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More stories on serious hospital errors report (DS)


WORCESTER — St. Vincent Hospital had more patient accidents and medical errors last year than any other acute care hospital in the state, according to a state Department of Public Health report released this week.

St. Vincent had 25 “serious reportable events” last year. There were 12 patients who were seriously injured from a fall, four surgeries in which doctors left a foreign object inside a patient, three medication errors, two suicide attempts, two pressure ulcers (bedsores), one air embolism (gas in the bloodstream), and one burn.

St. Vincent’s total number of incidents was higher than much larger Boston hospitals such as Massachusetts General Hospital (15), Brigham & Women’s Hospital (18) and Beth Israel/Deaconess Medical Center (17). Locally, the University and Memorial campuses of UMass Memorial Medical Center each had six incidents.

At St. Vincent, officials said their commitment to patient safety, and the administration’s encouragement to staff members to come forward and report errors without risk of punishment, may have inflated their high number in comparison with other institutions.

“One of the risks we run when you have this robust reporting is we might have more incidents than any other hospital,” said Dr. Octavio Diaz, chief medical officer at St. Vincent Hospital. “We reassure our staff that reporting these events is the right thing to do.”

There were more than 300 such events reported by acute care hospitals statewide, which led to 19 deaths, according to the report.

The state officials who compiled the information cautioned against using it to assess hospitals.

Last year was the first in which hospitals were mandated to report such incidents. DPH officials said that the data is too new, and the reporting practices of different hospitals too varied. No hospital faces punishment for having too many reportable events.

“In no way would we want to use these numbers to evaluate the quality that a hospital provides,” said Paul Dreyer, director of the state’s Bureau of Health Care Safety and Quality. It’s possible, he said, that a high number could very well indicate that a hospital such as St. Vincent is reporting its incidents more accurately than other institutions.

As an example, he pointed to pressure ulcers, also known as bedsores. There were 12 serious bedsores reported statewide by hospitals in all of last year. Through March, there already have been a dozen incidents of bedsores reported.

“As the reporting gets better, we might even see some numbers go up,” Mr. Dreyer said. “The goal is to reduce the occurrence of these events, and to track the progress toward this goal.”

To limit falls, St. Vincent has begun having patients at risk of falling wear yellow hospital gowns and booties, as an alert to hospital staff. Most patients wear either blue or brown gowns. Patients at risk for falls now have their medication dosages checked more often than other patients, he said, and staff has increased the number of times it will help such patients get to the bathroom or to a chair.

So far this year, only one patient at St. Vincent has been seriously hurt in a fall, according to the hospital.

To address leaving foreign objects in patients after surgery, St. Vincent will tag all of its surgical equipment and sponges with a pill-size transmitter. After every surgery, in addition to accounting for every item, an electric wand will be waved over the patient to check for hidden items.

“Any time someone is injured or a mistake is made, it is really a very serious event,” said Dr. Walter H. Ettinger Jr., president of UMass Memorial Medical Center. Every accident or mistake is thoroughly examined to try to prevent them in the future. UMass Memorial also uses a color-coding system for patients at risk of a fall, using bracelets.

He said the fact that hospital errors and accidents are made public motivates hospitals to improve.

“As a hospital administrator, when I know we’re going to be rated on something, we’ve got to pay attention to it,” he said. “It’s a big culture change for medicine. When I started 30 years ago, you would never admit you made a mistake.”

Dr. Mario Motta, president-elect of the Massachusetts Medical Society and a physician at Salem Hospital, said the results should help hospitals improve their quality of care.

“Accidents happen, we’re all human,” he said. “You want to make sure you can learn from your mistakes.”

Dr. Motta said he was not alarmed by the number of falls at St. Vincent, as there are any number of reasons why patients might have fallen. Hospitals used to tie down patients at night to keep them from getting up and hurting themselves. That practice, for obvious reasons, has been eliminated.

“When you allow patient freedom, you increase the risk of falls,” he said. “It becomes trickier to deal with.”

But four surgeries in which objects were left inside a patient, as happened at St. Vincent last year, is a major problem, he said. “They need to immediately conduct a quality review and identify the problem,” he said. “I’d be looking to see what’s going wrong in that operating room.”

