December 19, 1999|By NEW YORK TIMES NEWS SERVICE
WASHINGTON -- Federal investigators have documented almost 3,000 medical mistakes and accidents in less than two years at veterans hospitals around the country, and more than 700 patients have died in those cases, the Department of Veterans Affairs says in a new report.
The accidents and deaths occurred from June 1997 to December 1998, in the first 19 months of a new policy that requires employees to report medical errors and "adverse events." Since then, the department has been getting such reports at a rate of more than 200 a month.
The problems include medication errors, such as prescribing or dispensing the wrong drugs, the failure of medical devices, abuse of patients, errors in blood transfusions, surgery on the wrong body part or the wrong patient, improper insertion of catheters or feeding tubes, and a variety of "therapeutic misadventures" that caused serious injuries or deaths.
The comprehensive self-examination by the Department of Veterans Affairs, believed to be the first of its kind by any health care system in the nation, shows what could be expected if all hospitals had to report their errors, as recommended recently by the National Academy of Sciences. The number of reported errors would be high, but health care executives would get useful information about problems that need to be fixed, officials said.
Starting in June 1997, the Department of Veterans Affairs ordered its hospitals to report their mistakes to the agency's regional offices, which in turn send the information to Washington, where it is logged into an official file known as the patient safety register. Hospitals must try to identify the causes of each incident, to reduce the likelihood of repetition.
The new emphasis on patient safety was prompted by several factors: sporadic complaints of substandard care at veterans hospitals, pressure from Congress and the zeal of a senior official, Dr. Kenneth W. Kizer, who was undersecretary of veterans affairs from October 1994 to June of this year.
For decades, the veterans health care system had a reputation as hidebound and bureaucratic. But under Kizer, it emerged as a national leader in efforts to improve patient safety.
The report's author, Dr. James E. McManus, a surgeon from New York City who is the veterans department's medical inspector, said in an interview that "the adverse events reported by the VA were so serious that 24 percent of the patients died. One in four died." The study found 2,927 errors in the first 19 months of mandatory reporting, and 710 deaths.
The number of deaths in 1999 has not been determined. While each hospital analyzes its own cases, the department has not yet analyzed this year's figures for the nation as a whole.
As medical inspector for the Department of Veterans Affairs, McManus is a sort of watchdog and ombudsman, continually evaluating the quality of care provided to veterans. The department runs the nation's largest health care delivery system, with 172 hospitals, 132 nursing homes and more than 650 outpatient clinics.
McManus and other health care experts said they believed that the prevalence of errors at veterans hospitals was similar to that at other hospitals. "I don't think it's any different from the private sector," McManus said.
