Fire in the OR and how hospitals should report medical mistakes

Did you know that if there is a fire in the OR during surgery hospitals in some states don’t have to report the event to anyone?

When I read a recent story in the Cleveland Plain Dealer headlined, “Reporting Surgical Fires Could Improve Patient Safety in Ohio, Experts Say,” I was stunned.

The piece begins:

When fire breaks out and burns a patient during surgery in Pennsylvania, the hospital is required by law to report the incident to the state Patient Safety Authority. If a similar surgical fire ignites in New York or California, the hospital must notify the state health departments there. And if the same thing happens in Ohio? The hospital doesn’t have to tell any state agency … On April 30, officials at the Cleveland Clinic confirmed that six fires had broken out in Clinic operating rooms in the 12-month period that ended in March.

“Patients suffered ‘superficial burns’ in three of the fires,” they said. “And no one was harmed in the other three.”

“The Clinic didn’t report the incidents to any outside agency immediately after it happened because it wasn’t required to,” said Dr. Michael Henderson, the Clinic’s chief quality officer.

“But when health officials showed up in late April to conduct an inspection for the Centers for Medicare & Medicaid Services (CMS), the Cleveland Plain Dealer’s Diane Suchetka reports, “the Clinic told them about the fires.”

A few days later, Clinic chief executive Dr. Toby Cosgrove explained that “the three injured patients suffered superficial burns that resulted from ignition of flammable skin-preparation or other chemicals used during surgery … Each of the six fires,” the hospital explained, “was started by an electrocautery device which uses electricity to cut or destroy tissue.

“In none of these cases was there serious harm,” Cosgrove added. “And in no case did a patient sue the hospital.”

Cosgrove said that the inspectors from CMS made two recommendations: “That the Clinic remove all alcohol-based surgery preparation solutions from operating rooms and that it train anyone who enters an operating room in how to prevent fires and how to extinguish them when they do occur.” Sounds like a plan to me.

“Those recommendations,” Cosgrove added, “were implemented within hours.”

I’m impressed that the response to the inspectors’ advice was so swift. But I can’t help but wonder: Why didn’t anyone at the Clinic see a pattern when six fires, all related to the alcohol-based solutions, broke out in the ORs in just twelve months? Perhaps no one person at the Clinic knew about all six fires?

The story confirms that even highly respected hospitals need help in collecting information, recognizing hazards, and coming up with guidelines to prevent future accidents. They should be reporting “adverse events” to someone.

A Rare Accident

Before I say more about surgical fires, let me be clear: The odds that you will become a burn victim while undergoing a knee transplant are minuscule. According to an estimate by the ECRI Institute, a nonprofit organization that researches how to improve patient care, while 650 fires occur in health-care facilities in a given year, just one or two kill patients; 20 or 30 result in disfiguring or disabling injury.

Still, two dozen tragedies cannot be dismissed. ECRI’s Mark Bruley has been publishing articles on the causes and prevention of surgical fires for more than 30 years. He tells some harrowing stories — of a 2-week-old baby who died after a surgical fire, of a pregnant woman who, after doctors cut into her abdomen to deliver her baby, leapt off the surgical table, because her body was in flames.

Then there’s Lauren Wargo, a 19-year-old from Shaker Heights, Ohio, who went to an outpatient surgical center where a plastic surgeon was going to remove a mole from her eyebrow. The oxygen used during her surgery and an electrical device used to seal blood vessels combined to create a flash flame that left her face, neck and ear badly burned. Four years later, the 23-year-old still has to wear make-up to cover the scars on her face and is unable to completely close one eyelid.

How could this happen? As is too often the case when hospital errors occur, health care professionals weren’t communicating with each other.

In court the doctor testified that he turned on the electrical device after announcing that he was about to do so–and after he thought the anesthesiologist assistant had turned off the oxygen Wargo was receiving through a face mask.

The assistant testified that she never heard the doctor say he was turning on the device. If she had, she told the court, she would have repeated the statement to the doctor and would have turned the oxygen off. The jury found the doctor negligent and awarded Wargo $1.3 million in damages, according to court documents. The doctor has appealed.

Nearly all surgical fires are preventable, Bruley observes. “The use of established techniques for proper skin cleaning and for safe delivery of oxygen-enriched gas to the patient can virtually eliminate the hazard.”

In Wargo’s case, a simple change in procedure could have prevented tragedy. Rather than telling the assistant that he was turning on the device, the doctor should have been required to ask the anesthesiologist if he or she had turned off the oxygen — wait for a reply, and repeat the reply, before proceeding.

That said, I don’t want to spread fear about fires in ORs.. If you are going in for surgery, there are risks worth thinking about — infections for instance. But fretting that flames will be licking at your toes while you are having your appendix removed is like worrying that the hospital will be hit by a hurricane or taken over by terrorists. In any individual case, the chances are slim to none.

So why am I writing about surgical fires? Because they represent just 650 of tens of thousands of hospital accidents that go unreported each year. And, like surgical fires, a great many are preventable.

Only 25 States Require Reporting “Adverse Events”

The Cleveland Clinic’s excuse that it didn’t report six fires because “it wasn’t required to” might sound lame — until you realize that it is not at all clear who the hospital should have told. The Clinic was, after all, willing to volunteer the information when talking to Medicare inspectors at the end of the year. But someone should hear about adverse events when they happen, so that they can investigate causes, and come up with a plan of action to prevent future accident. Such guidelines could be of great use to hospitals nationwide.

