Beginning this summer, a new commission will bring New Hampshire hospitals together to excavate the causes of medical errors.
NHPR's Kerry Grens has more.
Medical errors are disturbingly common and they range in severity.
A nurse might give medication a half hour late.
A surgeon might amputate the wrong limb.
An error could be caused by a hard to read prescription or a poorly planned protocol.
And across the country it’s estimated that hundreds of thousands of errors happen in hospitals every year.
An oft-cited study by the Institute of Medicine places the annual death toll up to one hundred thousand.
Rowe: It doesn’t really matter if it’s forty four thousand or ninety eight thousand, one preventable death is too many.
Rachel Rowe is associate executive director of the Foundation for Healthy Communities and administrator of the state’s new medical errors commission.
She says that no institution that relies on human performance is immune from errors.
Rowe: Hospitals would not come together voluntarily if they did not think there was a problem or there was improvement needed in their institutions. I think every hospital would say they can do better.
Traditionally, hospitals have kept quiet about their mistakes.
They don’t want the bad press, and they certainly don’t want lawsuits.
So they’ve developed internal methods of assessing errors and improving safety.
Representative Jim Craig sponsored the bill to form the errors commission.
He says part of the problem is not enough communication between hospitals.
Craig: They could have a serious medical error take place in—I don’t know—Portsmouth Hospital and they could talk about internally. But the same thing could happen again at the Elliott Hospital in Manchester a month later because they didn’t share that information, they didn’t alert the other hospitals, talk about how they fixed it, they don’t talk about what measures they took to prevent it from happening again.
And that’s the purpose of the new commission—to get hospitals together to compare notes.
But there are a few hurdles to getting hospitals to be candid about operational blemishes.
Craig: If you think about it, in a sense, you’re airing your dirty laundry in front of your competitors. So there’s a human, they’re all people, and there’s a hesitancy to do that. We’re hoping that once people get comfortable with the process they will come in and handle it the way it’s meant to be handled.
But Concord Hospital President Mike Green says there’s no competitive advantage to learning about another hospital’s errors.
He says the bigger hurdle to getting hospitals to talk about mistakes openly is the fear of litigation.
That’s why even though people outside the industry would like to participate, the commission’s minutes will remain confidential.
Green: I absolutely and unequivocally believe that if you lose your confidentiality you lose some of your opportunity for improvement. And I think that has been borne out in some other states that have tried to create a more open process. Hospitals stopped identifying errors. So you lost your opportunity for improvement because of the concern that they had as to what would be the ultimate liability associated with that openness.
Interestingly, Concord hospital currently tells patients when errors occur.
Several studies have shown that people generally trust their doctors and understand when doctors expose a mistake and apologize for it.
But Green says giving that same information to the public could pave the way for unwarranted litigation.
It’s not clear though how much information a lawyer might get from the commission meeting since patients’ names are kept private.
Still, Green says inviting the public could take up too much time.
Green: If nothing else, involvement of consumers would make it a far less efficient process, because you’d have to spend probably two thirds of your time on education and one third of your time discussing what are the substantive issues you’re trying to address.
Meetings are exclusive to hospital executives, ambulatory surgical centers, and the department of health and human services.
The commission begins meeting in August.
For NHPR News, this is KG.
