Monday, Jan. 10, 2011 | 2 a.m.
Last month, the Sun published the fifth and final installment of its series, “Do No Harm: Hospital Care in Las Vegas.”
After spending six months documenting the injuries, infections and surgical mishaps suffered by patients in Las Vegas hospitals, the Sun turned its focus to possible solutions to these problems, including efforts by doctors and nurses in other states to rethink approaches to patient safety.
Last week, KNPR 88.9-FM’s “State of Nevada” public affairs program assembled experts who talked about what can be done to make Las Vegas hospitals safer and whether efforts elsewhere, particularly in Chicago and Rhode Island, could be used here.
The panel, hosted by Ian Mylchreest, included: Marshall Allen, the Sun’s health care reporter and author of the “Do No Harm” series; Dr. Timothy McDonald, co-executive director of the Institute for Patient Safety Excellence at the University of Illinois Medical Center in Chicago; Dr. Mitchell Forman, president of the Clark County Medical Society; and Sandra Coletta, CEO of Kent Hospital in Warwick, R.I.
The conversation was transcribed by the Sun’s Nadine Guy and edited for clarity and space.
Mylchreest began by asking Allen about the most striking thing he had seen in his visits to hospitals in other states.
Allen: The most striking thing is that they take a radically different approach to cases of patient harm. I’ve talked to dozens of patients who have been injured or infected in hospitals here, and a lot of them weren’t even told what type of infection they had. They certainly have never gotten an apology. There was really no acknowledgment of the harm that had been done.
Mylchreest: But a lot of these mistakes are human errors. Don’t human errors happen everywhere?
Allen: Well, this isn’t so much human error, it’s systemic problems that lead to harm. It could be a matter of not cleaning a room properly. It could be a matter of a cord left across a walkway that leads to a patient tripping and falling.
Mylchreest: So these places had fewer medical errors and fewer infections than hospitals in Las Vegas?
Allen: We don’t really know that. I think one of the big problems with this is that nobody is really measuring these things carefully throughout the country, so it’s impossible to make comparisons about who has more and who has less. What we do know is that when these things are measured it happens an alarming number of times.
Mylchreest: Dr. McDonald, a patient at your hospital was accidentally injected with the wrong medicine. She went into cardiac arrest and barely survived. Tell us how the hospital dealt with that situation.
McDonald: This is a case in the operating room. A resident anesthesiologist had picked up the wrong vial and injected it in the patient thinking it was a different medication. Once the patient went into cardiac arrest the resident identified what had happened. They resuscitated the patient, but the patient ended up in the intensive care unit afterward.
Our system is set up to allow residents like that or nurses or other doctors report to our hotline, which is what happened in that case. We were able to lock down that operating room to try and understand what it is that had happened and realize that we had two vials that looked very similar.
So we were able to explain to the family what had happened and hold all hospital bills as well as professional fees, which is what we did, and to apologize to the patient and learn ways that we might be able to change our system to prevent that sort of thing in the future.
It turns out it’s a major problem nationally where you’ll have vials of medication that come into the hospitals that look fairly similar, and so a lot of hospitals really have to concentrate on the ways to separate those out.
Mylchreest: Do doctors get into a routine and feel maybe too comfortable about their routines?
McDonald: I’d say that’s absolutely true. Think about yourself, you know the last time you were in your bathroom and you picked up a bottle you thought was aspirin and you took it and then you looked later and realized “that was a vitamin I just took” because the bottle looked just the same.
You get used to doing things the same way and you might be right 999 times out of 1,000. But it’s the one in 1,000 when a patient can be harmed. So we have to rewire things to take it to the point where the airline industry is, where it’s more like one in a million.
Mylchreest: How about getting the doctors and nurses and the hospital staff to comply with those new procedures?
McDonald: You build it into your workday and your system where you’re not relying on the resident to read that vial. You don’t even put that vial where they can grab it. That adds one more layer of safety for that patient.
Mylchreest: One case changed the way things were being done at the hospital at University of Illinois-Chicago, where you work. You ended up deciding to pay for all the patient’s medical care. What did you have to do to get hospital administrators to sign on to that?
McDonald: That was one of our initial challenges, going to the hospital administration. But we made the case for it from the standpoint of it clearly is the right thing to do. It’s not appropriate to bill patients for mistakes that we make. We were also able to show that there was a financially appropriate reason not to bill these patients because in the long run you will make up that money in decreased litigation but also transparency — the dollars that we lost related to this event and how we begin to hold people accountable who may have been part of that dollar loss.
Mylchreest: It sounds like you’ve changed the whole mentality from that siege mentality of doctors versus lawyers to a more cooperative one. Is it paying off for the hospital?
McDonald: It is in our case. One thing that we spend a lot more time looking at is: Are we safer than we were three years ago? And one of the things we’re proudest of is a significant reduction in our patient safety events. Concomitant with that has been a reduction in our lawsuits and our claims and the dollars that we’ve paid out for those.
Mylchreest: Your hospital applied something called the seven pillars of safety. What are those seven pillars?
