Reducing the Cost of Medical Errors: Spend A Little To Save A Lot

When hospitals make errors, patients end up injured, have longer hospital stays and some 100,000 or more die each year as a result. If patients are discharged too soon or without adequate care instructions, follow-up doctor appointments and few links to community or home-care services, those patients often end up bouncing right back into the hospital in fewer than 30 days.

From these blunders come significant costs—measured in terms of injury and death as well as dollars spent on “measurable medical errors” (those that cause harm to patients) and higher hospitalization charges. According to an April 7 report in Health Affairs, medical errors now cost our over-burdened health care system some $17.1 billion a year; the cost of avoidable hospital readmissions adds another $13 to 18 billion dollars a year.

Another study in the same issue of Health Affairs found that up to one-third of all hospital stays lead to hospital-related injuries ranging from serious acquired infections to deadly surgical mistakes. Don Berwick, the Administrator of the Centers for Medicare and Medicaid Services, said the study “raised the stakes by finding … that the number of adverse events could be ten times greater than we originally thought.”

As President Obama and Congress debate significant funding cuts to Medicare and Medicaid, the Department of Health and Human Services (HHS) is moving forward with initiatives already financed by the Affordable Care Act that do just the opposite. They are designed to exact savings in these programs by investing in initiatives and protocols that show promise in improving patient safety and in reducing hospital readmissions.

Evidence of this stepped-up approach was clear last week with the first-ever release of hospital-specific patient data that determines the number of “never-events”–eight serious, costly errors that CMS maintains should never happen–for example, foreign objects left in the body, patient falls and traumatic injuries, infected catheter sites, and serious pressure sores. The data are culled from a review of hospital bills submitted to Medicare for elderly and disabled patients between October 2008 and June 2010. Over strong objections from hospitals and their lobbying groups, (who question the accuracy of the data and managed to delay its release twice since the study was completed) CMS finally decided to publish the raw data on its “Hospital Compare” website.

Despite the fact that since 2008 Medicare has refused to reimburse hospitals for costs associated with these hospital-acquired conditions and stipulates that patients should not be billed for them either, “never events” still occurr far too frequently.

“More than 400,000 Medicare ‘never events’ occurred in the United States in 2008, with an estimated total cost of $3.7 billion,” write the authors of a new report in Health Affairs titled “The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors,” adding that the “cost of these events constitutes 22 percent of the total cost for medical errors.”

Unlike other hospital-specific information on Hospital Compare—for example, patient satisfaction scores; hospital readmission rates for certain heart conditions; 30-day death rates—the hospital acquired conditions data is presented as an unwieldy Excel file. In its current state (CMS plans to make it more accessible to the public later this month) the data set doesn’t allow easy comparison between hospitals unless you are very good at wading through and extracting information from a complicated spreadsheet.

Fortunately, Chicago Tribune reporter Judith Graham is more capable than I of doing just that. Graham found that, “All of Chicago's top medical centers appear on the list of hospitals with safety issues.” She notes that “the University of Illinois at Chicago Medical Center, the University of Chicago Medical Center and Rush University Medical Center all reported higher-than-average numbers of hospital-acquired bloodstream infections associated with catheters.”

But collecting—and eventually publishing—this data has spurred some Chicago hospitals (and presumably others around the country) to instate patient safety improvements. Graham reports; “Chicago's Resurrection Medical Center recorded 18 patient falls, the highest number in Illinois, during the period covered. Since then, the …facility has introduced hourly rounds where nurses check on vulnerable patients, asking if they need help going to the bathroom or reaching call buttons, to keep people from getting up unexpectedly and taking a tumble.”

She continues; “Chicago's Mount Sinai Hospital had the highest rate of older patients with serious bedsores, with seven such incidents. After becoming aware of the problem, the hospital…hired a second wound-care nurse in the fall of 2009. Now, its electronic medical records system automatically alerts a wound-care nurse when a patient is deemed likely to have serious skin problems.”

Despite continued complaints about the newly-public CMS data from doctors and administrators, the idea is not to punish providers for committing these errors, but to try and create a triage system for identifying the most urgent problems. Accountability and transparency are absolutely imperative if hospitals want to make major strides in improving patient safety. Quantifying the problem of medical errors is the first step in figuring out the best ways to reduce them.

For starters, the Health Affairs study notes that pressure ulcers were the most common measurable medical error found in all hospitals, “followed by postoperative infections and by postlaminectomy syndrome, a condition characterized by persistent pain following back surgery.” The authors found that just “ten types of errors account for more than two-thirds of the total cost of errors, and these errors should be the first targets of prevention efforts.”

