A Fantasy Brought to You by the New York Times: Medicine Without Risk

Sometimes I agree with New York Times’ editorials. Sometimes I don’t. But I rarely learn much from them. To my mind, the problem with the form is that it encourages opining without evidence. So, I admit, I rarely turn to the editorials.

But Buckeye Surgeon pricked my curiosity by referring to a recent New York Times editorial as a “masterpiece of naiveté and contempt.”

Such strong language suggested that the editorial might be entertaining. Thus, I went back and read what turned out to be a piece congratulating Medicare for having decided it “will no longer pay hospitals for the added cost of treating patients who acquire any of 10 ‘reasonably preventable’ conditions while hospitalized. Those include incompatible blood transfusions, severe bedsores, injuries from falls, poor blood sugar control, and infections after certain surgeries.”

This is what I mean about editorials: typically they are monologues that cry out for a good copy editor who asks sensible, logical questions.  The first query that springs to mind is this:  exactly what does “preventable” mean?  How is a “fall” preventable?

If Mr. Smith decides to get out of bed, begins shuffling toward the hallway, feels woozy, loses his balance and falls, how could the fall have been avoided?  Should a member of the staff be stationed not more than six feet from each patient, ready to race in and catch him if he teeters? Or should Mr. Smith have been tied to his bed?  (Thanks to HealthBeat reader Howard B. for his comment on hospital falls about a year ago.)

Personally, I would prefer the risk of falling to the trauma of finding myself strapped to a hospital bed.
Of course if there were a banana peel on the floor, or a clump of green Jell-o, I would agree:  someone was negligent. But that’s not how most hospital falls occur. A patient wants to get up and decides he can make it to the bathroom. Maybe he rings for a nurse, and becomes impatient when one does not materialize within five minutes.  Is the fact that the nurse was busy a preventable “error”?

Apparently the Times thinks so. Because it declares that “The most important benefit will come if the new rules persuade hospitals to work harder to prevent errors and protect their patients.”

Here, let me do a little line-editing. “Hospitals” don’t work hard. People in hospitals—doctors, nurses, administrators—do the work.  If the writer means “the hospital’s administration,” say so.  And, on that point, I would agree: hospital administrators and hospital boards should commit more time, thought and money to reducing problems that threaten patient safety including medication mix-ups, incompatible transfusions, and a high rate of hospital-acquired infections. They need to invest in the systems (including electronic medical records) that could significantly reduce the instances of iatrogenic illness (illness inadvertently caused by medical care.)

As I have suggested in the past, too often U.S. hospitals invest in hotel-like amenities—or monuments to a donor—rather than patient safety.

But the Times doesn’t seem to be talking about administrators so much as staff. For in the very next sentence, it grouses: “The policy focuses exclusively on hospitals, as directed by Congress, and lets doctors off scot-free.”  This seems to suggest that it is doctors (and perhaps the nurses as well?) who need to “work harder to prevent errors and protect patients.”

I wonder if the writer has spent much time in a hospital recently. Has he or she spotted many physicians just lounging about?  Or are the slackers the nurses who, from what I have seen, appear to be multi-tasking much of the time?

Let me suggest that telling staff to “work harder” is not the answer to hospital errors. Most often, patients are harmed because too many people are doing too many tasks under too much pressure—with too little time to communicate properly with each other.

Nor are most mistakes caused by one person. Normally, it takes two, three or four people to hurt a patient. The Times points a finger at the surgeon who leaves a sponge in the patient. What about the surgical nurses who are supposed to count the sponges at the end of the surgery to make sure such a mistake doesn’t occur?

The Times also singles out the “surgeon who operates on the wrong patient.” But how did that happen? Usually because someone else wheeled the wrong patient into the operating room.  And how did that happen? Because someone else misidentified the patient while or after he was being prepped for surgery.  Normally it takes a series of slip-ups to lead to a real humdinger like mistaken identity in the OR.

Except in cases of extreme negligence bordering on the criminal, many of the things that go wrong in hospitals are systems errors.  A patient develops bedsores because the ICU doesn’t have a beeper system reminding nurses that some patients need to be turned every two hours. Even if they have a beeper, nurses may have ignored it because another, sicker patient needed attention.

