A Genius Shines…And, Where the Light Doesn’t, Hospitals Don’t

By Michael L. Millenson in the Health Care Blog It doesn’t take a genius to figure out that hospitals could dramatically reduce the hundreds of thousands of deaths and injuries they unintentionally cause patients ever year, but it may take a genius to coax change out of ossified organizations. As for getting hospitals to publicly disclose injuries and deaths the law says they must? That’s another story entirely. On the good news front, The MacArthur Foundation has just honored Johns Hopkins’ Dr. Peter Pronovost with a “genius award,” the informal moniker for the go-and-do-smart-stuff prize given to MacArthur Fellows. Pronovost, you may recall, is the critical care physician who came up with the idea of culling lengthy guidelines on error prevention in the ICU into a simple checklist of five precautionary steps. When tested in ICUs throughout Michigan, the result was to “change the culture of [the] institutions in the interest of reducing the risk of medical errors and hospital-acquired infections,” the foundation noted. “Pronovost’s checklist intervention yielded a significant and sizeable decrease in rates of infection and is currently being replicated by hospitals across the U.S. and Europe.” While the achievement itself is good news, there are other reasons to cheer. To begin with, this is the first time that patient safety and quality improvement work has received the kind of high-prestige recognition that usually goes to traditional medical achievements. ********* Out of the spotlight, however, cultural change remains slow. The Philadelphia Inquirer’s Josh Goldstein, an old-school investigative reporter, reports that hospitals in Pennsylvania and New Jersey are not always complying with laws requiring them to tell state agencies about mistakes and serious complications, thereby “undermining efforts to improve patient safety.” In New Jersey, for instance, five of the state's 80 hospitals failed to report a single preventable mistake last year. In Pennsylvania, some facilities didn't report any serious events or even the near misses that might have harmed patients. The same problem is cropping up in squeaky clean, do-gooder Oregon. The Portland Tribune reports that 54 of the state’s 57 hospitals have signed up to voluntarily and anonymously report errors to a state agency, but these same hospitals “rarely will...follow state rules that they report the mistakes to the families of their victims.” A report by the Oregon Patient Safety Commission found that in all of 2007 hospitals notified patients or their families only 25 times of serious adverse events, while experts estimate that 800 to 1,700 such events happen every year.