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Mass. hospitals’ mistakes list widens

Massachusetts acute-care hospitals reported 753 serious medical errors and other patient injuries last year, a 70 percent annual jump that health officials attributed mostly to expanded definitions of what constitutes medical harm.

So-called serious reportable events in other types of hospitals, including those that provide psychiatric or rehabilitative care, rose 60 percent from 2012, to 206.

Instances where patients underwent a procedure on the wrong body part, were burned by an operating room fire or a too-hot heating pack, or were subject to contaminated drugs or improperly sterilized equipment saw some of the largest increases in reporting since 2012.

Hospitals also reported more patient falls, serious bed sores, assaults, and suicides and suicide attempts.


Dr. Madeleine Biondolillo, associate commissioner of the Department of Public Health, which collects the information, said it’s unclear whether incident rates are going up because the state broadened the type of incidents hospitals are required to report. The department also adopted a computerized system to replace faxes, making notifying health officials easier. Even so, the numbers show that even after more than a decade of focus on improving patient safety, lapses still occur regularly in hospitals across the country, medical safety experts said.

“Do I think things are getting better? No,’’ said Dr. Allan Frankel, a former safety head at Partners Healthcare and now chief medical officer of Safe & Reliable Healthcare, a Colorado-based consulting company.

Hospital executives are paying more attention to reducing hazards and some are more openly discussing problems with patients and regulators, but they are simultaneously under growing pressure to care for more and sicker patients and to cut costs.

“When you think about what the hospitals are dealing with, reducing adverse events is incredibly complicated,’’ he said.

The focus on eliminating patient harm dates back to 1999, when the Institute of Medicine released a groundbreaking report revealing that tens of thousands of patients die each year because of preventable medical errors.


Since 2008, Massachusetts hospitals have been required to notify the health department about serious reportable events, a rule that is intended to help regulators and hospital administrators better understand how errors happen and how to prevent them. In certain cases, regulators also investigate and cite individual hospitals for their mistakes.

Hospitals also must report these lapses to patients or their families.

The health department — as well as the federal government — prohibits facilities from charging insurers and government payers for services provided as the result of a serious reportable event, such as follow-up surgery to remove a clamp or sponge left inside a patient, as incentive to prevent these mistakes.

Biondolillo said the state has followed national guidelines and broadened what hospitals are required to report. Before October 2012, for example, hospitals were required to notify the state only about incidents that left a patient with a “serious disability.” Now, they must report any “serious injury.’’ Health officials also added four categories to the reporting requirement, including a patient death or serious injury resulting from “failure to follow up or communicate laboratory, pathology, or radiology test results.’’

Health department staff have been working with hospitals to ensure they are notifying regulators and families when they should be.

Still, in some cases, hospitals need to improve their practices. For example, reports of suicide or “self-harm with serious injury’’ in acute-care hospitals rose from one case in 2011, to 12 in 2012, to 22 last year. Most of these incidents involved patients taking overdoses of pills or cutting themselves in psychiatric units and emergency departments. Hospitals may need to more thoroughly search patients’ belongings for pills or sharp objects, she said.


Hospital reports for 2014 should give regulators a better idea of whether errors are rising, because no more major changes to the notification system are planned, Biondolillo said. “We are always concerned. One of anything is too many,’’ she said. “But next year we’re going to be able to give a much more definitive answer to that question.’’

That information will allow regulators to better target prevention strategies, she added.

Deb Wachenheim, health quality manager at Health Care For All, a Boston-based consumer advocacy group, said the data show hospitals are more thoroughly analyzing and reporting patient harm. “It makes me more confident that the information being reported to consumers is good and transparent,’’ she said.

Liz Kowalczyk can be reached at kowalczyk@globe.com.