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Hospital patient mishaps top 300

State report: Perilous falls occur the most

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By Stephen Smith
Globe Staff / April 9, 2009
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More than 300 Massachusetts hospital patients last year suffered perilous falls, got the wrong medication, or had medical instruments left inside them, according to a report released yesterday by state health officials.

The study - the most detailed portrait of its kind in Massachusetts - tallies episodes at every hospital, with the number ranging from none to 25 per institution. Many are deemed preventable.

Falls accounted for nearly two-thirds of the 338 episodes - referred to in the study as "serious reportable events" - that hospitals recorded in 2008. One hospital discovered that many of those tumbles happened when unsteady patients tried to make their way to the bathroom without assistance.

The state concluded that 19 deaths could be linked to the events. Hospital errors have been blamed for as many as 90,000 deaths a year in the United States, and health officials nationwide have argued that making those mistakes public will increase accountability.

St. Vincent Hospital in Worcester reported the most events, with 25. By comparison, Boston Medical Center, with nearly twice the patient volume, had just six.

But Department of Public Health regulators who drafted the study, as well as independent safety specialists, cautioned that consumers should not treat the findings as a quality report card, especially because they represent an inaugural assessment. The findings could be skewed, they said, by hospitals that are especially vigilant about reporting, and by others that more narrowly interpret the requirement.

"A high number of cases at the end of the day could be a signal of an organization that has a strong culture of safety and transparency," said Jim Conway, senior vice president at the Institute for Healthcare Improvement, a Cambridge think tank that works with hospitals to improve safety.

"But before we get lost in the numbers," he said, "we should remember that every one of these was a name, a face, somebody's mother, somebody's father, somebody's brother, somebody's sister."

Authorities acknowledged the roster of cases from last year almost certainly understates the scope of the problem. That became clear when state safety specialists reviewed the number of serious pressure ulcers - commonly known as bedsores - reported by hospital.

For all of last year, only a dozen such skin ulcers, which can lead to lethal infections, were reported statewide. Through the first three months of this year, 12 had already been brought to the attention of regulators.

"We have to make it the case that the hospitals view the failure to report a serious reportable event as worse than the occurrence of a serious reportable event," said Paul Dreyer, director of the state's Bureau of Health Care Safety and Quality.

No disciplinary action was taken against hospitals based on their total number of events. "The purpose of reporting is not to punish hospitals," said Dreyer, adding that medical centers can face sanctions if an event is particularly egregious.

Dreyer said field investigators regard St. Vincent as being especially conscientious about reporting serious falls or significant mistakes.

Dr. Octavio Diaz, St. Vincent's hospital's chief medical officer, said in an interview that doctors, nurses, and other staff members are urged to come forward swiftly - and without fear of retribution - if they see an error.

"If you have secrecy or you don't report these events openly and willingly, you're less likely to recognize them as serious events," Diaz said. "We want to recognize them . . . and do something about them."

Falls constituted nearly half of the incidents at St. Vincent, so the hospital embarked on a campaign to reduce those episodes. For example, certain patients now wear colorful slippers or booties that designate them as fall-prone, to alert staff members to be on the lookout. So far this year, only one patient has suffered a serious fall.

At Norwood Hospital, administrators grew concerned about a rash of falls on a ward for older patients with psychiatric conditions. The hospital reported 16 serious events last year - nearly all falls - which was one more than Massachusetts General Hospital, a busier medical center.

Like St. Vincent, Norwood adopted strategies to prevent falls. That meant adjusting medications that can leave patients dizzy. Patients' vision was tested, too. And staff members noticed that at dinner time, a tangle of patients wielding walkers, crutches, and canes created a dangerous gridlock.

Dr. Justine Carr, chief medical officer for the hospital's parent company, said administrators recognized that going public with patient injuries could wound an institution's reputation.

"It's very hard for us to feel singled out because we have this very needy population that we've struggled with," said Carr, who is also senior vice president for quality and safety for Caritas Christi Health System. "But we're beyond that. It's better to report and keep learning, and hopefully the public understands that."

Stephen Smith can be reached at stsmith@globe.com.