Mass. hospitals continue to make preventable mistakes
Full-service hospitals in Massachusetts reported making 821 preventable errors that harmed or endangered patients last year, according to a report released Wednesday.
That included 41 instances in which an unintended object was left behind after surgery, 24 operations on the wrong part of the body, and 290 serious injuries or deaths after a fall.
But the Department of Public Health’s annual study of serious reportable errors was not able to resolve whether medical errors are truly increasing or declining — even if data in the report show an increase in errors.
The total number of reported incidents rose 9 percent compared with 2013, when 753 mistakes were counted. But health officials said they are convinced the increase stemmed solely from better detection and reporting by hospitals, which now benefit from an online reporting system and clearer definitions.
“The continued increase in reporting is a positive indicator,” Katherine T. Fillo, the health department’s quality improvement manager, told the Public Health Council on Wednesday.
The data help the state target improvement efforts, Fillo said. For example, the state’s Suicide Prevention Program is working on developing methods for hospitals to reduce suicide and self-harm among inpatients.
The report chronicles a decline in surgeries performed on the wrong body part, down to 24 in 2014 from 36 in 2013. Fillo attributed the drop to hospitals improving the safety culture in operating rooms.
The health department’s report also tabulated error reports from rehabilitation, psychiatric, and state-run public health hospitals, which reported 236 incidents in 2014, up from 206 the year before. Also, for the first time, the 59 outpatient surgery centers in the state reported errors — 10 in all, six of them wrong-site surgery.
Although data on serious reportable events have been collected since 2008, the definitions changed in 2013, invalidating comparisons with previous years.
Data showing the number of errors at each hospital will be posted online by the end of Thursday.
Even as the numbers rise, health officials suspect that many incidents remain unreported. In a Harvard School of Public Health survey last year, one-quarter of Massachusetts residents said that they, or someone close to them, had experienced a mistake in their medical care during the past five years. The survey also found that many people didn’t report the error.
Andrew C. Meyer Jr., a malpractice lawyer with Lubin & Meyer in Boston, said that errors continue because hospitals are under increasing pressure to fill beds and keep costs down. “There are problems which are often related to the volume of patients being seen, resulting in a lack of communication and therefore a lack of follow-through,” he said.
“It’s extraordinary the amount of medical errors and deaths that occur on a yearly basis,” Meyer said, citing a 2013 study that reported 400,000 cases of serious harm or preventable deaths nationwide. “Medical error is becoming one of the leading causes of death in Massachusetts.”
Linda K. Kenney, a longtime patient safety advocate and executive director of Medically Induced Trauma Support Services, a Newton nonprofit, said medical errors are widespread and probably underreported.
But in her own experience, Kenney said, she has seen safety efforts slowly take hold. In 2007, she contracted a drug-resistant infection during ankle surgery. In 2011, when she went in for hernia surgery, she was showered with information about preventing surgical-site infections — but no one asked whether she understood it. Last year, before another operation, “Lo and behold, somebody did ask that question.”
“I still see problems, but I see progress,” she said.
Within a week of any of 29 serious reportable events, hospitals and ambulatory surgery centers are required to inform the patient, the payer, and the health department. All three parties must also receive a detailed report analyzing the cause within 30 days. State law prohibits health care facilities from charging for services resulting from medical errors.
The health department’s report coincided with the publication Wednesday in the journal JAMA Surgery of a study of surgical “never” events — errors that should never happen. It estimated that each year, surgeons operate on the wrong body part 500 times and leave unintended items in the body 5,000 times. Poor communication was often the culprit, but there was no good evidence that efforts to prevent these events were effective.
These surgical errors are “very rare events, but continue to be a safety concern,” Susanne Hempel, a behavioral scientist at the RAND Corp. and lead author of the study, said in an e-mail to the Globe. “We now know more about contributing factors, and we have evidence of some promising approaches to prevent surgical never events.”