Massachusetts hospitals see hike in surgical errors

Despite a decade-long campaign to reduce surgical errors, Massachusetts hospitals have seen a rise in these preventable adverse events, according to The Boston Globe.

Hospital reports for the first half of the year indicate that once all results are tallied, Massachusetts hospitals will see an increase of 65 percent of reported errors. The number is the highest since the state began collecting data five years ago, the Globe reported.

Health officials believe part of the reason behind the increase may be because the list of errors hospitals must report has grown and there is a wider definition of what constitutes surgery.  For example, the Globe said the state definition of surgeries now includes invasive procedures like biopsies, colonoscopies and electroconvulsive therapy.

However, Madeleine Biondolillo, M.D., director of Health Care Safety and Quality, told the Globe it's unclear whether actual rates of errors are increasing or whether hospitals are just recognizing and reporting them more often.

The famed 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System, estimated 44,000 to 98,000 Americans die each year as a result of medical errors. But Lucian Leape, a member of the committee that issued that report, told MedPage Today that based on the most recent studies, those statistics miss many more fatalities. 

"The big problem is that you can't rely on people to report when things go wrong," Leape said in a videotaped interview with MedPage Today.

According to the latest statistics from The Joint Commission, unintended retention of a foreign body and wrong-patient, wrong-site, wrong procedure, were the most frequently hospital-reported medical errors in 2012. But the accrediting agency notes that because the medical error-reporting is voluntary, it represents only a small proportion of actual events.

But surgical errors aren't the only type of preventable errors. Electronic health records also can create patient safety problems. Last week the Office of the National Coordinator for Health Information Technology (ONC) issued a Health Information Technology Patient Safety Action & Surveillance Plan that outlines guidance to make it easier for clinicians to report patient safety issues, calls for standardizing the reporting of adverse events, and urges organizations to work with the Joint Commission and Food and Drug Administration.

To learn more:
- read the Boston Globe article
- watch the MedPage Today interview with Lucian Leape
- check out the Joint Commission statistics (.pdf)
- here's the ONC's patient safety plan (.pdf)
- read the ION 1999 report (.pdf)

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