Medical Errors and Public Accountability

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The editors at Bloomberg have published a provocative piece concerning how medical errors can be reduced. The editorial cites a study from Johns Hopkins that reveals 4,000 surgical errors occur every year. Such errors are considered “never” events yet they continue to happen. The authors of the Johns Hopkins study note that these 4,000 errors are only those that are reported, leaving little room for doubt that more errors go unreported or even undetected until a medical crisis spurs further investigation.
So, the obvious question is-how do we prevent these medical errors? Data shows that hospital voluntary reporting doesn’t work at stemming this tide. What’s needed, according to Bloomberg, is a third party system that review medical charts. “The idea is to find “triggers” that indicate something went wrong — a change in surgical procedure, say, or a postsurgical patient’s being returned to the operating room or sent to the intensive-care unit. When a trigger is spotted, the case is investigated. In the adverse-events study, the Institute for Healthcare Improvement’s Global Trigger Tool detected more than 90 percent of hospitals’ adverse events.
This approach can require time and effort, but in hospitals with digital patient records, it can be programmed to work automatically. Several large hospitals have already begun using the trigger tool this way. It’s fast and accurate, according to David Classen of Pascal Metrics, a patient safety organization based in Washington, who led the adverse-events study.
Some states require hospitals to report their mistakes. That’s good, but a national reporting system would be better. All hospitals should report using the same standards of data collection and the same definitions of procedures and errors.”
The prevalence of medical errors clearly shows that a third-party solution is worth the investment if it prevents these “never” events from occurring. Doctors and hospitals have not been able to fix the problem. It’s time to look for a better solution.

Eva Bleich
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