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5 Scary Things About Healthcare Quality

Cheryl Clark, for HealthLeaders Media, October 31, 2013

Here's something else that's scary: The Joint Commission alert counts a total of 772 URFO incidents from all its hospitals between 2005 and 2012.

How can the number be that low?

California's annual "Fee Report" from February says that since FY year 2008, state officials have counted 1,061 incidents of "retention of a foreign object" inside patients. Just in California.

Clearly, not all URFOs are being reported to The Joint Commission.'


Adverse Events


Reported incidents of retained  surgical objects in CA

The California report indicates such forgotten surgical item incidents are not in decline either. The incidence has actually been going up.

5. Dwindling Interest in Immediate Jeopardy Fines

So adverse events are causing deaths and patient harm in numbers we can't be sure of. But there's not much outrage and even media interest appears to be drifting.

Every four months or so for the last five years, the California Department of Public Health has hosted an hour-long media teleconference to publicize the latest additions to what I call its "Hospital Hall of Shame" and to announce the fines which range from $25,000 to $100,000.

These are those organizations where patients have died or been severely injured from surgical errors, falls, fires, poorly maintained medical equipment, medication errors, procedures performed by inadequately trained providers, and many other mistakes.

Last week, however, when state officials announced 10 fines totaling $775,000 to nine California hospitals, for the first time there was no teleconference, just an e-mailed news release. Debby Rogers, deputy director for the CDPH's Center for Health Care Quality, told me she thought there was no longer the media interest to warrant a teleconference.

Have we become so accustomed to these incidents that we no longer care to write about these events? Or is it that state officials only think that is the case?

I don't know what the answer is, but it's all enough to give you nightmares.

Happy Halloween.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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3 comments on "5 Scary Things About Healthcare Quality"


Suresh Nirody (11/1/2013 at 2:53 PM)
He didn't actually "count" anything... He looked at four studies(covering 4,252 records reviewed, which were associated with a total of 38 deaths) and then extrapolated their rates to the total 34.4 million discharges in 2007 to get his lower boundary... Beyond the deaths he estimates a mind-boggling 2-4 million serious adverse events (not resulting in death) a year! What IS shocking is that the 1999 IOM report was based on data from studies in 1984, and this latest report is based on years old data as well. It is an indictment of the system that analysis of something so important has to rely on such old data! Also, given the magnitude of the numbers discussed, I've been completely amazed to NOT have seen any analysis of this report, either to support or to disagree with the methodology and his numbers and conclusions... Surely there are learned people who can, and should, do this!

Lisa Sams MSN, RNC (11/1/2013 at 1:27 PM)
Cheryl, thank you for highlighting the James article. The doctor consider "father" of patient safety is confident in the analysis. And you raise an important question about the level of interest in harm and death that occur during a hospital stay. Unless it happens to someone we know....or to ourselves....I believe we have learned to ignore the data because it is One Person at a time. Many attempt to tell their story and organizations like the Walking Gallery offer visual representation of lost or harmed loved ones. These are system issues, as mentioned in other comment. But calling it a system problem does not remove the provider, administrator and other staff from the analysis. As a long time advanced practice nurse, I see the value in system analysis and development of a plan that can be tracked until the culture change is truly integrated into care. If we can reach critical mass with patient communities and clinicians sharing information, collaborating and basically taking charge of the problem it will change. No clinician goes to work looking to cause harm and when it happens it is devastating. It is time to share basic information with patients and families in how to stay safe in the hospital, to push back, to question and when necessary engage the CEO through a Risk Management report...done on a scrap of paper is all it takes. Yes, these are complex system issues but if your spouse, your mom or your child is not receiving the care you think they should then push and push hard. We have a good history of patient community driving change in the 60's & 70's. It was women who changed our closed doors and drug induced hospital births to family centered care. They became educated and expected more.

stan davis (10/31/2013 at 7:15 PM)
very irresponsible to write "He says that at least 210,000 deaths a year in the U.S.[INVALID]and as many as 440,000[INVALID]can be blamed on provider mistakes". nowhere in the paper does it state this as "provider mistakes". the errors are part of a system, and requires a system approach to fix.