Ohio is not unique. While more than 25 states have passed legislation or created regulations related to hospital reporting of adverse events, roughly half of all states have no reporting requirements.

Injured patients can try to broadcast the news — but if they go to the media, they risk being sued. Moreover, in most cases where a patient is harmed, the hospital is likely to offer compensation that comes wrapped in a confidentiality agreement.

Regulators in all states should gather reports about hospitals accidents from doctors, hospital workers and patients. But the Agency for Health Care Research and Quality (AHRQ) reports that patients are rarely part of the reporting process, and most hospitals fail to disclose many adverse events. Reform legislation could change this. Medicare will be calling for greater transparency, and hospitals that don’t report errors are likely to find that Medicare will begin imposing financial penalties.

Perhaps more importantly, Medicare is likely to begin making medical errors public, along with infection rates. Experience shows that consumers often pay little attention to these reports; they continue to go to the hospital closest to home, or the one their doctor recommends. But hospitals and a hospital’s doctors do not like to see their names listed in reports suggesting lapses in patient safety. Putting the information on a website gives them an incentive to take a closer look at errors and accidents.

Seven States Serve as Models — How Patients Can Help

In January an Office of Inspector General (OIG) report (“Adverse Events in Hospitals: Public Disclosure of Information about Events”) reviewed 17 state adverse event reporting systems , and noted that seven states (Maryland, Massachusetts, New Jersey, Oregon, Colorado and Rhode Island ) disclosed “more extensive information than others (e.g., analysis of the causes of adverse events, guidance for reducing future occurrences, and information about improvements made by hospitals), which can serve as models for other entities.”

Meanwhile, the Empowered Patient Coalition and the Consumers Union Safe Patient Project are making a joint effort to capture a snapshot of medical errors and accidents from the patient’s point of view. They have designed a survey covering various categories of adverse events. Patients can simply check boxes, but they are encouraged to use the narrative sections to share vital details, observations and suggestions. Personal information remains completely confidential unless the patient gives permission to use or share it.

Transparency Can Lead to Prevention

Hospital errors should be made public, not so much to shame hospitals, or even to spur them to improve, but so that “hospitals can learn from others,” Fran Charney, director of educational programs at Pennsylvania’s Patient Safety Authority told the Cleveland Plain Dealer. “That’s the beauty of a reporting system.

“Smart people learn from their mistakes. Wise people learn from the mistakes of others.”

One of the best examples of how the system works, she told the Plain Dealer, involved a near-miss. In Pennsylvania, near-missed must be reported –just as airline pilots are required to share information on close calls.

In this case, a patient in cardiac arrest almost died because he was wearing a yellow wristband. The hospital used yellow bands to indicate that a patient had a “Do not Resuscitate” order. In this case, though, the patient had been transferred from another facility that used yellow bands for other purposes. He did want to be resuscitated. And, in the end, he was.

The catastrophe that almost happened led to the creation of universal color coding for wrist bands at hospitals across the country

Hospitals Should Begin to Implement Change Now

Of course not all hospital accidents are preventable — and in some cases, the accident may not be the hospital’s fault. “We need more data,” argue some hospitals and doctors.

But the truth is that we have a great deal of data, and much information about what works to keep patients safer. Hospitals don’t have to wait for Washington to begin publishing infection rate and medical accidents. .

As patient-safety expert Dr. Lucian Leape points out in a March 10 report for the Commonwealth Fund: “Data from a large number of hospitals, gathered by several sources, show wide variations in the incidence of one of the most lethal hospital-acquired complications, central line–associated bloodstream infections (CLABSIs). Compared with the evidence on how to prevent other types of infections—and most other kinds of adverse events—the evidence on how to prevent CLABSIs is quite strong.

Peter Pronovost demonstrated the potential for complete elimination of central line infections in his intensive care unit at Johns Hopkins Hospital seven years ago. In 2005, in a stunning display of generalizability, Pronovost and his team taught staff in over 100 Michigan hospitals to implement his protocol for central line insertion, and 68 hospitals completely eliminated CLABSIs for six months or more.

Yet, five years later, “we still have significant rates of CLABSI in most hospitals,” Leape writes, “and some are very high. What is going on?”

He answer his own question: “What is going on is that the vast majority of hospitals have not implemented the Pronovost protocol because they have not made a meaningful commitment to reducing preventable injuries, much less eliminating them. Despite an avalanche of data, exhortation from all kinds of experts, and impressive results by some, most hospitals have in place programs to implement only a few of the known safe practices, and none has a strategic plan to implement all of the 34 evidence-based safe practices endorsed by the National Quality Forum.”

How can we motivate hospitals to use what we already know about safe practice?

“The most powerful method for reducing pre­ventable injuries has been to require physicians to pro­vide data on their own performance and then provide them with comparisons of their risk-adjusted compli­cation rates with those of their peers,” writes Leape.

We know this, because the Veterans Administration (VA) has already done it:

The VA pioneered this approach in the 1990s with its National Surgical Quality Improvement Program, which has since been adopted and promoted by the American College of Surgeons.

Under this pro­gram, each hospital’s surgical specialty department receives feedback on its risk-adjusted complication and mortality rates, together with a comparison with all of the other (unidentified) surgical departments in the VA system. In response to these reports, below-average units made substantial improvements, leading over several years to system-wide declines in both complication rates and mortality.

If the VA can do it, why can’t private-sector hospitals?

Maggie Mahar is a fellow at The Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much. She blogs at Health Beat, where this post originally appeared.

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