As the Affordable Care Act’s provisions move forward, hospitals will find themselves rewarded for quality (for example, hospitals with better outcomes for stroke and heart attack patients and lower hospital-acquired infections rates, will receive higher payments). They will also be penalized for avoidable errors—starting in 2014, Medicare will cut payment by 1 percent to hospitals that have the highest rates of patient safety issues, for one. But the law also recognizes that using a “because I said so” approach to improving safety will be hard-pressed to bring about the desired results.

In recognition of this, yesterday HHS Secretary Kathleen Sebelius announced a new $1 billion funding initiative called Partnership for Patients that is designed to achieve two goals: reduce preventable injuries in hospitals by 40 percent; and cut preventable hospital readmissions by 20 percent. “Reaching those targets would save up to $35 billion over the next 10 years,” Sebelius said, adding that $10 billion of that would come from Medicare savings. “That's a return of up to $10 for each dollar we're investing.”

Funding for this initiative is already included in the ACA so it can’t be easily derailed by budget cuts. The Community-based Care Transitions Program has pledged to provide $500 million in grants toward community-based organizations that partner with hospitals to reduce 30-day hospital readmissions. (On April 6, the Commonwealth Fund published a relevant paper, “Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals” that presents four case studies of hospitals with “exceptionally low readmission rates.” The case studies are provided in order to offer other groups insight into the best practices for ensuring smooth care transitions and keeping patients from bouncing right back into the hospital.)

In addition, CMS—working with hospitals and organizations that develop best practice and patient safety protocols—will pitch in up to $500 million more to achieve the Partnership's other goal of reducing preventable errors. The initiative has won the backing of health care stalwarts like hospital groups, insurers, the American Medical Association and Consumers Union.

The recent movement toward increasing patient safety and reducing the costs of preventable errors and readmissions comes at a vital time. After accusing Democrats of trying to gut Medicare during the mid-term elections, Congressional Republicans are now proposing to slash funding for the program by $450 billion. This indiscriminate budget cutting reeks of the bold but rash gesture. The Ryan budget plan would go even further, completely transforming Medicare by turning it into a voucher system that would force seniors to buy private insurance plans on an open market.

Although Obama continued to try and appease conservatives by committing to major cuts to social programs in his budget framework speech this afternoon, the recent actions taken by HHS clearly signify that the administration has not abandoned key provisions for reducing health care costs by improving hospital quality and accountability. Yes, there may have to be painful cuts in Medicare and Medicaid, but they should not be at the expense of efforts that require modest spending to reduce waste, errors, over-treatment and poorly integrated care. Spending $1 billion on efforts to prevent serious errors and frequent hospital admissions that drive health care costs up tens of billions of dollars makes infinitely more sense than slashing blindly at important social services. Why is it so difficult for so many conservatives to grasp this logic?

9 thoughts on “Reducing the Cost of Medical Errors: Spend A Little To Save A Lot

  1. Such an important issue! Thanks for helping to publicize it.
    Those concerned about hospital readmission rates might also be interested in a simple discharge tool reported in the Canadian Medical Association Journal by a group of researchers at the Ottawa Hospital Research Institute, the University of Ottawa, and the Institute for Clinical Evaluative Sciences.
    This group examined detailed medical records from 4,812 people discharged from 11 Ontario hospitals between 2002 and 2006, and found that four factors could accurately predict the risk of re-admission or even death. They called the tool “LACE” to coincide with the factors, which are:
    * LENGTH of stay in hospital
    * ACUITY of the admission (whether or not it was through the emergency department)
    * COMORBIDITY of the patient (a score based on what chronic diseases the patient has)
    * EMERGENCY DEPARTMENT utilization (number of visits in the previous six months)
    Each of the four LACE factors is assigned a number of points based on its value. The higher the points, the greater the likelihood that a patient will be re-admitted unless relevant health issues are addressed to prevent serious complications.
    The Ottawa researchers then obtained similar results when testing the LACE tool using records from 1 million Ontario hospital patients discharged between 2004 and 2008.
    More on this at: http://myheartsisters.org/2010/04/29/hospital-discharge-outcome-tool/

  2. I applaud the Partnership for Patients plan. Thanks for the detailed review. Obviously Don Berwick, with his past record, is a great leader for this initiative, and I hope for all us, that it is overwhelmingly successful.

