Reported errors climb in area hospitals
Connecticut hospitals reported record numbers of patients killed or seriously injured by hospital errors in 2013.
When calculated in terms of patient volume, New Milford Hospital had the highest error rate, with 78.6 adverse events per 100,000 patient days, followed by Danbury Hospital, with 62.8 adverse events per 100,000 patient days.
Both facilities are members of the Western Connecticut Health Network.
The report by the state Department of Public Health covers 2013 and marks the first time the number of so-called "adverse events" in hospitals and other health care facilities has topped 500 -- more than double the number in 2012, when 244 such incidents were reported.
There was a large increase in the numbers of falls, medication mistakes and perforations during surgical procedures, the state report shows.
Much of the increase was due to an expansion of reporting on pressure ulcers, which added a new category with 233 "unstageable" ulcers that were not counted before.
Even without that category, however, reports of adverse events climbed 20 percent from 2012.
Safety a priority
The report is careful not to draw conclusions about the state of patient safety in Connecticut hospitals, mainly because the incidents are self-reported.
"We cannot say whether a high reporting rate reflects highly complete reporting in a facility with good quality of care, or perhaps modestly complete reporting in a facility with poor care, or neither better nor worse quality care," the DPH report said.
The report doesn't reflect the hard work many hospitals have put into improving safety, said Dawn Myles, WCHN's vice president of quality and patient safety.
"Patient safety is a top priority for our hospitals and we continually implement changes that result in significant improvements in patient care," she said in a statement. "As part of our High Reliability Organization work recently, we have focused on encouraging staff to report any potential safety issues, which allows us to make improvements in our work and provide highly reliable care. "
"We have trained over 6,000 staff across our network in HRO principles," she added, "to insure we are promoting transparency and a keen focus on safety."
Myles said the WCHN hospitals have specifically taken measures to prevent pressure ulcers, which comprise the bulk of the adverse events reported at the chain.
"We believe that our early detection system, designed to prevent more serious skin issues is driving our higher number of reported events," she said. "As part of our quality programs we have certified specialists in skin care, who oversee our programs and train in-house teams to have enhanced expertise in this area."
"We also have dedicated fall prevention specialists and teams," Myles said. "As a result, we continue to achieve improvement in these and other areas."
The most significant increases were in the numbers of patients harmed by foreign objects left in their bodies after procedures -- more than doubling to 25 from 12 in one year -- or those harmed by perforations during surgical procedures -- 79, compared to 55 the previous year.
Those are "the highest levels since the (data reporting) was adopted in mid-2004," the state report said.
Nearly half of the perforations that seriously injured or killed patients occurred during colonoscopies, while others occurred during endoscopies, hernia repair or other procedures.
Sponges, drain tips and clamps were among the objects most commonly left in patients after surgery.
The number of patients killed or seriously injured in falls also increased -- from 76 in 2012 to 90 in 2013 -- while the number of reports of wrong-site surgeries increased from nine to 13.
Medication errors doubled, from three to six. Reports of falls and wrong-site surgeries had declined in 2012, but the new figures from 2013 show those errors returning to higher levels.
Danbury reported five falls and five incidents of perforations during surgical procedures.
Hospitals with the lowest rates of adverse events were Charlotte Hungerford in Torrington, William W. Backus Hospital in Norwich and Connecticut Children's Medical Center in Hartford. They all had rates of less than seven adverse events per 100,000 patient days.
The DPH does not investigate all adverse events, but instead focuses on those that may indicate "a systems issue or issues related to inadequate standards of care," the report said.
Even in light of these discouraging numbers, officials of the Connecticut Hospital Association have said the state's acute-care hospitals have undertaken initiatives to improve patient safety, including strict procedures to prevent wrong-site surgeries, medication errors and pressure ulcers.
Dr. Mary Cooper, vice president and chief quality officer of the association, said hospitals have trained more than 10,000 hospital staff and physicians in "high reliability safety behaviors," under a statewide initiative that has received national recognition.