Hospitals cannot be prepared for every contingency. On the question of bedsores, Buckeye Surgeon observes: “All it takes is 30 minutes of unrelieved pressure from a mattress against your buttocks to compromise capillary blood flow to skin and subcutaneous tissues. Now imagine a 500 pound post op gastric bypass patient flat on her back on an air mattress. It takes 6 people to rotate her every two hours. She gets a pressure sore anyway. At what point was her care compromised? Please demonstrate the error. Ought we to have zero gravity chambers available for such scenarios?”

Finally, Buckeye points out that the notion of a “Never” event is deeply flawed when the list includes “urinary tract infections, surgical wound infections… c. difficile colitis, delirium, deep venous thromboses and other  such events that often arise in the setting of critical illness. Interestingly,” he writes, “you will not find a publishable work of science that describes how to reduce the risk of these events to zero.  Why? Because it’s impossible. If you put a rubber catheter into your bladder, I don’t care how sterilely it’s done, eventually a certain percentage of them will cause a urinary tract infection. It’s a foreign body, for godsakes.”

He has a point. Too often, patients want to pretend that medical care is risk-free. It isn’t. Whenever you choose to enter a hospital, or undergo an elective test or treatment, you are, in the words of Dartmouth’s Dr. Jack Wennberg “making a wager.”  You are gambling that nothing will go wrong, that you will not fall victim to a serious side effect, that you will not be touched by human error.

But in a situation where very ill patients are being treated by groups of sometimes tired, often harried human beings, patients are vulnerable.  Certainly, you have a right to expect that the hospital is doing its level best to reduce the odds that you will suffer harm. But pretending that “never events” won’t happen—or that they can’t happen to you –is just that, pretending.  This is why you and your doctor should always talk about risks as well as benefits before embarking on any medical treatment.

Finally, while I’m an advocate of containing Medicare spending, this doesn’t seem the best way to do it. If a hospital has a very high rate of hospital-acquired infections, I’m not interested in “punishing” the institution by refusing to pay for the extra treatment needed. I want the hospital fixed—or closed down.  Medicare should give the hospital a set amount of time to reduce the rate of infections. If it fails, Medicare should then refuse to send that hospital any more business. (This would, in effect, close its doors.)

As for the serious mistakes that should truly “never” happen (wrong site surgery, for example, or an incompatible blood transfusion), in these cases Medicare should require a thorough investigation, and a report, that is made available to the patient, the patients’ family, and the public, detailing exactly what happened. If someone in the chain has made an egregious mistake, that person should be fired. In any case, the hospital’s system for ensuring that the right patient is getting the right transfusion or the right surgery should be changed. And Medicare should require a second report explaining what changes have been made.

But the idea that refusing to pay individual physicians for “never” events will somehow make our hospitals safer by making doctors “try harder” to avoid harming patients is absurd. Trust me: a doctor’s worst nightmare is that something she or he does will injure a patient. Whoever thought that financial penalties are needed to “motivate” doctors in this area does not understand the profession.

What doctors need are systems that work, and nurses who haven’t been forced to work a double shift to help them do their job. Improving working conditions for nurses and doing whatever it takes to fully staff our hospitals would go a long way toward improving patient safety.

As for hospital administrations and hospital boards: yes, they might pay more attention to adverse events if they know that Medicare will not reimburse if an error leads to additional treatment. But the Times acknowledges that the new policy will not cost hospitals much money at first — “only about $21 million a year.”

Withholding relatively petty amounts of money, over what are often relatively minor mishaps, doesn’t begin to approach the type of structural reforms that our hospitals need.  Instead, such financial penalties are likely to lower hospital morale, dividing staff by encouraging individuals to blame each other for adverse events.

Instead of simply focusing what should “never” happen , Medicare should use positive reinforcement to encourage collaboration and esprit de corps,  by paying lump-sum bonuses for better outcomes—for example,  bonuses that everyone who treated those patients share.

