Report: Hospital Errors Often Unreported

Jan. 6, 2012 — -- Martine Ehrenclou felt sidelined when her mother was admitted to the hospital for acute pancreatitis.

"I didn't know what I was supposed to do and what my role was in her care," said Ehrenclou, 51, of Los Angeles. "I just thought I needed to comfort my mother and just talk to the doctors."

But what was explained to Ehrenclou as a common procedure for the condition turned fatal. While in the hospital, Ehrenclou's mother, who was 71, acquired a host of complications including pneumonia and a staph infection.

Within five months, Ehrenclou's mother died.

"It just happens," Ehrenclou recalled hospital staff members telling her.

"I didn't even know what to ask about what her medical records said, and whether there was anything indicated about a medical error," she said.

Hospital staff members could have made some mistakes with her mother's care, but Ehrenclou would never know.

A new report released Friday by the inspector general of the U.S. Department of Health and Human Services found that more than 80 percent of hospital errors go unreported by hospital employees.

The report, which looked at data from hospitalized Medicare patients, also found that most hospitals where errors were reported rarely changed their policies and practices to prevent repeat errors, saying the event did not reveal any "systemic quality problems."

The errors included overused or wrong medications, severe bedsores, hospital-based infections and even patient death.

In order to be paid by Medicare, hospitals are required to track and analyze medical errors. But organizations that inspect hospitals loosely regulate hospital tracking records, the study said.

Also, many hospital employees may not recognize "what constitutes patient harm," or they may not realize that particular events harmed patients and should be reported, according to the report.

The national report looked at nearly 300 adverse patient events acquired from medical records and traced the records back to its respective hospitals to see whether the hospitals had identified medical error. The report found very few hospitals did.

Sixty-one percent of unreported cases were not perceived as errors by hospital staff. The remaining 25 percent of unreported cases were situations that were typically reported by the staff, but happened not to be reported.

"We're always going to make mistakes," said Dr. Peter Pronovost, medical director at the Center for Innovation in Quality Patient Care at Johns Hopkins University Medical School of Medicine. "What we need to do is reduce harm."

The more serious events, like hospital-acquired infections and patient deaths, were no more likely to be reported than the smaller cases, like allergic reactions to medications.

Pronovost created a standard patient safety checklist for commonly performed procedures that are implemented in hospitals nationwide.

"We haven't used a checklist, in part, because we haven't acknowledged our fallibility and that we need a cognitive aid," said Pronovost.

The Center for Medicare Services also plans to develop and distribute a list of adverse events that should be reported, said Ruth Ann Dorrill, deputy regional inspector general for the Department of Health and Human Services.

"The hospital staff and managers want to treat their patients well," said Dorrill. "By identifying what's happening to patients, that'll provide a learning process."

Staff members may have feared retribution or may have not wanted to report their own colleagues, Dorrill said.

The study is one of many finding similar results. In April 2011, a study released in the journal Health Affairs found that one third of hospital visits will lead to hospital related injuries, and as many as 90 percent of hospital errors are missed by current surveillance systems.

Forty-four percent of the errors identified were preventable, Dorrill said.

But beyond staff education, family members and patients themselves should be educated too, said Ehrenclou, who authored the book, "Critical Conditions: The Essential Hospital Guide to Get Your Loved One Out Alive."

Ehrenclou promised herself she would never again feel uncertain about her role at the hospital as she felt about her mother. Three years later, when her godmother was admitted to a different hospital for complications because of her diabetes, Ehrenclou felt better prepared.

The hospital staff informed her that her godmother received twice the dose of the sedative benzodiazepine, and her body wasn't capable of clearing the medication.

Her godmother also endured bed sores during her seven-month stay. Although her godmother also passed away, Ehrenclou said she became more involved in her godmother's hospital care by asking questions to understand her condition.

"I would've done so many things differently with my mother. I would've gotten a second opinion from a specialist. I would've done research on her disease," said Ehrenclou. "I would've been on top of all of her medications. I would've communicated all of that to her doctors."

CLICK HERE to learn more about ways to prevent medical errors