Hospital patient safety under a spotlight
Charge Nurse Ann Massari assists patient Grace Muto, 86, of Harwood Heights, at Resurrection Medical Center. (Michael Tercha/Tribune)

By Judith Graham, Tribune reporter
7:56 p.m. CDT, April 10, 2011

Over strong objections from the hospital industry, (you bet they strong objected - when the American people awaken and notice just how murderous their hospitals can be, there will be hell to pay)(the government has published data about things that can go wrong in hospitals — falls, objects left behind during surgeries, bloodstream or urinary infections associated with catheters, incompatible blood infusions, serious bed sores and more.

The information is the first hospital-specific patient safety data to be released nationally by Medicare. Published last week, it comes from a review of hospital bills submitted for elderly and disabled patients between October 2008 and June 2010.

All of Chicago's top medical centers appear on the list of hospitals with safety issues, to one extent or another. For instance, the University of Illinois at Chicago Medical Center, the University of Chicago Medical Center and Rush University Medical Center all reported higher-than-average numbers of hospital-acquired bloodstream infections associated with catheters. Officials at each medical center questioned the government's method of counting infections while acknowledging mistakes in data they submitted to Medicare.

For patients, the information provides an opportunity to have a conversation about "what your local hospital is doing to improve their practices," said Patricia Merryweather, a senior vice president of the Illinois Hospital Association. But she cautioned that "since this is the first release of this information, there's some noise in the data and some hospitals may have had problems accurately reporting."


The American Hospital Association opposed the release of the Medicare report on so-called adverse events, which had been scheduled last fall but was delayed because of industry concerns. In an interview, Nancy Foster, vice president of quality at the hospital association, said it "is not a reliable reflection of patient safety issues in hospitals." Objections of this kind aren't new; hospitals often complain when Medicare releases reports about the quality of medical care.

But officials say the government is committed to shining a light on things that go wrong in hospitals, often because of poor communication between providers, inadequate follow-up or other breakdowns in the processes of care.

"Any potentially preventable complication of care is unacceptable," said Dr. Donald Berwick, administrator of the Centers for Medicare & Medicaid Services, in a statement.

Of 1 million elderly and disabled Medicare patients hospitalized annually, 13.5 percent — or 135,000 people — experience an adverse event, with associated costs of $4.4 billion, according to a November 2010 report from the inspector general of theU.S. Department of Health and Human Services. Among people of all ages, hospital errors account for nearly 100,000 deaths each year, according to the Institute of Medicine, an arm of the National Academy of Sciences.

Information included in the new Medicare patient safety report came from medical bills submitted by hospitals to Medicare for payment — a data source that several experts said is flawed and subject to "coding" errors. (if they can't even code the incidents correctly, how do we know that the numbers are not vastly understated?)  With each Medicare invoice, medical conditions treated are given a code that determines the payment amount.

While coding mistakes are common, ensuring that bills accurately reflect medical information is hospitals' responsibility, other experts noted. Also, since 2008, Medicare has refused to pay for complications associated with several adverse events, giving hospitals a strong incentive to check coding practices.

Asked about the new Medicare report, several Illinois hospitals owned up to opportunities for improvement and stressed that patient safety was a top priority. (To review results, go tohospitalcompare.hhs.gov, look under the "hospital spotlight" section on the right side and follow prompts.)

Data on hospital patient safety also appear in the Illinois Hospital Report Card (healthcarereportcard.illinois.gov), but with some differences: The Illinois report includes data from all patients from 2009, while the federal report reviews data from Medicare patients only, goes through mid-2010 and includes several more measures. In Illinois, Medicare covers nearly 40 percent of all patients hospitalized in any given year.

In the Medicare report, Chicago's Resurrection Medical Center recorded 18 patient falls, the highest number in Illinois, during the period covered. Since then, the Northwest Side facility has introduced hourly rounds where nurses check on vulnerable patients, asking if they need help going to the bathroom or reaching call buttons, to keep people from getting up unexpectedly and taking a tumble, said Carole Miserendino, the hospital's chief nursing officer.

Second-highest was Northwest Community Hospital in Arlington Heights, with 15 falls listed. The hospital a year ago implemented a new program ensuring that older patients at risk of falls wear yellow slippers and armbands so they can be easily identified and helped, among other measures, according to Cindy Dougherty, director of quality measurement and improvement.

Chicago's Mount Sinai Hospital had the highest rate of older patients with serious bedsores, with seven such incidents. After becoming aware of the problem, the hospital, at California Avenue and 15th Street, hired a second wound-care nurse in the fall of 2009. Now, its electronic medical records system automatically alerts a wound-care nurse when a patient is deemed likely to have serious skin problems, said Lori Pacura, Mount Sinai's chief nursing officer.

When Provena St. Joseph Medical Center in Joliet investigated 35 hospital-acquired urinary tractinfections associated with catheters recorded in the Medicare report, "we didn't see any particular trends," said Margaret Gavigan, chief clinical officer for Provena Health, the hospital's parent organization. Many of those incidents were coded incorrectly, she said. But recognizing that it had an issue, the hospital joined a national health care collaborative aimed at stopping urinary tract infections in October of last year.

Rush University Medical Center, on Chicago's West Side, had the state's second-highest number of hospital-acquired catheter-associated urinary tract infections, 18, and recently instituted an electronic system to alert physicians if a patient has a catheter that no longer appears medically necessary, said Dr. Raj Behal, senior patient safety officer. Separately, the hospital last year made reducing hospital-acquired bloodstream infections a corporate goal, setting specific standards for how catheters are inserted and maintained and using checklists to be closely followed by staff.

Objects left in patients after surgery — think surgical sponges, needles or tubes — are one of the more alarming adverse events tracked in the new Medicare report. Eighteen Illinois hospitals reported at least one such incident, but interviews with representatives of several of those hospitals indicated that circumstances were more complicated than they appeared.

All three cases of foreign objects left in patients at Advocate Christ Medical Center in Oak Lawn were coded incorrectly, said Dr. Lee Sacks, chief medical officer for Advocate Health Care. One was a screw tip that broke off during hip surgery that the surgeon deemed too risky to try to remove. Another was a catheter tip that broke off during a procedure and was successfully retrieved. Both should have been listed as "mechanical complication of a device," Sacks said.

In the third case, a surgeon found a sealant deliberately used in a previous procedure in an artery, and that too was listed incorrectly as a foreign object, Sacks said.

Similarly, at the University of Illinois at Chicago Medical Center, a device used to help drain a patient's wound was wrongly coded as a foreign object when it broke as doctors tried to remove it, said Dr. William Chamberlin, the hospital's chief medical officer.

Northwestern Memorial Hospital, on Chicago's Near North Side, makes no excuses for the object it left in a Medicare patient after surgery, despite all of the medical center's efforts to ensure this doesn't happen.

"All of these events are absolutely preventable, and it's our responsibility to put systems and procedures in place to prevent them," said Jay Anderson, vice president of quality.