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. This is the second in 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. The series is archived here.
Kudos to Columbia Tribune reporter Jodie Jackson for taking a close look at hospital inspection reports for University Hospital, a behemoth medical center that no doubt is influential in the rather small community of Columbia, Missouri. Jackson’s story is important because it describes serious flaws in the system of hospital regulation that Missouri residents depend on for safe medical care.
Jackson obtained a twenty-four-page report FDA investigators produced after making eight visits to the hospital between May and July 2008. The unsavory findings included rusty knife handles lying around and surgical towels, intended for a one-time use, reused to wrap “sterile” surgical trays. The report was prompted by a whistle-blower, a certified sterile processing technician at the hospital who didn’t like what he saw. Jackson reported that when an FDA inspector quizzed hospital staffers, they denied that single-use devices were being reused. Then, according to Jackson, the technician told the inspector where to find them, and her report corroborated his claim.
Then, four months ago, inspectors from the Centers for Medicare and Medicaid Services (CMS) visited the hospital and found similar problems:
Residue and debris on instruments in sterile surgical containers. Orthopedic instruments with bone or cement on them. A sterile processing technician washing dirty surgical instruments with gloves on, then opening a door and answering a phone without removing the soiled, wet gloves.
Inspectors wrote: “the cumulative effect of these systemic practices has the potential to affect all patients in the hospital.”
Jackson took the inspection process one step further and found that five days after CMS inspectors said that the hospital was not in compliance with standards for infection control and could lose its Medicare payments, the Joint Commission, a private accrediting agency, gave the hospital full accreditation, the gold seal of approval. Sometimes a hospital’s accreditation from the Joint Commission conflicts with the government inspection reports that tell of serious health and safety deficiencies. Jackson asked hospital personnel and others about these disconnects. Doesn’t one agency talk to another? Should there be a coordinated effort to determine if a hospital is safe? Jackson wanted to know.
The answers he got hardly inspire patient confidence. An FDA spokesman told the paper his agency “sometimes” shares reports with other agencies, but he could not disclose which reports. The CMS regional director said her agency is addressing the communication gap internally. Whatever that means. The Joint Commission learned about the CMS report from the hospital itself. “They were surprised. They hadn’t seen it,” said hospital CEO Jim Ross. Patricia Kurtz, director of federal relations for the Joint Commission, said they usually don’t see inspection reports. That apparently makes it possible to award a gold seal to hospitals that seem to reuse surgical equipment or have problems with infection control. “I’m surprised that we did not pick up these issues that the two federal bodies picked up,” said the Joint Commission’s media relations manager, Elizabeth Eaken Zhani.
This game of Who’s on First suggests that reporters and the public need to take these regulatory oversight matters into their own hands. That’s not so simple. The Association of Health Care Journalists (full disclosure: I am immediate past president of the group) has pushed the Joint Commission to make it easier to learn whether a hospital has lost accreditation or is in danger of losing it. Check out the Joint Commission’s Quality Check section on its website. Government inspection reports are a tougher proposition. These reports are not publicly available for hospitals. Nursing homes are required to post them; hospitals aren’t. A few states put them on line, but if journos or patients want to see the reports, they must file a FOIA request. Jackson’s story shows why that’s not an acceptable solution for patient safety.