Finally, Medicare should insist that, insofar has hospitals have surpluses or profits, they plow that money into patient safety. Hospitals that want to do business with Medicare should be asked to disclose how they are  investing their surpluses,  demonstrating that, when making financial decision, they are putting  electronic medical records and systems designed to reduce hospital-acquired infections ahead of parking lots, new lobbies,  bridges and new wings. In other words, a hospital’s investment decisions should not be made by its marketing department—nor by the “rain-makers” who want expensive new equipment for their specialty.

First, do no harm.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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10 replies »

  1. This is a very interesting issue that will have severe long term effects. Im wondering what the political and legal factors will be?

  2. James, Brian, Mark,
    Thanks for your comments.
    James– First, thanks very much for the link to Bob Wachter’s piece. It is excellent. and yes, the term “Never Events” comes from the NQF, which is
    where I first ran into it.
    As Wachter indicates, the idea of spotlighting Never events is a good one —the question is, what do you then do about it? The devil is, as he says, in the details.
    And Wacther points out, many of these errors are not preventable:
    “Once we leave infection control, the evidence base becomes more tenuous. A number of suggested activities have been promoted for preventing pressure ulcers. For
    example, in its Prevent Pressure Ulcers intervention, the Institute for Healthcare Improvement’s 5 Million Lives Campaign recommends six essential elements of care—daily skin inspections, keeping the patient dry, treating overly dry areas with moisturizers, optimizing nutrition and hydration, and minimizing skin pressure,23 and there are some anecdotal reports of success.24,25 Yet there is little
    robust, validated evidence of preventability.
    “Similarly, the efficacy of a number of commonsensical fall-prevention strategies (bed alarms, specially padded floors, lowering the mattress) has not been convincingly demonstrated,26 and studies of the effectiveness of hip protectors have yielded mixed results.27,28 The same is true for the prevention
    of air embolism, blood-type mismatches, and retained
    objects in surgery—they are all terrible adverse events thatseem likely to be preventable, but none have prevention strategies that have been validated in high-quality, rigorous studies.”
    Brian– As you know, I’m familiar with the work that has been done on improving systems–in particular the work done by Don Berwick & IHI. I also wrote the post listed on the side “Pilots Use Checklists . . ”
    At the same time, hospitals are not Toyota factories.
    All Toyotas (of a particular model) are alike.
    Every human body is unique.
    This leads to surprises, and makes many things difficult to predict–which is why creating safety systems for hospitals is such hard work.
    See what Bob Wachter says (in my reply to James) about how many of these adverse events are not preventable.
    I also read the National Quality Forum’s list of “Never Events” back in 2002 when I was writing my book.
    At the time, as Bob Wachter points out people who “served on the original NQF committee,
    recall that the original purpose of the list was to
    help states and others who wanted to investigate serious,preventable events. However, it was not long before some began to wonder about whether “never events” could be used for payment purposes rather than to facilitate public
    “Accompanying this change in purpose came an
    expansion in the types of included events, as the list grewfrom its initial focus on “how-could-this-happen” types of complications (for example, wrong-site surgery) to abroader, somewhat less sensational list of 28 complications of care judged by NQF to be unambiguously measurable and potentially preventable.”
    I would suggest that while “wrong site surgery” is somethign that should “never” happen, a patient falling is something that will happen—and while regrettable, is not preventable in the way that the NQF had in mind.
    So, now that we have established that I was not merely “opining”, let me suggest that the question is not whether hostpitals need better systems, but how we get from here to there.
    As Don Berwick has shown many times, in general, positive reinforcement works better than negative reinforcement. (The physiican who championed the check list illustrates the same point. He consistently uses positive reinforcement.) I would urge everyone to read
    Berwick’s book “Escape Fire” a collection of his eloquent, wonderful speeches about improving patient care.
    Those who believe that medicine is, or should be, all about money tend to believe that most human beings will respond best if you threaten them with financial penalities. In fact, if so threatened, many human beings will respond with cover-ups.
    Again Wacther makes the pont: “many believe
    that progress would be faster if there were a stronger business case for safety—more “skin in the game”—for
    providers and health care organizations” but “there is not universal agreement on this;
    some argue that creating financial incentives without an
    equal focus on building organizational skills and improving culture will yield few benefits.”
    I tend to agree with the latter group.
    When it comes to errors in our hospitals, what we need is far more transparency and cooperation–people admitting when a mistake has been made and working together to figure out how to fix it in the future. Financial penalties discourage transparency.
    Finally, you write: ” because for the past 40 years they’ve gotten paid for the commission of the error as well as to remediate it. Now they’ll eat the costs associated with remediation, which can be significant.”
    Where is the supporting informatin for your assertion? In fact, Wachter observes. “Studies on the cost of medical errors reveal that the
    existing hospital payment system already provides an
    incentive for prevention because the average increase in
    payment is often small (ranging from $700 per case for
    pressure ulcers to $9,000 per case for postoperative sepsis) and the costs to hospitals of treating the complications are,
    on average, three times higher than that.”
    (He cites a 2006 Health Affairs study. See link to Bob’s piece in James’ comment.)
    I think that if more hospital administrator realized how much errors cost –and that they are not a source of revenue–that would ecourage asdministrators to pay more attention to (and put more money into) systems that prevent errors
    twa– yes, this is an attention-getter. And that could be a good thing. It makes for a good soundbite, will get publicity, and could call more attention to the need for better systems to prevent, for example, hospital infections.
    Mark– Wachter makes the point that head to toe examinations of patinets upon admission may lead to over-treatment–giving antibiotics to elderly patients, for instance, because it appears that they MIGHT be coming in with an infection. And, these examinations could distract from other, more important, assessment of hte patient that could lead to better diagnosis of his primary complaint.
    Botetourt– YOu wrote ” This is an example of policy overkill. No hospital wishes to be paid when it commits a gross error–but to lump patient falls, UTIs, pressure ulcers into these categories makes little sense. The toughest part is sometimes figuring out whether, in fact, the patient had one of these conditions upon admission–so a part of the self-protection process involves urging very busy nurses and docs to take extra time to strip down patients and look everywhere for a potential pressure ulcer upon a patient’s admission. This is generally not related to the patient’s primary health problem.”
    I agree– Thanks.
    Mark —
    You write:
    “Ideally, hospitals would use bonus payments or profits to improve patient care. However, in the real world, the money goes to bonuses for top managers or stockholders.” This is true, and in my view, the major problem.
    Too many hospitals are run by MBAs who do not make
    patient safety a top priority. That’s the difference between healthcare in much of Europe and our “money-driven” health care system.
    Greg & Barb– No the hospitals cannot pass the cost on to the patient.

