This article first appeared in the St. Louis Beacon: July 28, 2008 - Let's say you're a recent transplant from Minnesota, now living in St. Louis, and as luck would have it, you're facing surgery with a hospital stay.
You've heard the hospitals in St. Louis are good -- some said to be among the nation's best -- but maybe you want to do some comparison shopping. In Minnesota, when your mother needed surgery, you went online to the state's health department website.
There you found a consumer health guide, with each hospital in the state reporting serious medical errors. It's been required by the state of Minnesota since 2003, as a way to identify and reduce medical mistakes.
Minnesota collects information about 28 kinds of serious medical errors. Also known as "never events," these are mistakes or lapses in treatment that everybody agrees should never happen, like operating on the wrong person or body part, leaving foreign objects in the body after surgery, fatal or severely disabling medication overdoses or serious bed sores. Since 2003, seventy-six wrong-site surgeries have been reported in Minnesota. (See list at the end of the article.)
Now you look for the same kind of information in Missouri. Not much to be found here. There's some basic and rather vague information on the Missouri Department of Health website comparing hospitals on rates of surgical and bloodstream infections.
But nothing on deaths or serious injury caused by medical errors.
Although 26 states now require hospitals to report serious medical errors, the state of Missouri does not -- not even to the Department of Health.
"We're still in the mode of secrecy here," said Louise Probst, executive director of the St. Louis Area Business Health Coalition , a group of major local employers that wants to improve the quality of health care in the St. Louis area. As part of that effort, the coalition released a report in October 2007 declaring that the St. Louis region is making "a C at best" in health-care quality, given its ranking in national studies.
"We really lag in terms of public reporting," Probst says. It's a situation that she calls "shameful."
The situation is different in Illinois. Stemming from a law that was passed in 2005, hospitals and surgery centers in Illinois have been required to publicly admit if they commit any of 24 types of "never events" since Jan. 1, 2008. The law also requires hospitals to analyze the cause and take corrective action after each event. As in other states, names of patients and health-care workers involved in the incidents remain confidential, and Illinois officials won't take disciplinary action for the mistakes.
Illinois also requires hospitals to report infection rates, nurse staffing and mortality rates, and give data pertaining to 30 common procedures.
Fact-finding Leads to Problem Solving
One of the reasons for public reporting of medical mistakes is that a community can't begin to address a problem unless it knows what it's dealing with.
"A lot of times people think, there's a problem in health care, but not with my doctor, or my hospital. I'm safe," Probst said. "It occurs in all communities. It occurs to everybody."
When asked, doctors and nurses say they support public reporting of serious medical errors. But they give a variety of reasons for why it hasn't happened in Missouri.
"For the 15 years I've been a physician, (public reporting) has been a problem," said Dr. Tom Hastings, a physician on staff at St. John's Mercy, St. Luke's, Missouri Baptist and Des Peres hospitals.
"We're kind of dysfunctional," he said of the local health-care industry. "We're fearful of (public reporting) but we know we need it."
Hastings said he's always wondered why the health-care profession couldn't be more like the airline industry when it comes to dealing with mistakes and improving safety.
"In the airline industry, any near-miss gets reported," he pointed out. The causes of the near-accident are analyzed and publicized and any information gained on how to prevent another one is shared with all airlines.
Efforts by the coalition and others to get the Missouri Legislature to pass a law mandating public reporting have gone nowhere. Laws have been introduced the past two years but never made it to a final vote.
Even some of the reporting by a handful of area hospitals to a national health-care quality survey has gotten scantier. Three years ago, the coalition recognized seven area hospitals for reporting figures to the Leapfrog Group. That organization was started in 2000 by several Fortune 500 companies in the wake of the landmark 1999 Institute of Medicine study, which reported that 70,000 to 90,000 lives are lost annually to hospital errors. The Leapfrog survey seeks to measure and reward quality health care.
