The Star-Ledger

Bad And Good News On Hospital Errors

State says higher numbers mean greater honesty and compliance

The Star-Ledger — Thursday, December 18, 2008

BY SUSAN K. LIVIO
Star-Ledger Staff

At first glance, the news appears bleak: Seventy-two people died from preventable hospital errors in New Jersey last year — 30 more than in 2006, according to a report released yesterday.

But state health officials and consumer advocates say they don't believe hospitals were more prone to fatal errors. Rather, they say, more hospital executives are complying with a law requiring that they disclose errors and work with the state to prevent them from happening again.

"Not only is there more hospital reporting, hospitals are now much more skilled at analyzing their patient care systems when there is an error and developing sophisticated solutions," Health and Senior Services Commissioner Heather Howard said.

According to the third annual Patient Safety Act report, 75 of the 80 hospitals operating last year disclosed 456 errors in 2007 — compared with 71 of 81 hospitals reporting 450 mistakes in 2006. In the law's inaugural year in 2005, 68 of 82 hospitals reported 376 errors.

The average number of events per hospital rose to 5.7 in 2007, up from 4.6 in 2005, according to the report. Only one hospital did not report during the entire three-year period. Howard contacted the sole holdout and this year, the hospital is complying with the law, said health department spokeswoman Donna Leusner. Five hospitals did not report in 2007.

AARP-NJ representatives, who keep close tabs on the law, said they agree that the rising numbers probably means "better reporting."

"We would expect the numbers are going up. Hospitals are getting better at training staff to report," said Patricia Kelmar, associate state director for advocacy for the 50-and-above consumer group. "This is good news."

As in the previous reports, falls and bedsores continue to be among the most frequently reported mistakes. Patients fell 197 times in 2007, up from 165 in 2006 and 125 in 2005.

Falls were responsible for 14 patient deaths last year, according to the state's analysis of the data. Patients fell due to a lack of planning, inadequate staff training and poor communication between workers.

Pressure ulcers, more commonly known as bedsores, continue to be a problem among patients — typically men — who log long hospital stays, affecting 65 patients in 2007. As with falls, bedsores were allowed to grow because of inadequate planning, training and communication, the report said.

But the occurrence of bedsores has declined from 2006 and 2005, when 129 patients and 77 patients, respectively, were afflicted. The decline in pressure ulcers may be a result of the program sponsored by the state and the New Jersey Hospital Association that focused on patient care and pressure ulcer prevention, according to the report.

There were 63 mistakes last year involving surgery, such as the patient getting the wrong procedure or a foreign object being left inside the patient. As a result, 17 patients died, according to the report.

Some consumer groups like AARP have criticized the Patient Safety Act because it does not require the state to reveal the names of the hospitals where mistakes occurred. Lawmakers argued that promising confidentiality was the only way the state could get hospitals to cooperate with reporting and correcting mistakes.

Yesterday, AARP, the New Jersey Hospital Association, and Sen. Joseph Vitale (D-Middlesex), who sponsored the act, acknowledged they've been working on another piece of legislation that would provide more consumer information about hospital safety.

Vitale said he introduced a bill Monday that would disclose hospital "never events" — mistakes that should never happen, such as giving a patient the wrong blood type, wrong-side surgeries and falls resulting in hip fractures. Some of these events are included in the Patient Safety Act reporting, but the information comes from billing and administrative records.

"No one could argue these events should not be reported," Vitale said.

The Hospital Association is open to releasing information about serious safety-related incidents to keep consumers informed, as long as reporting under the Patient Safety Act — which includes an internal analysis of what went wrong — remains intact, said Helene Holmes, vice president for clinical affairs.

"The Patient Safety Act is working the way we want it to," she added.

The report may be found at http://www.state.nj.us/health/ps.

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