  3. Actually, in this article Maggie commits the very crime she accuses the NYTs Editorial Page of: opining without supporting information. As several readers point out, there is an extensive literature on successful prevention of “never events,” typically achieved by restructuring systems, not making staff work harder. So Buckeye Surgeon’s righteous indignation notwithstanding, the NYTs is (generally) right, and its usually better to rely on science than anecdote to get to the truth.
    Also, this is not a small financial issue for health systems, but potentially the most disruptive change in reimbursement policy since DRGs were introduced in 1984. Many health systems that have not taken dealing with these issues seriously so far will face significant distress with the new rule, because for the past 40 years they’ve gotten paid for the commission of the error as well as to remediate it. Now they’ll eat the costs associated with remediation, which can be significant.
    So the new rule constitutes a strong financial incentive to get busy with the known processes that can dramatically improve safety and reduce errors. For that reason, its sensible and long overdue.

  4. Why can’t we just trust these hospitals and doctors to do a good job? I mean, after all, these hospitals and doctors have worked very hard over the last 30 years to give us the best health system in the world. Right? Right?
    But seriously, maybe these measures are not exactly right, but if you have ever worked in a hospital you have to know that there is a tremendous need for external accountability. Of course no individual doctor or nurse or administrator wants to harm a patient. Yet we have systems that allow this to happen every day. Something needs to change. Perhaps this is not the best solution, but it is certainly an attention getter and perhaps hospitals and physicians will step up and determine more appropriate measures to which they can be held accountable instead of resisting under the banner of “just trust us”.

