Obama Urged to Mandate Medical Error Reporting

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President Obama made a brief mention of healthcare outcomes -- in the context of healthcare spending -- during his Super Bowl pregame interview with CBS News anchor Scott Pelley on Sunday, but some are looking ahead to what he might say during his annual State of the Union address on Feb. 12.

One high-profile healthcare safety advocate, Paul O'Neill, former U.S. Treasury secretary and chairman and CEO of Alcoa, wants the president to seize the prime-time, national platform to make a bold statement about the problem of medical errors.

"In your State of the Union message, announce that you have ordered each of the veterans' hospitals and U.S.-based military hospitals to connect with the Internet at 8 a.m. every day to post every hospital-acquired infection, every patient fall, every medication error and every injury to a caregiver that occurred during the previous 24-hour period. Announce that this will commence March 1, and that it is your intention to require all U.S. hospitals and nursing homes to start doing this on April 15," O'Neill wrote in a Jan. 27 op-ed published in the Pittsburgh Post-Gazette.

As chief executive, Obama can order Department of Veterans Affairs (VA) and Military Health System to report errors, though it is less clear whether he can place the same requirements on private facilities, even as a condition of participation in Medicare or Medicaid.

"To have the desired impact, it is important that this information be reported separately for each facility for each 24-hour period," wrote O'Neill, who served in the George W. Bush administration and now is on the board of the Lucian Leape Institute at the National Patient Safety Institute. "That is because, every 24 hours across the nation there are, on average, 4,658 newly identified hospital-acquired infections, 1,369 patient falls and perhaps as many as 800,000 medication errors."

O'Neill, co-founder of the Pittsburgh Regional Health Initiative, has long championed adapting the Toyota Production System to create safer healthcare environments. He said that it was important to post data daily in the name of transparency.

"It is not possible today for a citizen to go on the Internet to discover how safely, or how carelessly, a local provider is providing care," he wrote. "And it is not possible for care-giving institutions to gauge their own performance and compare it to others. By your action, you could enable individuals to choose where they go for service, based on the absence of error, not on the basis of proximity or advertising claims. And you would allow care-giving institutions to identify the best performers across the nation and learn how to improve their practices."

But he cautioned that the disclosures not be used in a punitive manner, and suggested that Obama promise to end the requirement in three years if it is not result in significant error reduction and cost savings.

This non-adversarial approach makes sense to James Conway, principal of the governance and leadership group of Washington-based healthcare analytics and clinical quality improvement firm Pascal Metrics, and a senior fellow at and former senior VP of the Institute for Healthcare Improvement (IHI), Boston, an organization founded by well-known healthcare quality guru and onetime Centers for Medicare and Medicaid Services administrator Dr. Donald Berwick.

"I would not want to penalize the organizations that are reporting the higher level of events," Conway told InformationWeek Healthcare. Additional reporting makes people more attuned to problems, Conway said. He explained that organizations with a strong culture of safety tend to have a "preoccupation with failure." That means they are committed to identifying and then rooting out sources of failure, he said.

"While the goal is to eliminate these events, we will need to be very careful not to penalize those organizations that report more -- they may be preoccupied with looking for trouble. Others, while having many instances of harm, will see few," Conway later added in an e-mail.

"Some hospitals in the United States are experts in finding trouble and some aren't," Conway said. "Some use very sophisticated means of identifying errors," he said, specifically naming the IHI's Global Trigger Tool for Measuring Adverse Events, a system for reviewing patient records based on clues that could indicate potential errors.

"You're discovering tenfold more adverse events [with the tool than without it] because it is very sophisticated," he said. This estimate comes from an April 2011 article in Health Affairs, written by University of Utah healthcare quality gurus Dr. David Classen and Dr. Brent James, and contributed to by a team from IHI. The article found that voluntary reporting and even following the U.S. Agency for Healthcare Research and Quality's Patient Safety Indicators missed 90% of adverse events picked up by the Global Trigger Tool.

"The least effective tool is voluntary reporting," said Conway, who also is a former executive VP and COO of Dana-Farber Cancer Institute in Boston. When he was at Dana-Farber, the goal was to have the highest level of reported errors and the lowest level of errors that actually reached patients.

O'Neill fostered a culture of worker safety at Alcoa. "Paul as chairman of Alcoa woke up every day and looked at safety reports," Conway said. "It drives you to an exceptional level of performance."