Why Do Hospitals Still Allow Preventable Adverse Events?

Michael Wong

Posted 5/01/12 on The Doctor Weighs In

Can Hospitals Afford to Give Away Money? If not, then why are Preventable Adverse Events Still Occur in Hospitals?

This are questions that I posed to lawyers, insurers, and healthcare professionals attending a major healthcare conference, the Crittenden Medical Conference.

According to the Institute of Medicine, each preventable adverse event costs about $8,750 — and this excludes potential litigation costs.

Can hospitals afford to give away money? So, why do preventable adverse events still occur in hospitals?

I was honored to be invited to speak at this conference. Held this April 16-17 in Scottsdale, Arizona, the conference featured healthcare experts who spoke on some of the most pressing matters facing the healthcare industry, including the implications of healthcare reform, rising malpractice claims and awards, and decreasing provider reimbursements.

Barbara Rebold (Director of Operations at ECRI Institute) and I were the only representatives for patient safety organizations at the conference. For those who don’t know ECRI, it is an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care. ECRI has previously been referred to on this blog on technology hazards and how the FDA may have acted hastily earlier this year.

Barbara emphasized the need for the preservation of peer review and quality assurance, which provides critical information and data on medical events. In short, data provides solutions, as described in this slide:

The third member of our panel, Andrew Bolin (an attorney with Beytin, McLaughlin, McLaughlin, Bolin & Willers), spoke about the legal requirements and consequences of peer review and quality assurance.

In urging providers, insurers, and lawyers to not be scared of peer review and quality assurance, I spoke of how data produced by peer review and quality assurance can be used to help lower healthcare costs, while improving patient safety and outcomes.

Pointing to the tragedies of Amanda AbbiehlLeah CoufalJustin Micalizzi, and Louise Batz, I underscored the commonality of these unfortunate patient tragedies — healthy patients who were put on Patient Controlled Analgesia (PCA) pumps without monitoring shared a common result — sadly, none of them came out of the hospital alive.

These patients demonstrate that respiratory depression can happen with any patient who is on PCA, regardless of how healthy they be or how low a “risk” they might seem to be. I presented this data showing the prevalence of incidents arising from the use of PCA pumps:

Pennsylvania Patient Safety Authority:

  • about 4,500 reports associated with PCA pumps
  •  6-yr period (June 2004 to May 2010)

Medmarx (national voluntary medication error-reporting database):

  • 9,571 (1%) of 919,241 voluntary medication errors reported were associated with PCA (only 801 facilities reporting)
  • 5-yr period (July 1, 2000, to June 30, 2005)

Veterans Health Administration (root cause analyses since 1999):

  • 13% involved two types of pumps
  • about 50% general-purpose and 50% PCA (because there are 10 times more general pumps in use at VHA than PCA pumps, this means errors with PCA pumps are 10 times more likely than with general pumps)

I provided the solutions of the Veterans Affairs Administration. Bryanne Patail (biomedical engineer at theUS Department of Veterans Affairs, National Center for Patient Safety). As he told me in our recent discussion:

Use of PCA pumps is a process, and improving that process is an area that involves many stakeholders. In looking at fixes, they can be categorized as strong, intermediate, or weak fixes. The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump if a possible over infusion occurred. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.

As Bryanne told me, this strong fix will reduce adverse events:

A capnograph measures in real-time the adequacy of ventilation. Using this technology could prevent more than 60% of adverse events related to PCA pumps.

Although a human life should never be measured in terms of dollars and cents, does capnography monitoring of PCA pumps produce a return on investment?

The best example of the long-term benefits of PCA with capnography is St Joseph/Candler Hospitals (see pages 47-50) in Savannah, Georgia. Not only have they been event free for eight years since implementing the “strong fix” of using capnography and have averted almost 500 preventable adverse drug events, they calculated that they:

  • prevented estimated potential expenses of almost $4 million
  • 5 year ROI of $2.5 million

For a pdf of my conference presentation, please click here.

My presentation prompted attendees to discuss the issues raised in the following questions:

  • If any patient receiving narcotics can suffer respiratory depression, does a hospital knowingly jeopardize the safety of a patient using PCA if the hospital does not monitor with capnography?
  • Have Veterans Affairs Administration and St Francis/Candler Hospitals established a new legal standard of care that all patients using PCA must be monitored with capnography?
  • Are hospitals missing an opportunity to reduce adverse events and costs if they do not monitor patients using PCA with capnography?

Michael Wong is the founder of the advocacy group, Physician-Patient Alliance for Health & Safety (www.ppahs.org). Michael has been behind many healthcare initiatives, including encouraging people to quit smoking, to get tested and treated for hepatitis, and to take their medications as prescribed by their physicians. Michael is currently developing a safety checklist targeting PCA (patient-controlled analgesia) pumps. Michael can be emailed at mwong@ppahs.org

5 thoughts on “Why Do Hospitals Still Allow Preventable Adverse Events?

  1. This is a great post about an important topic, but I was disappointed that it fails to address the broader question – why DO hospitals continue to allow preventable adverse events? Not only does it cost them big bucks, but it kills patients. Any other corporation suffering such a large business flaw would make it priority one to fix. Ideas, anyone?

  2. This is the great paradox in health care. How can it be that the most well intentioned group of people — doctors who have devoted their lives to alleviating human suffering caused by disease — represent one of the nation’s biggest public health hazards when working together in our country’s hospitals. I think it is because they are scientists and believe that the level of harm that occurs is a statistically irreducible number. They forget — or have not been trained to notice — that much of this harm is preventible. Further, they are not trained in the science of clinical process improvement.

    Brent James and others have demonstrated that it is possible to provide a new level of training to MDs, but there has to be interest and commitment on the part of hospital and physician leaders to make that the norm. Thus, far, medical schools and residency programs have been negligent in not including it in the curriculum. The ACGME standard requiring such training is observed in the breach.

    1. Paul, I agree with everything you say about MD’s. I believe it is a form of willful blindness on our part, plus we think it’s someone else’s problem. As far as the someone else, I cannot let hospital CEO’s off the hook – they are in the leadership positions in hospitals and in the best place to initiate and sustain these efforts. If for no other reason than the almighty buck, I am mightily puzzled why the business case for reducing harm is not compelling to them.

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