Protecting patients: Hospitals wrestle with reporting and fixing medical mistakes

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.

Without that, says James, problems — and patients — get buried.

Tracking patient safety is tricky for many reasons, not just the lack of reporting.

Experts use some terms — sentinel events, adverse events, patient harm — interchangeably or in completely different ways. They refer to "adverse drug events" and "never" events (because they should "never" happen) and "sentinel" events, but they don't all categorize them the same way. There are errors and "things that just happen, nobody's fault."

And they talk of "patient harm" that doesn't actually hurt anyone. Ask for specifics and you may not get any, thanks in part to patient privacy laws, fear of lawsuits and differing interpretations of those aforementioned words. It's complex and the confusion doesn't seem confined solely to the public, which gets limited information.

But those experts agree on one thing: Only if you track events — regardless of what you call them — can you find patterns that suggest solutions.

In April, health officials changed reporting requirements from eight general sentinel-event categories to mandating that 34 specific examples of life-altering, major injury be reported. Thraen hopes the new rule, requested by facility representatives, will paint a more realistic picture for hospitals as they strive to identify and fix patient safety issues.

Reportable events range from the dramatic — wrong-site or wrong-patient surgeries, infants being discharged to the wrong person, giving a patient too much radiation or any sexual assault on a patient — to the less startling, including infections and adverse reaction to medications, among others.

The fancy term is "iatrogenic harm," meaning any harm that occurs in the course of care, whether it actually hurts the patient or not. Getting a wrong medicine may just mean you don't get the right one, not that it causes a medical problem, for example. Nebeker says mistakes account for less than 25 percent of such harm, and "we believe we should be preventing all kinds of harm, not just those from errors."

James remembers a patient in intensive care with a life-threatening infection. The only drug that offered a small hope of survival was imipenem, a penicillin-derived antibiotic. But the patient was allergic to penicillin. What to do? Doctors talked it over with the woman's family and decided she had a better chance of surviving the allergy than the infection. They gave her the drug. Still, the allergic reaction qualified as a "patient safety event," James says. "These sorts of judgments are quite common."