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Obama Administration Introduces Plan to Reduce Preventable Medical Errors

April 12, 2011 at 4:39 PM EST
The Obama administration announced a new patient-safety program Tuesday on the heels of medical journal Health Affairs publishing a study showing that one in three people admitted to hospitals suffers a medical error or accident. Margaret Warner talks with Heath Affairs' Susan Dentzer about the study and the new plan.
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GWEN IFILL: Next, medical mistakes in the American health-care system. It’s an issue that first captured national attention more than a decade ago, and it remains a significant problem.

Margaret Warner has the story.

MARGARET WARNER: Twelve years ago, a landmark study found up to 98,000 Americans may be dying each year from hospital-induced mistakes.

Today, the Obama administration announced yet another program to address that. The new initiative aims to reduce medical errors and accidents and save more than 60,000 lives and $35 billion in health-care costs over three years.

Today’s move comes on the heels of a study published last week in the journal “Health Affairs,” suggesting the problem is even worse than previously thought. It found that one-third of all people admitted to a hospital fall victim to a medical error or accident.

Here to tell us more about all this is Susan Dentzer. She’s the editor in chief of “Health Affairs” and a health analyst for the “NewsHour.”

And, Susan, welcome back, as always.

SUSAN DENTZER: Great to be back, Margaret.

MARGARET WARNER: This was pretty stunning finding. One-third of all people who check into the hospital develop something in the hospital?

SUSAN DENTZER: Very shocking, indeed.

Our study looked at a new way of going back over hospital records and looking for signs that something bad had happened and investigating those and making sure that something untoward had happened.

And, in fact, when that was done in one — for one month in 2004, at three hospitals that were very sophisticated hospitals in the United States that had very advanced patient safety programs, still, one in three of the hospital admissions during that month had an adverse event associated with them.

Now, we don’t know how much harm or injury or death.

MARGARET WARNER: Give us an example.

SUSAN DENTZER: But, for example, it’s things like, if you have what’s called a central line, which is a tube that can be inserted in your chest, if you’re very seriously ill, to deliver medication or to drain fluids out, if you get an infection associated with that, that’s called a central line infection. There are thousands of these every year.

They get into your bloodstream. They are very hard to treat, and they can kill you. That’s an example of an adverse event. Pressure ulcers. If you’re not being turned often enough, and you’re leaning back in a hospital bed, your bone can sort of press into your skin, create this sore.

The sores can get very bad. They can actually go into your muscular bone. You can eventually die of those. Those are preventable also. Those are adverse events.

MARGARET WARNER: Now, another disturbing thing in this study — or one of the studies in this issue was that most of these errors weren’t detected by the normal monitoring system of the hospitals.

SUSAN DENTZER: That’s exactly right.

All of these hospitals had voluntary reporting systems, so the staff is encouraged to voluntarily report that an adverse event was — did in fact happen. This other methodology found that there were 100 times more, easily, of these events than were voluntarily reported.

And other ways of looking at these events, also, this — more sophisticated methods of looking deeply into the records, found many more of these events than had previously been thought to occur.

MARGARET WARNER: Now, the study that came out in ’99, which you covered as a journalist at the time, that was supposed to be a wakeup call. What was it called, “To Err Is Human”?

SUSAN DENTZER: Right.

MARGARET WARNER: And there were all these promises to do more on the part of the government and hospitals.

Did anything improve? Was progress made?

SUSAN DENTZER: Yes. That and then a subsequent study, “Crossing the Quality Chasm,” also said we have to improve quality.

And, in fact, by many metrics, we have. For example, now, if you go into a hospital after you have had a heart attack, in the vast majority of hospitals now, you will get what you should get, which is an aspirin within 24 hours and a beta blocker, which prevents a secondary event. So, that’s going very, very well.

Bloodstream infections are down 63 percent in a 10-year period, so that’s going well. However, we just learned last week from the head of the joint commission which accredits hospitals that there are still 40 wrong-site or wrong-patient surgeries performed every week in the United States.

And this is after 10 years of having people sign on your arm that it’s this arm that’s going to get operated.

MARGARET WARNER: Operate on this arm.

SUSAN DENTZER: All of these precautions that have been taken, and still 40 times a week this is happening.

MARGARET WARNER: So, in a nutshell, what is there in the Obama administration — the new effort, that has any greater chance of making a difference than all these other efforts?

SUSAN DENTZER: Two things primarily.

Teeth. The government has been handed under the Affordable Care Act, the health reform law, lots of new tools to essentially push hospital systems in the direction, pay them less. For example, already, hospitals are not paid if they have one of these adverse events, and they’re not paid for the additional medical costs of treating those events. They don’t get paid.

So, they have incentive now to fight this. And then in addition, the nation’s payers are tearing their hair out about the cost of health care. And here we see there’s money on table lying there, because people are getting these adverse events, and we’re paying extra to care for it.

So, the nation’s payers now are really mobilized to push very hard. And that’s part of what was announced today, a commitment of employers and others to help encourage people to use the best hospitals, take other precautions to essentially protect themselves against adverse events.

MARGARET WARNER: So, what is a patient to do, if you know you have to go in the hospital and you can actually make a choice?

SUSAN DENTZER: Well, the first thing to do is to be as active a part of your care team as you can. Ask as many questions as you can. Am I getting — are you about to operate on my right leg? Do you know who I am as a person?

You can also go and Google “20 tips to prevent medical errors.” It will take you to an information sheet put out by the Agency for Health Care Research and Quality. It has a really wonderful list of things, precautions you can take to maximize the notion that you will get out of the hospital safely.

MARGARET WARNER: And you mentioned that choosing the hospital — there are tools now to choose the right hospital.

SUSAN DENTZER: Absolutely right.

You can go to www.hospitalcompare.hhs.gov. And you can see exactly how many adverse events have been recorded at the hospital that your doctor has suggested you go into. And you can actually say, Doctor, I would really like to go to a safer hospital. Can you help me find one?

MARGARET WARNER: Well, let’s hope if we have this conversation another five years from now, the news is better.

Susan Dentzer, editor of “Health Affairs,” thanks.

SUSAN DENTZER: Thanks, Margaret.