Many Maryland hospitals are not complying with a law that requires them to tell the state when patients are seriously disabled or die after unexpected events such as medical mistakes, a state analysis concludes.
The state's Office of Health Care Quality also found that even hospitals reporting the injuries often do so late and may be keeping patients and their families in the dark.
"There needs to be a culture change at hospitals," said Carol Benner, who officially retired yesterday as director of the health care quality agency after earlier handing over day-to-day duties to acting director Wendy Kronmiller. "Some hospitals still want to sweep things under the rug."
Still, the state hasn't issued any fines, which can run to $500 a day. Benner and Kronmiller say hospitals need more time to learn about the reporting system, which took effect in March 2004 and is designed to encourage them to acknowledge and fix problems.
The state agency acts as patient safety educator as well as hospital cop. It keeps self-reported problems confidential and assigns some employees to work with hospitals on improving patient safety, rather than punishing the hospitals. In contrast, if the state office learns about an adverse event from a complaint, it launches an investigation that could result in sanctions as harsh as the revocation of Medicare payments.
Maryland hospitals reported 125 serious adverse events from July 1, 2004, through June 30, including 85 deaths. Based on an Institute of Medicine study that suggested as many as 98,000 inpatients a year die nationally because of medical errors, Benner said Maryland's 69 hospitals could be expected to report 1,200 or more serious adverse events per year.
The new law requires hospitals to report all Level 1 adverse events, defined as those that result in death or serious disability.
An adverse event is an unexpected occurrence related to medical treatment, not to the natural course of a patient's illness. The law defines serious disability as any impairment that limits a major life activity and lasts longer than seven days or is present at discharge.
The state's analysis showed:
Hospitals reported that they told families about such adverse events in only 46 of the cases -- just 37 percent -- despite the fact the
law requires such notification.
Ten hospitals reported more than half of the Level 1 adverse events. The high level of reporting from the 10 indicates they have aggressive patient-safety programs, Benner said.
Twenty-seven hospitals, or 39 percent of those required to report, didn't report any events.
Underreporting is common in systems that ask health-care providers to confess to internal problems, studies have shown.
One reason is that hospitals are accustomed to investigating medical errors and accidents in secretive peer-review sessions, where individuals are either blamed or absolved. While patient-safety efforts in recent years have focused increasingly on fixing faulty processes rather than blaming individuals, hospitals worried about giving ammunition to malpractice lawyers still balk at telling all to outsiders.
"It's easier to report this to someone that's not a cop," said Mary Whittaker, director of quality assurance at Greater Baltimore Medical Center.
GBMC was one of two hospitals cited for failing to comply with the adverse-event reporting rule last fiscal year. Whittaker, who joined GBMC after that period, said the hospital has revised its procedures to ensure it complies. Bon Secours Hospital, also cited for noncompliance, has done the same, spokeswoman Phyllis Reese said.
"We welcome the process," Reese said. "We see this as an opportunity to check and balance our procedures."
Mandatory reporting is one part of a multipronged approach the state is taking to improve patient safety.
Legislation also mandated last year's creation of the Maryland Patient Safety Center, now run by the Maryland Hospital Association and Delmarva Foundation, an Easton-based quality-improvement consultant. The center already has trained about 2,500 health-care workers in patient safety, association spokeswoman Nancy Fiedler said. It's also developing a system for hospitals to confidentially report and learn from "near misses" -- incidents that nearly resulted in injuries but were caught before they did.
Even the limited adverse-event reporting Maryland hospitals are doing shows the rules pack potential to identify problems causing injuries, state and hospital association officials said.
The hospitals are required to submit analyses showing the root causes of the mistakes or accidents. The Office of Health Care Quality already has used them to issue alerts to other hospitals so the mistakes aren't repeated. One alert, for example, warned that 20 falls resulting in death or serious disability had been reported. Half were fatal, most of them because of traumatic brain injuries.
But an alert the office plans to issue soon shows just how much some hospitals have to learn. It tells the story of an operating-room patient who was burned when a physician using a cautery accidentally ignited a patient's oxygen. One of the hospital's suggested solutions: Educate patients on how to avoid operating-room fires.
That, the alert says, "seeks to spread the blame to a class of people who are least at fault in OR fires -- patients!"