  5. James, thanks for the reference for ‘never events’. After I posted, I read back through all of the cited articles and couldn’t figure out where the term came from… the NYT and the National Review didn’t use it. The ‘buckeye doctor’ clearly picked it up somewhere and Maggie picked it up from him (her).
    To ‘botetourt’, I do hope that these regulations prompt a more thorough exam of patients entering the hospital. To miss an existing bed sore or UTI, etc. is certainly malpractice. These exams should improve care. We can’t just treat the admitting Dx and ignore other problems. Besides, if these Dx are established on admission, the hospital can get paid for them!

  6. Not to worry–hospitals are prevented from “balance billing” patients for amounts not covered by Medicare–except those charges which are a part of the Medicare “contract”–the inpatient deductible, and co-insurance. Most hospitals are providing a substantial discount to the inpatient Medicare program already–usually a lot more than is received by commercial plans–so any unreimbursed “never” events will only add to that overall discount. This is an example of policy overkill. No hospital wishes to be paid when it commits a gross error–but to lump patient falls, UTIs, pressure ulcers into these categories makes little sense. The toughest part is sometimes figuring out whether, in fact, the patient had one of these conditions upon admission–so a part of the self-protection process involves urging very busy nurses and docs to take extra time to strip down patients and look everywhere for a potential pressure ulcer upon a patient’s admission. This is generally not related to the patient’s primary health problem. Some hospitals are conducting expensive laboratory screens to make sure a patient does not harbor an infection upon admission, which might not be detectable without a lab study. This is all extra work, at extra cost, and usually has little bearing on the patient’s primary reason for being in the hospital.

  7. “The NY Times does not use the term ‘never events’. That comes from the (arch conservative) National Review which, being extremist, takes the concept of ‘reasonably preventable’ and runs it to the extreme to point out the dangers of socialized medicine. (And you seem to have followed it there.)”
    The term “never events” actually comes from a list published in 2002 by the National Quality Forum (NQF) of 27 items that should never happen in a hospital. The list was later expanded to cover 28 items. The CMS Medicaid policy takes items from that list as items they do not wish to reimburse, as do various state Medicaid programs.
    You can get background in the NQF list here: http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf
    A very well-reasoned look at this topic was done by Dr. Bob Wachter in a paper that may be found here: http://psnet.ahrq.gov/public/Wacher_JQPS_2008.pdf

  8. The term is ‘reasonably preventable’. This is a concept that most people can understand. These conditions have been shown to be reasonably preventable through proper staff training and policies. Nobody believes that the incidence of these events can go to zero… but they can be reduced significantly.
    The NY Times does not use the term ‘never events’. That comes from the (arch conservative) National Review which, being extremist, takes the concept of ‘reasonably preventable’ and runs it to the extreme to point out the dangers of socialized medicine. (And you seem to have followed it there.)
    (BTW, having lived with European socialism for several years, now, I am finding it works quite well… especially in the health care area for doctors and patients… but not that profitable for health care corporations.)
    Staff morale should improve when they have better training and clear policies (and of course resources). These are system errors, not witch hunts to assign blame.
    This rule gives hospitals incentives to improve the system. Most hospitals hopefully will find it easier to fix the system than pay for the cost of treating the system failures.
    (See the article in the sidebar “Pilots Use Checklists. Doctors Don’t. Why not?”)
    (Naive) Ideally, hospitals would use bonus payments or profits to improve patient care. However, in the real world, the money goes to bonuses for top managers or stockholders.

  9. Well stated…my biggest worry with this is that if 1) certain “never events” are not truly “never,” in that there is a risk of them occuring even under the best circumstances, and if 2) hospitals won’t be getting paid for them even if they put in place state-of-the-art saftey protocols, then either:
    1) the patients themselves will get billed, or
    2) the hospitals will raise their fees on everybody to recoup these expenses, or
    3) they’ll cut expenses and staff, making nurses and others even more overburdened and placing patients more at risk, or
    4) they’ll close doors more often, leaving more people without care.
    None of these scenarios is really very satisfactory.

  10. Will the doctor’s and hospitals simply bill the patient directly for these expenses if Medicare refuses to pay them? If I am not mistaken, I sign an agreement before medical treatment that makes me personally liable for all expenses not covered by insurance. So, who is being punished here?