Study: Victims of Mistakes in Hospitals Not Reporting Errors

Dec. 11–Twenty years ago, one mistake at a renowned Boston hospital cost a Boston Globe reporter her life and permanently damaged the heart of a North Andover teacher. Today, nearly one in four Massachusetts residents still believe they or someone close to them has been affected by a medical error, a recent study by the Harvard School of Public Health found.

Of those people, more than a third chose not to report the mistake.

Justin Sayde, administrative and research manager at Harvard School of Public Health, said the aim of the study was to gather preliminary data and get a sense of the scope of the medical error problem in the state. It was co-commissioned by the Health Policy Commission and the Betsy Lehman Center for Patient Safety and Medical Error Reduction.

The center is named for the Globe healthcare columnist who died after she was prescribed four times as much chemotherapy medication as necessary during a study at the Dana-Farber Cancer Institute in 1994. Maureen Bateman of North Andover died a little more than two years after she participated in the same trial.

“We’re just really trying to wrap our heads around the extent of this issue,” Sayde said. “It is very much still an issue. That’s the takeaway point. There have been some improvements, but something needs to be done.”

The study, released a week ago, asked 1,224 Massachusetts residents whether they or someone close to them believed they had experienced a medical error situation. Twenty-three percent responded that they had. Of those people, 54 percent chose to report the error, while 37 percent chose not to.

“The challenge here is that the reporting is spotty. The requirements depend on where you live. It’s different state by state,” Sayde said.

Of those who reported the incident, most told only their doctor, and just 8 percent reported it to a state agency. Those who chose not to report the error gave a variety of reasons, but 36 percent said it was because they didn’t know how.

“I think part of the issue is that most of the public isn’t aware of how to report these errors,” Sayde said. “I wish I could say there’s a hard and fast rule about what should be done if you think you’ve been involved in a medical error situation. The whole purpose of the Lehman Center is to look at what’s happening and try to … formulate a protocol.”

The Department of Public Health requires that hospitals report errors like the one that killed Lehman and injured Bateman, in addition to many other types of mistakes. The state defines a “serious reportable event” as an error that is “clearly identifiable and measurable … and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the healthcare facility.” Examples include falls that result in injury, operations done on the wrong body part, procedures that leave foreign objects inside the patient, complications due to contaminated medications and more.

In 2012, Methuen’s Holy Family Hospital reported three major errors. In 2013, the number more than doubled, with eight incidents reported. The case was similar at Lawrence General Hospital and Merrimack Valley Hospital, which has since merged with Holy Family Hospital and is now called Holy Family Hospital at Merrimack Valley. Both reported four incidents in 2012. In 2013, the number at Lawrence General rose to seven. Merrimack Valley Hospital reported eight.

Lawrence General Hospital’s Chief Medical Officer, Dr. Neil Meehan, like Roach, attributed the increase to new reporting standards for hospitals. Still, he acknowledged that those in the field have been pushing to address a wide variety of patient safety issues in recent years. Lawrence General’s Chief Executive Officer Dianne Anderson sat on an expert panel during a presentation about the problem at the recent relaunch of the Lehman Center. Established in 2004, it closed in 2010 due to lack of funding, but was re-established this year as part of a larger piece of healthcare legislation passed in 2012.

(c)2014 The Eagle-Tribune (North Andover, Mass.)

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