Patient Safety Improving but Work Still Needed

DAVID ROSENFELD

Patient Safety Improving but Work Still Needed

A color-coded wristband system may be a low-tech solution to help prevent errors.

Medicare Delivers Ultimatum to End Preventable Mistakes as Hospitals Adopt Low-tech and High-tech Solutions

Hospital associations in at least 12 states, including Florida, urge their members not to charge for serious preventable medical errors dubbed "never events."

But when Medicare announced in October that it wouldn't pay for the same type of mistake, that was a different thing entirely because for the first time the largest healthcare payer will make that determination.

The move will likely save $21 million for Medicare, though more importantly, it signals a sea change close to nine years after the Institute of Medicine's now-famous report To Err Is Human shocked the healthcare community into improving patient safety.

Medical errors in Florida are likely down this year, though it's difficult to say how much because of confidentiality protections and the assumed deficiencies in error reporting. They are likely down, however, mainly because hospitals are continuing to adopt both low-tech and high-tech solutions, experts say. Collaborative efforts to share best practices between providers are also having positive effects, though several efforts are stalled.

In Florida, the legislature this year stripped the non-profit Florida Patient Safety Corporation of $700,000 in annual funding. The group collected and analyzed reports of "near misses," events that come extremely close to a serious medical error such as amputating the wrong leg.

Left without state funding, executive director Susan Moore is looking toward federal funding possibly next year as a certified Patient Safety Organization. But the federal effort under the Agency for Healthcare Research and Quality too has stalled. Its long-awaited rules and regulations are planned for release in November.

Regardless, hospitals and doctors have made great progress in reducing errors, Moore said. "Facilities and providers are all much more aware than they used to be," she said. "That's the first step in making a hospital visit a safe thing: People are thinking about it. Patients too are really getting to the place where they understand they can ask questions of their providers. It's a change in attitude."

About a year before the legislature cut funding to the Patient Safety Corporation, it reformed the way state regulators handle mandatory medical error reports under code-15 after it was revealed the Florida Agency for Healthcare Administration wasn't doing anything with most of the reports. Last year, it received reports on 600 separate errors.

The legislature moved the Patient Safety Program to the Office of Research and Development within AHCA. Since then, the program has created a Web site called Florida Health Finder where it posts information, among other things, about preventable hospital readmissions. It's about to embark on a 90-hospital collaborative to reduce those readmissions, said Heidi Fox, program administrator.

"There are lots of studies on different practices," Fox said. "Most are very simple, but you're talking about a lot of people and a lot of procedures."

A simple, low-tech method to reduce medical errors during surgery is to review the procedure during what's known as the "golden moment" just before wheeling the patient into the operating room. That's the time to double check that the correct surgery is being performed on the correct patient and to review any other important details.

The Florida Hospital Association proposed another low-tech solution this year with a color-coded statewide wristband system that would be an easy to recognize way to categorize patients that was consistent from one facility to the next.

On the high-tech side, Surgicount Medical, a company that makes surgical sponges marked with a type of bar code, is looking to expand its presence among hospitals. Leaving a sponge inside a patient's body cavity, known as a retained object, is one of the most common preventable medical mistakes, occurring in 1 out of nearly 8,000 procedures.

Simply remembering to account for all the sponges before the patient is sown up would be the simple solution. Surgicount Medical's Safety-Sponge system scans each sponge into a computer so an alarm goes off if doctors are about to leave a sponge within a patient. After 200,000 surgeries performed with the Safety-Sponge, there has been not one retained object, said Rick Bertran, president.

The cost of the Safety-Sponge system, at $120,000 to $150,000 per 10,000 surgeries, could be far less expensive than at least one medical liability claim, Bertran said. The product is currently used in Florida only at Shands Healthcare in Gainesville and Jackson Memorial Hospital in Miami. Other competing products using similar technology may be used elsewhere in Florida, but most hospitals haven't acquired the technology.

Those in the medical malpractice arena have noticed a decrease in liability claims, an indicator due in part to fewer medical errors. It could also be that programs such as Sorry Works have helped reduce claims even when medical errors occur.

"It follows that a reduction in claims also reflects a reduction in medical errors," said Cliff Rapp, vice president of Risk Management at First Professionals Insurance Company, Florida's largest malpractice insurer. "It's anecdotal, but that's probably because of the heightened awareness to errors and different patient safety measures."