These words were apparently uttered by legendary college football coach, Paul W. “Bear” Bryant. While the advice is applicable to just about any person or subject matter, a recent federal government report shows that U.S. hospitals are in dire need of a reminder.
According to a Department of Health and Human Services study, hospitals are failing to document their medical errors. The study, an examination of Medicare patients’ records, found that hospital staff failed to report 86 percent of “adverse events,” (harm done to patients as a result of medical care) to their respective internal incident reporting systems.
This systematic failure of hospitals is worrying in a number of ways.
Due to the severe underreporting of incidents, the number of actual injuries and deaths from medical errors is probably significantly higher than the oft-quoted estimate, 98,000 deaths annually, reported by an Institute of Medicine report over a decade ago.
Failure to acknowledge medical errors probably also means that hospitals are failing to give victims of medical errors critical information about what caused their injuries. Consequently, hospitals and their staffs are evading accountability for their actions. That is, hospitals are likely failing to acknowledge and compensate patients for injuries caused by errors, particularly preventable ones. And medical providers are not appropriately disciplined for these errors.
Moreover, hospital staffs are likely committing the same errors repeatedly because, if they fail to acknowledge the existence of errors, then they are also failing to change their policies and practices to prevent similar future errors. In fact, the study found that only five reported incidents led to policy or practice changes at a hospital. Quite succinctly, these findings reflect the perilous conditions for patients in hospitals.
Indeed, this study is yet another piece of evidence of the under-recognized patient safety crisis: Less than two years ago, an HHS study estimated that 1.6 million Medicare beneficiaries suffer injuries from medical mistakes costing taxpayers at least $4.4 billion a year. HHS also found that medical mistakes kill 15,000 Medicare patients a month, or 180,000 Medicare deaths per year – more than the IOM’s estimate, which estimated deaths for all U.S. patients.
The HHS Office of Inspector General, which authored the incident reporting study, recommended that HHS agencies work together to create a list of potentially reportable events and technical assistance to hospitals. Developing lists of potential reportable incidents is a logical step to assist hospital staff in tracking medical errors. It is also critical that the public be informed about hospital safety. Hospitals should be required to report incidents and disclose the data to the public. Public disclosure will improve the accountability of medical providers who commit such errors, will lead to changes in hospital policies to prevent the errors, and consequently will reduce the number of medical errors.
So returning to Coach Bryant’s wise words, when adverse events occur, hospitals must:
(1) Admit it. Report the incidents, not just internally, but also to the people affected by the actions – the patients and the public.
(2) Learn from it – Analyze the incident reports. Identify trends in types of errors and infections.
(3) Don’t repeat it – Change the policies and practices to prevent unnecessary deaths and injuries. Discipline those who flout these policies and commit preventable errors. Adequately compensate patients injured by preventable medical errors.