MetroWest hospitals have few medical mishaps, says report

By David Riley/Daily News staff
The MetroWest Daily News
Posted Apr 09, 2009 @ 11:25 PM

Hospitals west of Boston say they already have taken steps to prevent patient falls, surgical errors and other medical mishaps detailed in a public report by state health officials this week.
PDF: Read the report on serious hospital events

The study, the first of its kind, tracks a year of patient safety data reported by every acute-care hospital in Massachusetts. The report looks at 338 "serious reportable events," ranging from performing the wrong procedures on patients to medication errors to crimes committed on hospital grounds.

Local hospital officials said the new public reporting requirements are mostly positive.

"We should be held accountable," said John Polanowicz, president and CEO of Marlborough Hospital. "By and large I think we take really good care of the communities we serve."
But along with the Department of Public Health, hospitals warned against judging a facility’s care on the first year of results.

Like facilities throughout the state, falls made up the vast majority of incidents at local hospitals.

MetroWest Medical Center reported three falls, while Marlborough Hospital reported only one. Milford Regional Medical Center saw five falls and Newton-Wellesley Hospital had four.
MetroWest also reported a "retained foreign object" left in a patient after a surgical procedure at its Leonard Morse campus in Natick, as well as a sexual assault reported on its Framingham Union campus.
Police investigated the assault allegation and found it to be without merit, said Dr. Michael Gottlieb, chief medical officer at MetroWest Medical Center.

"Sometimes we need to report these events prior to their full evaluation," he said.

Gottlieb said he could not discuss specifics on the foreign object left in a patient, but the hospital has stepped up already-strict procedures meant to prevent a sponge or smaller object being left in a wound.
Among other precautions, doctors and staff are required to count all instruments and gauze pads at various times in a procedure to make sure nothing is missing, Gottlieb said. Most hospitals have similar policies.

"People are people, and we have to have procedures in place that will allow us to function in as error-free a way as we possibly can," he said.

The Department of Public Health investigated all reported incidents, and each was resolved to their satisfaction, Gottlieb said.

Caritas Norwood Hospital reported 15 falls. All but one of happened in a geriatric psychiatry unit that many other facilities do not have, Marketing Vice President Teresa Prego said.

The hospital last December launched several initiatives to reduce falls. While five falls happened in the first quarter of 2008, only one has happened so far this year, Prego said.

"We’re very focused on tracking these kinds of things and looking for continuous improvement," Prego said.

Keeping patients mobile and social is important, but also can puts them at greater risk of falling, Prego said. The hospital has started pharmacy consults when patients are admitted to see if medication makes them dizzy or prone to sudden drops in blood pressure.

Patients also are evaluated to see if a cane, walker, exercises or other aids might help their steadiness, Prego said.

The hospital found that most falls happened during an unstructured time after dinner, and now has more organized social activities with full staffing, Prego said.

Both Polanowicz and Gottlieb said modern hospitals have rightly moved toward using restraints on patients as little as possible, but that can also increase the risk of falling.

At Marlborough, staff assess patients to see if they are prone to falling. If so, they wear purple wristbands and non-stick slippers, as well as having purple star magnets affixed outside their rooms, Polanowicz said.

Nursing staff also responds as quickly as possible to calls from patients to help them safely to the bathroom and other places, both hospitals said.

While falls can be minimized, they are difficult to eliminate completely, Gottlieb said.

"I think we all know of patients or relatives or things that have happened in our own family where frail elderly have fallen right under our own eyes," Gottlieb said.

Hospital and state officials say the new reporting requirements foster conversations on why these problems happen and how to prevent them. Most already tracked this type of information.

"Health care should not be a blind item for people when they’re entrusting their lives essentially to other people," Gottlieb said.

But the state and hospitals also cautioned that in the first year, some facilities may have reported incidents more aggressively than others. Information will prove more useful over time as facilities work out kinks in reporting, they said.

Officials at Milford Regional Medical Center and Newton-Wellesley Hospital could not be reached for comment yesterday.

(David Riley can be reached at 508-626-3919 or