Tag Archives: never events

CMS releases hospital-by-hospital data on never events

About nine months after its original due date, the Centers for Medicare and Medicaid Services have overcome industry opposition and made data for hospital acquired conditions publicly available online. The data come in a 1.2 MB zip file, inside of which you’ll find a hulking 26,889-line spreadsheet.

The sheet breaks down the nation’s 4,700 or so hospitals, using Medicare fee-for-service claims from October 2008 through June 2010, based on the rates of eight different “never events,” each of which is compared with the national rate for the event in question. The hospitals can be sorted by name and state. Below, I’ve illustrated the national rates for all included HACs.


According to MedPage Today’s Emily Walker, CMS published the data to help patients make informed decisions and to help hospitals improve their quality of care. They did so, she points out, over strenuous industry objections.

The data was originally scheduled to be published in September 2010 but was met with strong resistance from hospital groups such as the American Hospital Association (AHA); the groups say that CMS never made specifics available for how it calculates the HAC rates, making “fundamental assessments of the accuracy of capturing the incidence of these conditions” impossible to conduct.

“Hospitals continue to urge CMS not to publish these data,” read a March 31 joint statement from the AHA, the Federation of American Hospitals and the Association of American Medical Colleges.

After 8 years, Quebec’s adverse event reporting law remains unenforceable

The Montreal Gazette‘s Charlie Fidelman has assembled a round-up of what has, and hasn’t, happened in the eight years since Quebec passed a law requiring hospitals to tell patients about all adverse events as soon as staff became aware of them.

According to Fidelman, “the provincial Health Department has yet to set up its registry of adverse events,” which it was supposed to track in order to improve patient safety. It’s expected to finally get started next year.

Until then, hospitals are supposed to track their own events and report them each year, yet “no hospital contacted by The Gazette includes adverse events in its annual reports.” This may have something to do with the fact that the requirement came with no clear enforcement mechanism.

Initiatives not improving patient safety; poor implementation to blame

A large-scale study that followed mistakes in health care delivery at 10 North Carolina hospitals from 2002 to 2007 found that, despite state efforts, there was no improvement in patient safety over the time period. According to The New York Times‘ Denise Grady, the problem lay primarily not in design, but in execution. Even when safeguards were in place, they were not followed.

The study, published in the New England Journal of Medicine, reviewed thousands of patient records and looked for any of 54 red flags that something had gone wrong.

Dr. [Christopher] Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.

The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

Problems cited in the study include a lack of electronic medical records, doctors and nurses regularly working long hours and poor compliance with even simple interventions such as hand washing. Proposed solutions include computerized drug ordering systems and a mandatory nationwide monitoring system.

“Never events” still happen sometimes

Photo by Garrett P. via Flickr

MedPage Today’s Crystal Phend drew two key lessons from a recent paper on the persistence of “never events,” particularly wrong-patient and wrong-site surgeries, in Colorado.

The first, drawn from an invited critique (subscription required), is that research often underestimates the frequency of never events because, like this study, they rely on self reporting and overly narrow definitions of the events in question. After all, it’s not wise to assume that folks are going to voluntarily link their name to a wrong-patient surgery.

The second is that attempts to prevent never events, such as the Joint Commission-required pre-surgery routine, don’t cast a wide enough net.

Nonsurgical specialists were just as likely to cause significant injury from wrong-site errors as those in the procedural specialties, who have gotten more of the focus (31.2% versus 30.8%, P=0.67).

That’s because, in their analysis, the researchers put the responsibility for wrong procedures at the step where things went wrong, Stahel told MedPage Today. And sometimes that’s before the cutting stage.

“In certain cases we realize that the harm is already done before the patient sets foot in the hospital,” he told MedPage Today.

“Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to achieve a zero-tolerance philosophy for these preventable incidents,” Stahel’s group wrote.

Reporters encounter hospital’s lack of transparency

Blythe Bernhard and Jeremy Kohler of the St. Louis Post-Dispatch investigated a string of serious mistakes at a local hospital and found the story of a 16-year-old girl who suffocated in a bean-bag chair after being sedated. It’s a remarkable and chilling story on its own and, as AHCJ Immediate Past President Trudy Lieberman points out, it’s made even more valuable for health journalists thanks to Kohler’s willingness to explain his investigative process.

Acting on multiple tips referring to a botched 2007 kidney removal, Kohler began the laborious process of triangulating the error. You should really take a minute to read his entire explanation, but if you really don’t have time, just take note that his path was something like this: Tips from sources -> Joint Commission -> Missouri Division of Insurance -> National Practitioner Data Bank -> Missouri Department of Health and Senior Services -> Missouri Board of Professional Registration for the Healing Arts -> The actual hospital.

And even then, he was unable to get clear confirmation that surgeons had removed the wrong kidney from a patient. Instead, the hospital cited privacy regulations.

Last week, officials with SSM Health Care, the St. Louis-based corporation that operates DePaul and several other hospitals, said they could not speak about specific patient cases because of federal privacy laws. “The desire to defend ourselves and paint an accurate and full picture does not outweigh our patients’ right to privacy,” they said in a statement.

Even a subject like this, which clearly involves what Kohler calls “information that patients in need of a surgeon would be interested in knowing,” the obstacles between readers and the truth about a “never event” appear insurmountable.