McDonald: The first pillar is reporting the incident. Pillar 2 is the beginning the investigation, which we try to trigger within the first half-hour of a report. Pillar 3: Effective communication to patients and families right away when harm occurs. And as we get information we’ll continue to be honest and share information. Pillar 4 is our apology and our disclosure as well as waiving hospital bills and in some cases, down the road, offering substantial financial compensation to patients and families. The fifth pillar is what we’re going to do to prevent it in the future. So that is the process or performance improvement. Pillar 6 is our quest to collect data on all of this, so we fully understand it. Pillar 7: Our commitment to educate everybody, particularly the youngsters, our medical students, our nursing students and our junior residents, with our belief that over time the culture will continue to change.
Mylchreest: Is there resistance by local physicians to joining with these safety practices?
Forman: I think there is a resistance on the part of everybody involved in this, from the hospital administration to some physicians to the legal system. This is not necessarily in the best interest of the legal system to have this happen.
My own feeling is there exists the laws, the guidelines, the regulations in place now in all of these hospitals. And the one area I think they’ve dramatically failed is enforcing them.
Becoming more transparent may be part of it. However, transparency without education, without learning from the experience, is a problem. We have to create an environment that talks about patients’ safety over and over again and create this culture, which it looks like they’ve done very successfully in Chicago.
Mylchreest: Do you think that same kind of solution might work in Las Vegas hospitals?
Forman: From what I understand about Dr. McDonald’s hospital is it was a self-insured hospital. So, comparing it to the typical situation we have here — private, for-profit hospitals — it’s a different equation.
Will they see the light, as obviously the administration and the legal system that Dr. McDonald’s hospital did? I simply don’t know. And the other part of it is: We have the attorneys who are suing physicians and different insurance companies. Will they come to the table, too?
I don’t know if the exact same thing could happen here, but I’m not sure that it’s necessary. Stressing safety, incorporating it into the system, creating a culture that looks at transparency and education, accountability and laws, is what we need to enforce here.
Allen: You want patients to be more involved in their health care. Isn’t it a bit paternalistic to suggest that patients aren’t able to understand something like an infection rate? And for instance, if an infection rate is two or three times higher at Hospital A than it is at Hospital B, wouldn’t they understand enough to know that they might prefer to go to Hospital B?
Forman: I think that information can also be misleading in the sense that, “Look at this particular hospital. This is an inner-city hospital and it gets tremendous trauma victims.” It’s very different from a community hospital where you see certain kinds of infections. You need to look at each case individually.
Mylchreest: But isn’t that a kind of a Catch-22? You want patients to be better informed and to be more mindful consumers of health care, but then the information often isn’t available.
Forman: I absolutely agree that the information needs to be made available, but it needs to be packaged in a way that people can understand.
Mylchreest: Dr. McDonald, I want you to weigh in on the transparency question. Part of the seven pillars is to report things immediately. How does that reconcile with keeping consumers in the know and not sensationalizing things?
McDonald: It’s nothing more than being honest with patients and their families from the beginning of the therapeutic relationship until its end.
Mylchreest: Sandy Coletta, you’re CEO of Kent Hospital in Warwick, R.I., which changed its protocol when a man died of a heart attack in the emergency room. The man turned out to be the brother of actor James Woods, who filed a lawsuit against the hospital. The hospital apologized and reached a private settlement. What happened with James Woods’ brother, Michael, when he came to Kent Hospital?
Coletta: The specifics of his case are something I’m not going to get into, but what came of it was our hospital needed to look at itself in a mirror. We think about transparency as having people be able to see into your organization and information, but you also have to be willing to see yourself.
In the case of Michael Woods, it became very obvious that we had not done everything that needed to be done and that there were physicians’ orders that were not carried out. Our patients and our community trusts us, and we have to be willing to accept and acknowledge where we have failed and take that responsibility and then work to make sure it doesn’t happen again.
Mylchreest: So what have you done?
Coletta: With the Woods family, we created the Michael J. Woods Institute at Kent Hospital. Our health care system has evolved through a whole array of changes and Band-Aids and policies and ways to try to prevent error, all layered one on top of the other. And from our perspective, we’ve decided it’s time to step back and rethink and redesign how care is delivered.
Mylchreest: This has obviously been a huge cultural change for the hospital. Why is it so difficult to implement?
Coletta: This can’t happen at an organization unless leadership drives it. Otherwise those barriers of being afraid, of “what’s going to happen to me if I say something or if I do something” get in the way. I don’t know that they, all to the last individual, feel comfortable yet. It is a long process, but we’re also going to do our best to identify risks and remove the risk or put a protective barrier in, so that the patient is not harmed.
Mylchreest: Dr. Forman, Rhode Island is similar to Las Vegas in that it doesn’t have all of the medical facilities that big-city hospitals do. Do you think we can draw some lessons from what happened with Sandy Coletta and James Woods’ family?
Forman: Absolutely. Promoting patient safety is a good business model for a hospital to follow, for them to be involved in litigation, for them to have to constantly address issues regarding patient safety is not smart business. I think along those lines we can do a lot more than what we’ve done in the past, but doesn’t necessarily mean reinventing the system. It means enforcing existing guidelines, rules, regulations and laws.
Mylchreest: So what’s stopping them from doing that?
Forman: I think part of it is being complacent. Part of it is you get to do the things a certain way. Part of it is not educating people and reinforcing the education over and over and over again. It’s not holding people accountable.