Hospitals: Staff won’t immediately face penalty. UC program first assumes that the system is at fault.
The Orange County Register
University of California hospitals hope to reduce medical errors by promising not to punish the doctors and nurses who make mistakes — a move that could revolutionize the culture of hospitals across the country.
UCI Medical Center has been slowly moving toward a blame- free environment for the past five years, and as part of that push this week the hospital started using the Electronic Event Reporting System. The system, which is designed to eliminate errors at the five University of California hospitals, will likely inspire hospital administrators and shock patient advocates.
Instead of hunting for a head to roll when something goes wrong, the new program approaches mistakes by assuming that a system, not a person, is usually at fault.
So if a patient gets the wrong medication, a nurse or doctor won’t immediately face punishment. Instead the health-care worker is encouraged to come forward and fill out a computerized ”event report,” that records the mistake. Hospital administrators will then interview everyone else involved from the patient to the pharmacist.
Rather than rush to punishment, which could include barring doctors and nurses from the hospital and reporting them to the state medical board, UC hospitals plans to analyze the computer reports. Administrators would then make changes — making sure that drugs with similar names don’t end up next to each other on a medication tray, for instance — that are supposed to ensure no one repeats the same mistake.
An Institute of Medicine report in 1999 estimated that 44,000 to 98,000 Americans die each year as a result of medical mistakes. That report and others have prompted state and federal demands that hospitals reduce medical errors, and the Electronic Event Reporting System is part of the UC system’s answer to that demand.
”What we’re talking about is, without a doubt, the most important problem in health care,” said Harvard professor Dr. Lucian Leape, one of the leaders of the patient-safety movement, who spoke this fall at a UC conference.
Leape and other speakers said in order to improve patient safety, the entire culture of hospitals needs to change. Doctors and nurses need to get enough sleep, be given the right equipment and have efficient ways of communicating. They also must work in an environment that allows them to admit honest mistakes without fearing retribution, Leape said.
This non-punitive counterculture seems counterintuitive to patient advocates who say hospitals and physicians don’t do enough to weed out bad doctors or disclose medical mishaps to state regulators and the public.
An Orange County Register investigation in September found that since 1997, 50 local doctors have harmed at least 119 patients and endangered untold others in hospitals. But only seven had their privileges pulled by their medical centers. And California’s 481 hospitals alert the state Medical Board about discipline against doctors at half the rate of New York’s 282 hospitals.
“The medical profession cannot be trusted to regulate itself outside of public oversight,” said Jamie Court, executive director of the Foundation for Taxpayers and Consumer Rights, a patient-advocacy group based in Los Angeles.
”The medical profession sees a need to reduce errors, but it is unwilling to take responsibility publicly for the errors that are made,” he said. ”If a sponge is left in a person, it should be up to someone other than the doctor’s colleagues to determine whether or not it’s malpractice.”
But supporters of the UC initiative said the less threatened health-care workers feel, the more forthright they’ll become and the safer patients will be.
”Why would anybody ever report their mistake? The fear of being blamed is not irrational,” said Dr. Lee Hilborne, director for the Center for Patient Safety and Quality at UCLA. ”The public wants accountability, but other than in the case of reckless behavior, there is a system underlying the problem that puts good people in dangerous situations. The punishment belongs with the system, but we’re looking downstream for a person to blame.”
If after analyzing how an error occurred, UC hospital administrators determine that a physician or nurse was just plain negligent, that person will be punished, said UCI Senior Medical Director Dr. Eugene Spiritus.
More often than not, medical professionals are trying to do their best, Spiritus said.
Spiritus and other proponents of the system said encouraging honesty will not encourage lawsuits. In fact, a report by the Bayer Institute for Health Care Communication found that patients are less likely to sue if their doctors are forthright and caring about their mistakes.
The event-reporting system has been running at other UC hospitals for several months, but hospital officials said it is too early to tell how effective the culture change has been. In the next few months, all the hospitals will be on board: UCI, UCLA, UC San Francisco, UC Davis and UC San Diego. Officials admit it is probably easier to institute such drastic changes at teaching hospitals, which are historically more flexible, experimental places.
But representatives of other local medical centers said they think a similar program could work for them. And everyone seems to agree that to effect any meaningful change will mean reaching the people who make hospitals run: the nurses. Nurses say they’re eager to see a change.
”We’ve been reactive for far too long,” said Rebecca Israel, a nurse who serves as Mission Hospital’s patient-safety officer. ”We have to turn that around and spend more time looking at how to protect patients from errors.”
”Doctors are very afraid of admitting mistakes, and so are people higher up the chain of command,” Israel said.
She likened the culture of secrecy at hospitals to that of companies such as Enron or WorldCom.
”Once you start trying to figure out who did what wrong, you start opening drawers that people don’t want open and finding things people don’t want found,” she said. ”You have the top 1 percent of the company protecting each other. That’s not just doctors. It’s everyone.”
Register staff writer William Heisel contributed to this report.
Contact Saar at (714) 796-6880 or [email protected].
