5 Scary Things About Healthcare Quality
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.'
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.
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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