Mistakes hospitals don't want you to see
Seattle Times health reporter
Over the past year, hospitals in Washington left "foreign objects" in 36 surgery patients. And 21 people got surgery on the wrong body parts.
Hospitals have reported such "adverse events" to the state Department of Health since 2000, also including performing surgery on the wrong patient, and medication errors that can kill or seriously harm patients.
But now the Washington State Hospital Association says it doesn't want the public to know which hospitals made the mistakes. It contends that a bill passed last year forbids release of such records, and the association has gotten the state to halt disclosure.
At least one state lawmaker is vowing to fight back.
"That was not the intent of the Legislature; that was not the intent of the bill," said Rep. Tom Campbell, R-Roy, who sponsored a previous law that allowed for public disclosure of such records. "The intent was to give the public the maximum information.
"We want to know if somebody was killed by using the wrong gas; if they're cutting off the wrong legs ... I'd like to avoid that. The public has a right to know these things. Their tax money is being used here. It's their lives, their families."
The state health department gathers statistics on 28 types of "adverse events and incidents," though many categories don't have any reports. For example, no hospitals have recently reported deaths or serious disabilities from contaminated drugs or devices. And none have discharged infants to the wrong person.
But some categories receive multiple reports: In addition to the foreign objects left behind and the surgeries on wrong body parts, hospitals across the state have reported eight cases of patients receiving the wrong surgical procedure, and there were six cases of death or disability from medication errors in the past 14 months.
The point of the record-keeping, say health officials and hospital managers, is that sometimes patterns can be revealed and the hospitals can use the reports to help prevent problems from happening again.
For example, Providence Everett Medical Center reported three separate adverse events on the same day — June 14, 2006 — in which the wrong surgical procedure was performed on patients. It also reported three incidents of surgeons leaving behind foreign objects over a six-month period from July 2006 through January 2007.
After making the reports of the wrong surgical procedures involving hip and knee replacements, which were due to equipment problems, the hospital changed long-standing procedures, said Paula Bradlee, Providence Everett's director of organizational quality.
The hospital added an equipment check to its time-honored "surgical time-out" process that happens just before a surgery team begins, as it pauses to verify patient identification, the procedure ordered, the position of the patient, the surgery site and side of the body. A similar process took place after the foreign-objects reports, she said.
"We bring a group of people together to sit down and look at what occurred, and put together an action plan to make sure it wouldn't happen again," Bradlee said.
Public disclosure is also important for that improvement process, Bradlee said. "I think it ultimately helps us. It puts more of a focus on safety."
Change in perspective?
Since 2000, the reports of adverse events have been public under a law, sponsored by Campbell, that declared that hospital information received by the state through such filed reports or inspections may be disclosed.
But last year, when the Legislature passed a sprawling compromise law intended to settle a bitter fight over medical malpractice, it included language in the 63-page bill that the hospital association now says bars public disclosure. It argues that because the reports are to be part of a hospital's "quality improvement process," they are subject to confidentiality protections.
The hospital association maintains that the new law reflects the Legislature's change in perspective about adverse events, said Cassie Sauer, a spokeswoman for the association.
"It shifted the philosophy from 'Who made this mistake and let's go get them' to more of a 'What are the systematic reasons why there are mistakes?' " she said.
The state hospital association has been an industry leader on transparency in the health-care industry, including public disclosure, Sauer insists. But she argues the adverse-event information is "more sensational" than information offered to the public by the hospital association itself, and isn't particularly helpful to patients.
"I don't know that it's a really good way for people to make decisions about what hospitals to go to," Sauer said.
For one thing, "the incidents are so rare," she said. And there is no context in the records to help explain differences between hospitals, such as whether one hospital sees more patients, or tends to treat older or sicker people.
For example, it might make sense that a hospital that sees more homeless people or drug addicts would have more incidents of "pressure ulcers," also known as bedsores, she said.
Instead, the hospital association says its own statistics on its Web site, www.wsha.org, are a better measure of hospital quality. Those data focus on how hospitals treat heart-attack patients or how well they do on infection control.
"Huge step backwards"
But Rep. Campbell, who has spent years fighting for legislation to force more reporting of health-care data, counters that the hospital association has used a "back-door" approach to change what had been a long-standing understanding that the reports should be public.
"They're taking away the public's right to know; this is a huge step backwards," he said.
"I hate to use the term 'bad faith,' but that's what I feel. We made an agreement, and now, through this whole process, it's been broken."
For now, the state health department will no longer release hospital-specific numbers on adverse events, said Byron Plan, who runs the department's Office of Health Care Survey.
"Now where we find ourselves is two laws that say two different things," he said.
The department is seeking a formal interpretation from state Attorney General Rob McKenna, officials said.
And Campbell said he will offer new legislation that would order the department to disclose the information.
"We're going to make it real clear for them," he said. "I feel like putting a little line on it that says, 'and we really mean it!' "
Carol M. Ostrom: 206-464-2249 or firstname.lastname@example.org
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