Massachusetts Personal Injury Library

State reports hospital mistakes

Massachusetts attorney Thomas M. Kiley concentrates on legal issues regarding health issues. A recent report by the Massachusetts Department of Public Health documented 338 mistakes made at Massachusetts hospitals in the past year due to perilous falls, wrong medication, or leaving medical instruments in patients. The report’s findings were published in The Boston Globe.

According to the article, two-thirds of the 338 mistakes were falls called "serious reportable events (SRE)." The report concluded that those incidents were linked to 19 deaths. This is the first comprehensive study of these kinds of incidents the state has conducted. These kinds of hospital mistakes have been connected to 90,000 deaths a year in the United States. The state decided to make this report public to make hospitals more accountable and to try to reduce the number of future accidents from happening.

Hospitals are using the reports to improve their safety record. For instance, when St. Vincent Hospital realized they had 25 falls last year they instituted a new program having certain patients wear colorful slippers or booties that designate them as fall-prone so staff members can watch out for them. So far this year, since the new program was implemented, only one patient has suffered a serious fall.

Similarly, Norwood Hospital adopted strategies to prevent falls. These strategies included adjusting medications so patients don’t feel dizzy, testing patients’ vision, and preventing a gridlock of walkers, crutches, and wheelchairs at dinner time.

The Department of Public Health is instituting a new reporting system with this report in the hopes that it will provide a format for hospitals, health care providers and public health officials to follow and prevent making these kinds of errors in the future. The new reporting system is based on the National Quality Forum reporting system. This NQF system requires hospitals to report a total of 28 adverse medical events, grouped in six categories:

Surgical—62 events (18%)

Product or device-related—5 events (1%)

Patient protection-related—3 events (1%)

Care management-related—26 events (8%)

Environmental—231 events (68%) falls (224 events)

Criminal—11 events (3%)

State health officials think that the numbers actually understates the scope of the problem. The purpose of the report is not to punish hospitals who make mistakes, but to encourage hospitals to be accountable and transparent in an effort to improve their safety records. The reporting will allow the state to gain a greater understanding of why these events happen and how to prevent them in the future. The state has implemented a forum for hospitals to share best practices on ways they address these kinds of events in their facilities.

For the second year of data collection, the SRE analysis will also include race, ethnicity, age, and gender. It also will include incident-specific data such as the location in the hospitals where events occurred, time of day, and protocols and procedures followed at the time of the event. This kind of data will help hospitals in developing policies and procedures to reduce these kinds of events from happening in the future.