety measures — decubitous ulcers (bedsores), infections due to medical care (particularly catheters and IV lines) and post-operative sepsis, a serious bacterial infection. The latter two complications are often life-threatening."
  • "Loyola’s rate of bedsores was almost nine times the state average, the only hospital of the eight ranked ‘significantly worse’ in that category."
  • "Loyola, the U. of Chicago and the U. of Illinois all were reported to be ‘significantly worse’ on the rate of infections caused by medical care."

Healthgrades’ 7th Annual Student reported other alarming statistics on patient safety concerns:

  • The Institute for Healthcare Improvement estimated 40,000 instances of medical harm occur in the healthcare delivery system daily.
  • Patient safety events have costed the federal Medicare program nearly $8.9 billion and resulted in 96,402 potentially preventable deaths from 2006-2008.
  • From 2006 through 2008, 88,180 Medicare in-hospital patients who experienced one or more patient safety events died.
  • Of the 99,180 actual in-hospital deaths, 97.19% or 96,402 could have potentially been avoided.

Healthcare consultant Michael Millenson explains why patient-safety-incident public reporting is so critical:

"It shows whether a hospital’s managers and clinicians are working together to reduce or eliminate serious safety problems. The best efforts of caring and hardworking individuals won’t be successful unless systematic error prevention is built into traditional care delivery processes as part of a genuine culture change. High-tech medicine poses inherent risks, but given a government study that nearly one-third of hospitalized Medicare patients suffer some sort of adverse event, a hospital that doesn’t have its act together on safety can be downright dangerous."

Healthcare providers and hospitals need to have a serious death reduction discussion, with a focus on better medicine and patient safety procedures. The focus has too often been placed on red herrings such as "the need" for tort reform, and reducing medical malpractice lawsuits and victims’ recovery awards. Millenson speaks the truth when he writes: "Most patients don’t want to sue. They only want fair compensation, compassion and the knowledge that someone else won’t be harmed again in the same way." Let’s hit the refresh button on this discussion. Common complaints by hospitals highlight "inaccurately coded Medicare claims" and faulty reporting results due to outdated information, says Millenson. This is precisely why the need is so great for hospitals’ comeplete transparency in reporting annual safety events.

This shouldn’t be about cutting quarters, defensive doctoring, and blaming medical malpractice lawyers. The need for publicly reported incidents and safety reports stems from the goal of preventing, not covering up, additional injuries, infections, and conditions patients develop during their hospital visits.

HealthGrades’ 2010 report says it best:

"Avoiding mistakes by chance is no longer acceptable. When patients enter the health care system, they entrust their health and their lives to their caregivers. The health care system must continue to put systematic safe practices in place to ensure that the system create to save them doesn’t unintentionally harm them"

"There’s an important distinction between great doctoring and great safety" says Millenson, and he’s right. It’s time for Chicago and nationwide hospitals to come to terms with this reality.