CITY HOSPITALS LIE ABOUT ERRORS?

THOMPSON STUDY FINDS MANY HOSPITALS UNDER-REPORT MEDICAL INCIDENTS TO THE STATE HEALTH DEPARTMENT

-- Calls for Reinvigorating Reporting System to

Improve Care and Reduce Excess Costs --

A comprehensive study issued today by the Office of the Comptroller William C. Thompson Jr., found that many New York City hospitals substantially underreport "adverse events" to the New York State Department of Health (DOH). 

DOH considers an adverse event to be an unintended, undesirable development in a patient's condition "that was not caused by the natural course of illness, disease or proper treatment." Under State law, hospitals are required to report 31 categories of medical errors and other adverse events, such as "new acute pulmonary embolism" and "medication error," to DOH through the New York Patient Occurrence Reporting and Tracking System (NYPORTS).

"Reportable adverse events typically result in longer hospital stays and higher costs to the healthcare system," Thompson said. "We found that the reported events in just a single NYPORTS category led to more than $70 million a year in excess costs to the State's healthcare system. When NYPORTS was established in 1998, its original mission was to improve hospital patient safety and quality of care and to avoid unnecessary hospital expenditures by reducing the numbers of adverse events. That mission has been compromised due to under-enforcement and under-reporting."

Thompson's staff reviewed NYPORTS filings by each hospital in the State for each reporting category for 2004 through 2007. Among the findings in Thompson's report:

*       Some hospitals reported adverse occurrences at rates (per 10,000 patient discharges) up to 20 times greater than other comparable hospitals. Some hospitals reported several hundred occurrences while others of similar size reported just several dozen. One hospital in Queens reported 111.3 occurrences per 10,000 patient discharges while similar size hospital in the same borough only 6.0 per 10,000. Enormous reporting disparities were found for a wide array of reporting categories, from "new deep vein thrombosis" (a blot clot than can become fatal) to "acute myocardial infarction [heart attack] unrelated to a cardiac procedure."

      Such extremely wide reporting disparities do not reflect actual differences in the numbers of adverse events. This was acknowledged by a DOH official, who said that "some [hospitals] are better reporters than others." In addition, an analysis of whether greater risk factors at certain hospitals were positively correlated with higher reporting rates for several of the most-reported occurrences found little or no such correlation; hospitals that might have been expected to have high reporting rates had low ones and vice versa.

      The hospital with the second highest reporting rate in New York City is regularly on the U.S. News & World Report annual listing of the nation's "best" hospitals, indicating that a high reporting rate does not mean a hospital is substandard.

*   From 2004 to 2007, New York City hospitals reported only 37 medication errors and 22 hospitals, including several of the City's largest, reported none at all. Hospitals are required to report all instances of medication error that cause death, permanent harm or a "near death" event. A landmark national study by the Institute of Medicine of the National Academies concluded that at least 400,000 hospital patients nationwide are harmed and 7,000 die because of medication errors annually.

*        New York City hospitals reported adverse occurrences at an overall rate 44% below Upstate hospitals and 39% below Long Island hospitals. In 2001, when DOH observed similar disparities between NYPORTS reporting in New York City and other parts of the State, the agency indicated that underreporting was the main cause of the City's lower rate.

*      There were very wide, inexplicable disparities among comparable hospitals in reporting surgical site infections. For example, in 2006 one major academic medical center reported 32.0 post-operative surgical site infections per 10,000 discharges while another major academic medical center reported only 3.6 per 10,000. With the implementation of the

      State's new Hospital-Acquired Infection Reporting System in 2007, DOH has discontinued NYPORTS reporting of post-operative surgical site infections. The reporting disparities that occurred in 2006 and earlier years indicate that DOH will need to be vigilant to ensure complete reporting under the new infection reporting system. 

*        Weak enforcement by DOH is in large part responsible for incomplete hospital reporting.  DOH rarely cites hospitals for non-reporting and, when they do, the fines levied have been minimal -- only $2,000 for a first violation. In 2001, DOH announced it would seek legislation to increase the fine for health facility violations to $6,000 for a first violation, $25,000 for a recurrence and $50,000 if the problem is not corrected during a third inspection. But an increase in health care facility fines was not enacted until 2008, and the new fines fall well below the levels DOH recommended in 2001. Fines remain at $2,000 per initial violation and reach $10,000 only if the violation "directly results in serious physical harm to any patient or patients."  

*        DOH commitment to NYPORTS has flagged. Originally, DOH intended NYPORTS to foster higher quality care by covering a wide array of occurrences. This mission was eroded in 2005 when DOH discontinued 22 of the 54 occurrence categories then in use. Also in 2005, DOH effectively ended enforcement of five other categories (reporting is still officially required but there are no consequences if a hospital fails to report them). In addition, the most recently released NYPORTS Annual Report covers a three-year period, 2002-2004, the NYPORTS Statewide Council has not met in at least two years, and publication of the periodic NYPORTS News and Alert has ceased.  Lack of staff resources has virtually precluded giving feedback to hospitals.

"In this time of unprecedented financial stress on hospitals, there is another reason to step up efforts to improve hospital quality and safety," Thompson said. "A robust NYPORTS can help avoid the excess costs associated with adverse occurrences, which burden all New Yorkers."

In light of his findings, Thompson recommended that:

*        DOH enforce mandatory reporting. Under-reporting undermines the utility of the NYPORTS program. Enforcement could be strengthened through higher fines, expanded use of medical records audits and retrospective chart reviews. To keep the cost of improved enforcement modest and cost-effective, it should focus on hospitals which have been shown to be at greatest risk of under-reporting based on past performance and on high frequency adverse event categories with the greatest potential for patient harm and potential savings to the healthcare system.

*       DOH selectively restore some discontinued reporting categories and consider adding new ones. Restoring some NYPORTS categories, revising others and adding new ones would produce additional information that could be of enormous value in improving quality of care and medical outcomes.

*      The State adequately fund NYPORTS. It has been well documented that reducing adverse events in hospitals saves money.

*        Hospitals be adequately funded to fully implement electronic records systems. Such systems pay for themselves by better identifying reportable adverse events, which can lead to corrective action that keeps costly adverse events from occurring.

*        DOH release annual NYPORTS reports and issue them more promptly. DOH also should resume publication of the periodic NYPORTS News and Alert.        

"New York State started out as a bold leader in the area of mandatory adverse event reporting," Thompson said. "DOH intended that hospitals to be able to log onto a NYPORTS web site and compare their reporting rates in different categories against their peers and for the Department to use NYPORTS reporting to find out about emerging quality of care problems in individual hospitals and industry-wide. Lessons learned from NYPORTS reporting were to be used to develop risk reduction strategies, improve care and cut costs. NYPORTS needs to be reinvigorated so that these basic functions can be performed."

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