Slowly the public is coming to realize that hospitals are not always safe places. When the Institute of Medicine published its landmark study “To Err Is Human” a decade ago, pointing out the ubiquitous problem of medical errors in the U.S., the press yawned. Since then, though, a grassroots patient safety movement has blossomed, and the media’s interest has grown along with it. More journalists are using data and old-fashioned shoe leather reporting to dig into what’s killing Americans in places that are supposed to make them well. A few years back, I had a conversation with Dr. Mark Chassin, who was then trying to make New York City’s Mt. Sinai Hospital a safer place. Chassin has now moved on to head the Joint Commission, a private group that accredits hospitals. Knowing that medical professionals and hospitals are loathe to police themselves while at the same time trying to weaken government regulation, I asked Chassin what will really cause a change.
Chassen replied that the pressure will have to come from the public in the same way that public pressure created environmental protection laws. Someone needs to call attention to patient safety the way Rachel Carson warned of environmental disaster in Silent Spring, Chassen told me. A book with the power of Silent Spring has yet to emerge, but rank and file journalists are beginning to tell the stories of what’s going on in their local hospitals. Hospitals, which would rather have reporters write about new wings named for rich dudes and the latest technology they just acquired, are not keen on having their mistakes exposed. Sometimes political pressure to keep these stories under wraps is intense, making it hard for the press to do its job. This is the first of a series of posts that will examine what the media are doing to report on patient safety in their communities. We invite readers to keep an eye out for patient safety stories and send them our way. Our goal is to spark a dialogue among stakeholders and the press, leading to safer care.
In a state where gamblers can easily access the odds on any video poker machine, Nevada patients have had no way of knowing their odds of being injured in a hospital, the Las Vegas Sun told its readers in part one of a splendid series on hospital safety. The series, by reporters Marshall Allen and Alex Richards, aims to change that.
Allen and Richards spent two years investigating hospital safety using a state database
of 425,000 inpatient visits. They found reports of 969 incidents of preventable hospital injuries in Las Vegas hospitals, some of which resulted in death and permanent disability. One woman’s windpipe was torn during the insertion of a breathing tube. Oxygen was pumped into her chest cavity instead of her lungs. She died. Another patient developed gaping, bone-deep bedsores on his buttocks and heels while recovering from heart surgery. Two years later, the paper reported, he can barely walk.
What made numbers like the 79 cases of advanced stage pressure sores, the 248 cases of post-operative falls, and the 475 cases of bloodstream infections caused by central-line catheters more dramatic was the fact that most were preventable. Allen and Richards pointed out that preventing pressure sores and central-line infections does not require rocket science, only a culture of safety and a willingness to follow good medical practices like hand washing, helping patients when they go to the bathroom, and turning them to prevent bed sores. Instead, they told readers that “a dangerous culture of mediocrity has become the status quo” in Las Vegas hospitals.
It was not surprising hospitals didn’t want to talk to the reporters. Only one of them did. Nor was it surprising that the reporters uncovered what they said were failures by the hospitals to report incidents, as state law requires them to do. The Sun’s reporters looked at the state’s regulatory efforts to pass a law intended to bring greater transparency to the problem of hospital mistakes. In 2002, Nevada passed a law requiring hospitals to report “sentinel events,” which the state defined as “unexpected incidents that cause serious physical injury or the risk thereof.” However, the numbers available to the public are reported only as state-wide aggregated data, not as hospital specific breakdowns—the result of a compromise between the industry and lawmakers.
Even though the paper reported that the compromise made the “information essentially meaningless to consumers,” it took the giant step of analyzing the data that existed, and guess what? Some hospitals may not be reporting all of their sentinel events as the law requires. Allen and Richards analyzed 1,363 incidents of statewide hospital-acquired harm in 2008 and 2009 that appeared to fit the state definition of sentinel events. Yet during that period, they found Nevada hospitals reported only 402 sentinel events. Hospitals reported only one sentinel event involving an advanced stage decubitus ulcer, a bedsore surrounded by dead flesh. The paper found seventy-two.
In part two, Allen and Richards zoomed in on hospital-acquired infections, a problem in almost every nook and cranny of the U.S. In 2008 and 2009, lethal, drug-resistant “super bugs” infected Las Vegas hospital patients more than 2000 times; 239 patients died, although the reporters could not tell from hospital billing records whether the infections played a role in patients’ deaths.
No health agency tracks these cases, and the paper pointed out that hospitals had scotched proposed legislation in 2009 that would have required them to publicly report cases of MRSA infections. In fact, Nevada’s state epidemiologist, Dr. Ihsan Azzam, did not know how many patients had contracted infections until the Sun told him.
I especially liked the context provided about a Nevada VA hospital that has a zero tolerance policy toward hospital infections. Each patient is swabbed at admission, and carriers are immediately isolated. Each test costs about $25, and the hospital says the test is cost effective. Las Vegas hospitals issued a statement to the paper, saying they screen only high-risk patients, claiming that it is “a cost-effective and efficient method to reduce the rate of MRSA in hospitals.” The paper pushed back, reporting that despite such policies, “the overall rate of infections at hospitals is rising.”
What makes the Sun series so powerful is its effective blend of personal stories, interpretation of how people relate to the numbers, sharp analysis of the data, and context—lots of context—about the failures of the state and federal regulatory processes, the power of a very powerful industry, and the clinical facts about the harm caused by the hospitals. The stories were long enough for readers to understand what may happen to them, but they did not overwhelm, as some kinds of these investigations do. Neither were they typical of the all-too-brief health stories that settle for the standard formula: a lede anecdote, a few graphs of data, a rebuttal from the medical stakeholder, and a weak kicker.
Perhaps the industry’s refusal to talk actually made the story stronger. The facts and the reporting stood on their own without dilution by a PR quote from some hospital official. The paper also made creative use of multimedia, like posting reader stories and audio from voicemails, so others could hear for themselves the anguish that patients experience.
At the end of part one, the Sun urged others in the media to follow its lead. “The Sun’s investigation can be replicated, imposing a new era of transparency within the hospital industry,” Allen and Richards wrote. Allen told me the paper got a ton of response to the stories, including a state investigation and two new laws proposed. “This is incredibly encouraging,” he said. “We’re shifting the political power structure by exposing these things.”
That is exactly what journalism is supposed to do.