Protecting patients: Hospitals wrestle with reporting and fixing medical mistakes

Utahns who want information on their local hospital's patient safety record are out of luck. State health officials consider information on serious adverse events "privileged," bucking a growing national trend of making such information public.

And despite offering juicy enticements — confidentiality and no penalties for problems — total reports from Utah's 53 hospitals and 30 surgical centers average a paltry 35 "sentinel events" a year. Those, by definition, are the ones that kill or cause permanent major injury.

The facilities need not tell the state about lesser events, even those that are life-threatening or extremely costly.

Nobody, including patient safety experts, believes that number comes close to a real reckoning of sentinel events.

Utah Department of Health patient safety pointwoman Iona Thraen says the voluntary self-reports capture about one-tenth of actual cases. A national patient safety assessment by the Institute of Medicine (IOM) estimates Utah hospitals would average about 300 deaths a year caused by "medical harm," which includes both human error and unforeseen events that complicate care or hurt patients in the course of treatment.

Calling the state's reported number "grossly low," Dr. Brent James says a recent study by the IOM estimates a single high-complexity hospital should have reported more than 130 such events in a single year — about 30 times what's being reported.

"Health care and hospitals are between the fourth and sixth cause of preventable death in the United States — responsible for more deaths than the entire AIDS epidemic, or breast cancer or all motor vehicle accidents in a year," says James, Intermountain Healthcare's vice president of medical research.

Still, hospitals and their staffs "do far more good than bad. It's just that treatment powerful enough to heal can also harm, and it's often a thin line between," says James, also executive director of the Institute for Health Care Delivery Research, and who helped produce the IOM's unnerving 1999 "To Err Is Human" report.

Despite lack of reporting, Utah is considered a patient safety leader and innovator. And this, too, is perplexing but true: Those hospitals and surgical centers that report the most sentinel events may provide the best care. At least they're aware of their patient safety issues, says Dr. Jonathan Nebeker, associate director of the SL Informatics Decision Enhancement and Surveillance Center at the VA medical center.

Utah health experts defend the state's vow of silence in exchange for information, even though that information's not forthcoming. "We want to create a culture of safety for patients, but we also want to create such a culture for the care providers," Thraen says.