http://www.heraldtribune.com/apps/pbcs.dll/article?AID=2004409300691
The Herald-Tribune
Sarasota, FL
Sarasota Memorial received good safety ranking
Sarasota Memorial's recent errors didn't figure into a report.
By MARGARET ANN MIILLE
margaret.miille@...
Sarasota Memorial Hospital is among 88 hospitals nationwide and nine in Florida singled out for their high overall patient safety scores.
Sarasota Memorial and its HCA-owned competitor across town, Doctors Hospital of Sarasota, earned that distinction during the summer from HealthGrades, a Denver-based health care quality company.
But for both hospitals, the rating belies recent experience.
Sarasota Memorial has grappled three times in the last seven months with confirmed medical errors. All the mistakes came after the periods that HealthGrades used to determine its ratings.
Two of the errors made at Sarasota Memorial wouldn't show up in the private health-rating company's reports because they weren't a matter of public record. In the third case, HealthGrades didn't have enough information to make a reliable rating.
There is no category pertaining to the time the wrong patient underwent a heart catheterization in March. Nor is there one for Sarasota Memorial's most recent error, which involved giving the wrong medicine to four patients.
The information that HealthGrades receives about transfusion-related errors, such as one Sarasota Memorial made in late June when a critically ill woman received the wrong type of blood, generally isn't reliable enough for inclusion.
The Denver company's measures also don't include a category for incidents where surgery is performed on the wrong body part, a mistake that happened at Doctors Hospital in June, when a doctor preformed arthroscopic surgery on the patient's wrong knee.
Samantha Collier, HealthGrades' vice president of medical affairs, acknowledged Wednesday that no one organization has a complete picture of hospitals nationwide.
"There isn't this nice, strict definition of what quality of care is, or what patient safety is," Collier said. "It's almost an academic argument … That is what everyone is arguing about."
The data that HealthGrades uses from the Centers from Medicare & Medicaid Services is risk-adjusted, meaning it takes into account age, gender and underlying medical problems.
A comparison of patient safety data of the nine acute-care hospitals in Sarasota, Manatee and Charlotte counties is based on 12 categories, including these:
Death in procedures where mortality rates are usually very low, pressure sores from a hospital stay, failure to diagnose and treat a problem in time, foreign objects left in patients during surgery, collapsed lungs because of a procedure or surgery done in the chest area and infections contracted at hospitals.
Other categories concern the post-surgery problems of hip fractures, excessive bruising or bleeding, inadequate organ function and fluid imbalance, respiratory failure, severe infection and wound deterioration.
Category scores are rated as better than average, average or worse than average.
Among nine hospitals, Sarasota Memorial and Doctors tied for the overall best scores. Each scored better than average five times and average seven times.
Charlotte Regional Medical Center in Punta Gorda also scored better than average five times, but got five average scores and two worse than average.
Bradenton's Blake Medical Center, which like Doctors is owned by the giant HCA, received better than average marks four times and average eight times.
Bon Secours St. Joseph Hospital in Port Charlotte was rated better than average in three categories, average in eight, and worse than average in one.
Manatee Memorial Hospital in Bradenton and Fawcett Memorial Hospital in Port Charlotte each were rated better than average twice and average 10 times.
Englewood Community Hospital scored better than average once, average eight times and worse than average three times. Trailing is Bon Secours-Venice Hospital, which received nine average scores and three worse-than-average marks.
The limits on public reporting of problems at hospitals prevent organizations such as Healthgrades from assembling a complete snapshot of patient safety at any particular hospital.
It's up to the consumer to fill in the gaps, Collier said.
"I think the patients need to understand that there are significant variations of quality of care and patient safety," she said. "So they need to do their research."
Collier says health care consumers should pump doctors and other health care practitioners for meaningful information about procedures they plan to undergo.
"I think all consumers recognize that things happen. But consumers want to know what are the error rates and what are they doing to correct it," she said. "Don't be surprised if you get "I don't know.' But what should come right after 'I don't know' is 'I'll find out for you.'"
Sarasota Memorial's latest mistake occurred more than two weeks ago. Four patients were given cardiac medication, which increases the heart rate, instead of anti-inflammatory medicine.
Hospital officials are giving few details of the incident except to say that no one died. They refused to comment on a Fox 13 news report that one person suffered a heart attack while the other three required catheterization.
Dr. Bernard Feinberg, the hospital's chief of staff, has said that someone in the pharmacy department mistakenly drew the wrong drug, which had packaging similar that of the intended medicine.
Medication mistakes account for more than half of all medical errors made at hospitals, said Hedy Cohen, a registered nurse and vice president of the Pennsylvania-based Institute for Safe Medication Practices. The nonprofit organization collaborates on a voluntary reporting program specifically for medication errors.
Mistakes involving medicine can come from things other than human error. They include medical devices such as intravenous equipment that don't work properly.
Mistaking one drug for another that looks nearly identical falls within the realm of what is called "confirmation bias." It is what consumers do in grocery stores when they reach for a product that seems to bear the telltale logo of their favorite manufacturer.
To reduce the potential of such errors in hospitals, a for-profit arm of Safe Medication Practices is working with the pharmaceutical industry to make sure that drug labeling and packaging are clear and distinctive, and not likely to be confused.
Cohen, who also is hired by hospitals to conduct their internal investigations of how errors occur and what can be done to avoid them in the future, advises hospitals to discuss the problems with the communities they serve.
"It's really important to communicate how seriously you are taking it," she said.
Cohen said her organization also has been working with the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, to develop a policy to be launched next year for preventing errors among drugs that look alike or whose names sound alike.
HealthGrades' Collier said it's difficult to get a handle on what is good, quality health care.
"Quality is kind of this intangible thing," she said. "You can't really describe it, touch it or feel it, but you feel it when you don't get quality. We do a much better job of knowing what quality isn't than is."
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