  3. I’d like to add this recent newspaper item to your evidence: Probe: Hospital readmissions take toll in Pennsylvania (http://www.pittsburghlive.com/x/pittsburghtrib/news/interactives/?v=4467)
    “Pennsylvania hospitals charged more than $1.25 billion in 2009 to treat patients who were readmitted for complications or infections that might have been avoided, a Tribune-Review investigation has found.
    University of Pittsburgh Medical Center’s Presbyterian and Shadyside hospitals led the state with a combined 806 readmissions and charges totaling more than $67 million, according to the Trib’s analysis of the latest data from the Pennsylvania Health Care Cost Containment Council.”
    Read more: Probe: Hospital readmissions take toll in Pennsylvania – Pittsburgh Tribune-Review http://www.pittsburghlive.com/x/pittsburghtrib/news/health/s_726032.html

  4. Purpose
    Disinfection procedures are an important part of preventive measures to prevent
    the spread of contagious and infectious diseases. Given what we disinfected, and
    the purpose (prevention, decontamination) should choose an effective biocide [1].
    From reliable biocide performance demand quickly with as wide a spectrum of the
    microorganisms that do not harm the patient and staff should not be residue on the
    surface, should not affect the surface of materials and must be biodegradable [2].
    Especially in recent years faced increasing number of resistant microorganisms. We have
    contributed to the resistance, both with an inappropriate choice of biocides, and their
    use(inadequate concentrations, time of performance, and the replacement of biocides).
    However, obstinate strains of microorganisms , which are becoming increasingly resistant
    to the procedures of disinfection, have emerged [3-12].
    Devices for magnetic resonance imaging represent the specific conditions for
    disinfection. Among the relevant facts include the presence of electronic equipment in a
    single device that limits the possibility of selecting the appropriate biocide to disinfect the
    device. It is also not negligible exposure to the patient surface of the device, particularly
    contamination of equipment or transfer agent in the surface of the device in a patient or
    staff [1, 10, 13, 14, 15].
    Neutral electrolyzed oxidizing water (NEOW) is a biocide with a broad spectrum of
    activity, with immediate action on the surface leaves no residue. Because of its physical
    and chemical mode of action is not expected that the micro-organisms have developed
    resistance. Natural biocide bound electrons of the surroundings and thus destabilize the
    bacterial wall micro-electrolysis itself is formed and hyper-oxide ions, which are also
    disinfecting effect, quickly and without delay. Just as the biocide is a not necessary rinse
    surface [16, 17].
    Since the device for magnetic resonance imaging routinely fails to disinfect, we
    were interested in this part, how surface of the device loaded with the presence of
    microorganisms and what effect NEOW of microorganisms in different acceptable ways
    of spreading on the surface. The purpose of this study was to determine the reliability of
    NEOW using two different methods of disinfection on 3.0 T MRI Scanner.
    Methods and Materials
    The experiment was performed at the University Medical Centre Maribor Slovenia in the
    Department of Radiology. The disinfection of the 3.0 T MRI GE Signa HDxt Scanner was
    completed by the procedure indicated by the manufacturer in the technical instructions
    (sodium hypochlorite solution). The disinfection was completed by using the sprayer
    and the method of cold fogging. NEOW with redox potential value of 830-850 mV
    (Steriplant®N, Obisan Institute, Slovenia) was used as a biocide. The experiment tested
    the number of colony-forming units on the model of Staphilococcus aureus ATCC 25923.

  5. Great article Maggie,
    As a survivor of 3 life-threatening medical errors (2 in hospitals) and most recently a post-operative infection, this topic is of great interest to me. I now spend my time teaching patients & family caregivers how to get the care they need and how to foresee and prevent some of the errors.
    I am so thrilled to see the silence being broken & that medical errors are “coming out of the closet”. I think the surface has just been scratched on the numbers. I’ve only seen one recent report that addresses misdiagnosis. Are you aware of any studies on misdianosis or other “Office” errors? The focus to date has been on hospital errors.
    I share some of my stories on my blog at http://savvypatient.org

  6. Margo,
    Thanks for your comment and please note that I wrote this article, not Maggie. I also have training as a patient advocate and believe that safety initiatives and reducing errors are extremely important parts of the movement toward better care.
    Naomi

  7. Very good article Naomi. An additional consideration would be the many lost lives that J.A. Johnson and J.L. Bootman estimated in their U of Arizona study in the mid 1990’s indicating nearly 200k people died as a result of medication errors. Also research by Dr. Barbara Starfield at Johns Hopkins adds another 145k to the toll. The numbers and the lack of public response are hard to fathom when compared to other causes and concerns for death from war, or major killers heart disease and cancer. Your point about investing in saving lives and dollars still seems to be greeted by a tone deaf Washington. I join the other responders in hoping that Dr. Berwick will continue to lead efforts to curb the causes of these grim results impacting so many families.