New Jersey was ahead of the national trend when, more than a decade ago, state officials implemented a hospital-reporting system designed to reduce the occurrence of significant medical mistakes and improve the quality of care at the state’s acute care facilities.
That early work has paid off, according to a new analysis of data compiled by the Leapfrog Group, a national nonprofit that serves as a healthcare-quality watchdog. While these “never events” — major medical errors like surgery on the wrong body part, fatal medication mix-ups, or serious patient falls — referenced in the review still do occur, state filings show hospitals here have lower rates of many of these critical errors than facilities do nationwide.
A Leapfrog review of hospitals across the United States found that one in five lack internal policies to account for and deter these drastic medical outcomes; the study did not look at errors directly but focused on the protocols in place to prevent these mishaps. In New Jersey, at least 90 percent of the state’s hospitals reported they had a “never event” policy in place, according to an analysis of survey results by Castlight Health, a San Francisco-based healthcare information company.
The Garden State’s standing drew praise from healthcare quality advocates and hospital officials, who were proud to have played a role in the success. New Jersey was one of eight states to achieve this level of compliance among the hospitals that responded to the survey; only three states — Maine, Massachusetts and Washington — did better, with 100 percent of their facilities reporting a “never events” policy in place.
The Castlight analysis credits the National Quality Forum for drawing national attention to these errors with a 2006 report. The following year, federal officials took note and cut certain Medicare payments to hospitals that had high numbers of certain “never events.” Leapfrog also began adding questions about the rate of these errors, and policies designed to protect against them, as part of its hospital report card evaluation in 2007.
Leapfrog uses the NQF definition of “never events,” which include 29 specific outcomes in a half-dozen categories: surgical mistakes, errors with products or devices, failures with patient protection or care management, environmental mishaps, radiological errors, and criminal acts.
The watchdog group recommends hospital officials take five steps when these mistakes do occur, including apologizing to the patient and family, waiving costs associated with the event, and making the “never events” policy public. Leapfrog also calls for reporting errors to an outside, independent body within 10 days and performing a root-cause analysis of the system that failed.
[related]Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, said the same goals are embedded in the state’s Patient Safety Act. She said the measure, signed into law in 2004, paved the way for the strong showing by Garden State hospitals in this latest Leapfrog report.
“We are pleased to see that New Jersey hospitals rank well against the nation in taking seriously these most egregious medical errors and have policies in place to identify what went wrong, establish plans to prevent them in the future, and protect patients from added health care costs related to the error,” Schwimmer said.
The Patient Safety Act, sponsored by Sen. Joseph Vitale (D-Middlesex), the longtime health committee chairman, borrowed from a growing interest in quality-control mechanisms in the business world to try and improve patient care and hospital performance. Vitale said the measure, which took two years to pass, required balancing patient needs with the liability concerns raised by hospitals, some of whom worried the information could be used against them in unjustified medical malpractice lawsuits or labor actions.
“The key was motivating facilities to change behavior while offering them the opportunity to have protected internal discussions on how to address poor patient outcomes through these events,” Vitale said. The law requires the state Department of Health to collect the data, but it shields the reports from public view and prevents their use in litigation or employee disputes.
Like the Leapfrog recommendations, the act requires that all hospitals report the worst medical errors to state regulators within 10 days and conduct a thorough review of their internal protocols to find, and correct, the root cause of the problem. While it doesn’t mandate an apology, the law insists hospital officials disclose the issue to the patient’s family and bans them from charging for additional treatments that were required as a result of the mistake.
“We applaud the commitment of New Jersey hospitals to reach such high levels of compliance with the Leapfrog standards,” said Kerry McKean Kelly, who heads communications for the New Jersey Hospital Association, the industry trade group. “NJHA is proud to be one of the organizations that worked with Sen. Vitale on passing our state’s Patient Safety Act. It’s an excellent example of various groups — legislators, hospitals, quality improvement organizations, patient advocates — all coming together for the sake of patients.”
While the state can’t share the hospital reports required by the Patient Safety Act, other regulations require hospitals to report various medical errors and poor outcomes to DOH officials, a number of which also qualify as “never events.” Data published last year as part of a technical supplement to the annual Hospital Performance Report showed that Garden State hospitals beat national estimated rates in seven out of 10 Patient Safety Indicators, including the number of times surgeons mistakenly left a device inside a patient, the occurrence of unintended punctures or cuts, and negative reactions to blood transfusions. Areas where their performance appeared to lag behind national norms involved post-operative cases of bleeding, pulmonary embolism, or deep vein thrombosis.