This year, the number of area hospitals reporting to Leapfrog is five -- Anderson Hospital in Maryville, Ill., Des Peres Hospital in Des Peres, Jefferson Memorial Hospital in Crystal City, Lincoln County Medical Center in Troy and St. Louis University Hospital in the city.
In its report last year, the local Business Health Coalition said "the St. Louis region continues its distinction as having the lowest hospital reporting of Leapfrog's 32 regions."
St. John's Mercy Medical Center was one of the first area hospitals to report to Leapfrog, according to Tracey Moffatt, vice president of performance improvement at St. John's. But the hospital dropped out in 2006, because participating proved irrelevant, she said.
Moffatt said none of the hospital's regional health payers ever adopted Leapfrog as the "gold standard" for patient referrals. "There was no payback" for St. John's, she said.
Yet on its website, Leapfrog says that more than 1,300 hospitals currently participate in the survey, representing 58 percent of all hospital beds in the country.
Heartburn for Hospitals
Local hospital officials will tell you that public reporting is a scary issue for them, in part because they fear they won't be compared fairly. They say that health-care watchdogs need to focus first on making sure that reporting is standardized.
"Everybody is for transparency," Moffatt said. "I think the reason hospitals are reluctant to get involved is because what's being talked about is reporting, rather than the process of reporting. That's what gives us heartburn."
Moffatt said she traveled to Minnesota just a year ago with a team of people from three other hospitals to look at that state's public reporting of hospital errors. The team found an impressively standardized and fair system, she said.
"The thing I love about Minnesota is that their hospitals got together and agreed what the data would be," Moffatt said. "I'd like to see us begin that journey. Minnesota would tell you it took them years to get there."
Denise Murphy, vice president of safety and quality for Barnes-Jewish Hospital, also says she favors public reporting of serious mistakes, "but it needs to be done very, very thoughtfully," she said. "It should be done with some statewide standards."
Other states besides Minnesota have figured out how to report data fairly. In 2004, New Jersey passed a law requiring hospitals to report serious, preventable adverse events to the state and to patients' families. Connecticut has adopted a mix of 36 events that hospitals and outpatient surgical facilities must report. And California now requires hospitals to disclose 28-never-events.
Pennsylvania compares hospitals on mortality rates for a wide range of illnesses and throws in each hospital's average charge to boot.
Murphy says she's concerned about hospitals being over-legislated, which she says has been a complaint in Pennsylvania.
"We have to be careful that we don't tip this over to such a highly regulated business that we end up having data graveyards, where people are not allowed the time at the front line to make things better," she said.
Reduce Infections to Zero
To those who talk about the problems of comparing hospitals fairly, a nationally recognized leader in reducing hospital-acquired infections basically says: "Get over it." In a speech here last year, Dr. Richard Shannon challenged the St. Louis medical community to set a target of zero for eliminating such infections.
Shannon, chairman of the Department of Medicine at the University of Pennsylvania Health System, set a goal to reduce hospital-acquired infections to zero in the coronary and intensive care units when he was chairman of Allegheny General Hospital. Using workplace techniques developed by Toyota, Dr. Shannon was able to reduce such infections to nearly zero within 90 days, a rate that has been sustained for four years.
When hospital officials say that some infections can't be helped, Dr. Shannon has an answer: "Please raise your hand if you want to get one."
There is a developing trend, however, that may push hospitals toward reducing medical errors, and it boils down to money. Except for lawsuits, hospitals in the past weren't financially motivated to reduce errors. As the coalition points out, "Health care is one of the only industries where the customer pays for mistakes."
But that's beginning to change. Starting in October 2008, Medicare will no longer pay for five "never events" and certain infections. And some large private insurers are starting to follow the government's lead. Last year, Blue Cross Blue Shield announced it won't pay; in April, CIGNA said it wouldn't, either.
Moving Toward Disclosure
More hospitals do seem to be disclosing medical errors to patients, if not to the general public. In 2005, Barnes-Jewish Hospital began developing a disclosure-training program with staff, Murphy said.
