‘Never events’ on the rise at NH hospitals

But reporting requirements, compliance could be source of increase


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Adverse events are commonly called “never events” because they are never supposed to happen to patients in hospitals. 

In New Hampshire, they include serious, avoidable incidents in hospitals, such as surgery on the wrong patient or body part, items left inside a patient, burns, falls, medication errors, assaults, sexual assaults and suicide. They must cause serious harm or death to qualify as reportable adverse events.

The number appears to be climbing over the first five years that state law has mandated public reporting, but experts say the increase could be attributed to changes in the definition of pressure sores and increased reporting.

A total of 42 such events were reported by the state’s 26 hospitals and ambulatory surgery centers in 2010, and there were 73 in 2014, according to the 2014 Adverse Event Report compiled by the state Bureau of Licensing and Certification, the most recent year available.

Michael Fleming, director of the Bureau of Licensing and Certification, said the most important part of the reporting program is the opportunity for different hospitals to learn from each other’s mistakes.

“I believe everybody is engaged to pull these numbers down to as low as possible, but in order to do that you want to encourage full transparency so that people can figure out why these things are happening,” Fleming said.

To that end, this year hospital officials had input into the final adverse event report.

Hospital participation made for a more well-rounded explanation of events, Fleming said. For instance, hospitals included the number of beds and surgeries performed to give context to the numbers.

It will take another year of reporting to see if the increase in numbers requires further investigation, Fleming said. Some of the increase could be the result of a better understanding on the part of hospitals about what to report, he said.

Hospital compliance

According to the 2014 report, there were three major areas responsible for 83 percent of the events reported. Falls accounted for 34 percent, pressure ulcers 30 percent and surgical events for 19 percent.

“[I]t is important that we focus on these and address what the New Hampshire hospitals are doing to prevent them from occurring,” the report noted.

Fleming believes the state’s hospital and acute care facilities are reporting as they should, although he is in the process of investigating a complaint against a hospital that may not have been in compliance. The ambulatory surgery centers reported no adverse events for 2014.

He wouldn’t identify the hospital because of the investigation, but said hospitals face a $2,000 fine if they fail to report and his bureau audits 10 percent of complaints each year.

After reporting an incident, the hospital is required to perform a root cause analysis of and initiate a corrective plan.

A 2013 study by John T. James in the Journal of Patient Safety estimated that 440,000 people die each year from adverse events in hospitals.

“The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed,” James reported.

“Fully engaging patients and their advocates during hospital care, systematically seeking the patients’ voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.”

Anne Diefendorf, vice president of patient safety and quality at the Foundation for Healthy Communities, a sister organization of the NH Hospital Association, spoke to InDepthNH.org on behalf of the state’s hospitals.

“In many ways, we’re pleased,” Diefendorf said about the 2014 Adverse Event Report. “We feel the integrity of reporting has continued to be a strong focus of the hospitals.”

Progress is being made as hospitals share information with each other and more events might be picked up as a result, she said.

“In terms of falls and pressure ulcers across the board, people are trying to be more robust in terms of their surveillance,” Diefendorf said.

Overall, the major focus of the hospitals right now is to find ways to engage more with patients and their families, Diefendorf said.

Consumer knowledge

Lisa McGiffert, director of the Safe Patient Project for Consumer Reports, said it is important for people to understand that reportable adverse events make up only a portion of hospital errors. They don’t include, for instance, people harmed by hospital acquired infections.

“These errors are narrowly defined,” McGiffert said. “People should recognize these are not all errors that happen in hospitals.”

And they do not include the many falls or other events that do not result in death or serious injury. McGiffert is skeptical that all hospitals report as required.

The adverse events just shouldn’t happen at all, she said. “They are all preventable,” McGiffert said.

Even with the limitations of the systems in 28 states that report, McGiffert said: “I think it’s important for this information to be tracked.”

The states that track adverse events have a host of different systems, events and protocols. Some report publicly by hospital, such as New Hampshire. Others provide only aggregate information.

State Rep. Cindy Rosenwald, D-Nashua, co-sponsored the original legislation that mandates hospitals report adverse events. She noted some of the areas of increase, especially in the fall and pressure sore categories.

“They have made a few changes to adverse events reporting and that has driven up some of the numbers,” said Rosenwald, who is the House deputy Democratic leader. Rosenwald believes the mandating law is working well and helping hospitals to focus on making needed improvements to eliminate them. She submitted legislation this session to extend the NH Health Care Quality Assurance Commission for five more years.

The commission is charged with reviewing and analyzing quality of care and patient safety issues in hospitals such as the adverse events at hospitals and ambulatory surgery centers.

The commission allows hospital officials to meet and share confidential information about never events and near misses to seek out and share solutions, she said.

“I think hospitals take these very seriously,” Rosenwald said. “We’re so proud of the quality of New Hampshire’s health care system.”

Fleming said he doesn’t believe any of the 2014 adverse event errors in New Hampshire resulted in death, but the detailed investigations and remedial plans are not made public.

“Most are not fatal, but they are all serious,” he said.

“Again the whole idea is to get the number down really, really low and have everybody looking at their systems to learn from other people’s mistakes,” Fleming said.

The law has been worth the work to enforce and document even if the number of events isn’t going down, he said. “If nothing else, it holds the hospitals accountable to report.”

Fleming said patients are always told if they are the victim of any error in the hospital, not just serious ones. Family members must be told if the patient dies as a result, he said.

The state has created a separate database of events that hospitals report out of an abundance of caution that don’t meet the criteria of an adverse event, Fleming said.

“At least we know the hospital was being transparent,” he said.

As to the prospect of reducing the numbers further, Fleming said: “My opinion is zero is impossible. However, it is a good goal that everybody strives for.” 

InDepthNh.org is a New Hampshire-based nonprofit investigative news website. Nancy West can be reached at nancywestnews@gmail.com.

The 2014 Adverse Event Reporting report can be seen at dhhs.nh.gov/oos/bhfa/documents/adverseevents.pdf.

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