As part of that effort, Murphy took the unusual step of asking the parents of a young man who was killed by a medical mistake at Barnes to make a videotape of their experience for Barnes staff.
Michael Jaggers was recovering from a stem cell transplant for Hodgkins disease at Barnes in September 2000, when he was given a dose of morphine that was five times what he should have received, say his parents, David and Jonet Jaggers of St. Peters.
Michael died three weeks later, after being taken off life support. He was 28, a strapping 6-foot-7-inch athlete who had been the center on his basketball team at Francis Howell High School.
Two days after the mistaken dose, with their son in a coma, a Barnes doctor told the Jaggers what had happened to Michael. A hospital investigation determined that a part-time nurse who was working the Labor Day holiday had failed to reduce the flow of an IV drip to compensate for a new bag of morphine that had a higher concentration, the Jaggers say they were told. Doctors had decided to increase the morphine dose for Michael because he had developed sores in his throat from chemotherapy.
"We were really blown away," said David Jaggers, when the couple was first told of the mistake. But they say what helped them get through their shock and grief was the honesty of a Barnes doctor.
So, when Murphy approached the Jaggers three years ago and told them, "We want to make Michael the poster child for patient safety" at Barnes, the Jaggers were willing. About a year ago, after the couple retired, they also joined the hospital's patient safety and quality committee.
"We told Michael's story on video," said Jonet Jaggers. "And Barnes is using that to help doctors understand the importance of disclosing, because it really made it much easier for us to deal with. If they had tried to cover it up, it would have been so much worse."
Despite what they've gone through, the Jaggers see the same pitfalls that hospital officials mention when it comes to reporting serious medical mistakes to the public. They don't think public reporting would have prevented the mistake that killed their son.
"I think it's a good idea, but there's a lot of education needed to interpret the data," David Jaggers said. "It could be helpful, but it could also be detrimental, too. It depends on how they report."
Those who favor public reporting of never events say it should be done with the aim of improving hospital quality, not as a punitive measure.
"There needs to be a change in mindset for the community," said Dr. Hastings. "If you're reporting never events, that means you're interested in quality, that you don't want it to happen again."
Hastings said he also thinks that public reporting will only happen when state law requires it.
"That's the unfortunate reality," he said. "There's been ample opportunity to voluntarily report and it hasn't happened."
So if the legislature doesn't act and hospitals won't push the envelope, how will public reporting ever come to Missouri? Probst thinks it has to come down to patients themselves, those who pay for the care and are victimized by the mistakes.
"It needs to come from the consumers and purchasers," she said. Mistakes in medicine "are a lot more common than people realize."
28 never events
The St. Louis Business Health Coalition has endorsed adoption of this list of so-called "Never Events" and is encouraging hospitals not to bill for these incidents should they occur. If any of these events have occurred to you or members of your family the Beacon would be interested in learning about them and following up.
- Surgery performed on the wrong body part
- Surgery performed on the wrong patient
- Wrong surgical procedure performed on the patient
- Retention of foreign object after surgery or other procedure
- Stage 3 or 4 ulcers (bedsores) acquired after admission to the facility (not necessarily resulting in death)
- Artificial insemination with the wrong donor sperm or egg
- Any incident in which a line designated for oxygen or other gas contains the wrong gas or toxic substance
- Infant discharged to the wrong person
- Care provided by a person impersonating physician or nurse
- Abduction of a patient
- Sexual assault of a patient
Death and disability associated with:
- Medication error
- Incompatible blood/blood products administration
- Labor or delivery of low-risk pregnancy
- Hypoglycemia
- Hyperbilirubinemia in neonates in the first 28 days of life
- Spinal manipulative therapy
- Use of restraints or bedrails
- Electric shock or elective cardioversion
- A fall
- A burn
- Death due to unusual causes following surgery
- Contaminated drugs or devices
- Device malfunction
- Intravascular air embolism
- Patient disappearance
- Patient suicide or attempted suicide
- Physical assault of patient or staff
Joan Little is a St. Louis freelance writer.