is hard to imagine fire engulfing a patient on the operating
table. But it does happen—even at highly respected medical
centers. An electrical device is turned on while the patient is
receiving oxygen . . . Or, electricity meet an alcohol-based solution
that was used to clean a patient’s skin before making an incision .
Rarely is a patient severely burned in an OR. Although
the Cleveland Clinic experienced six surgical fires last year, only
three patients were hurt and they suffered minor burns. Yet
it is amazing that there were six surgical fires at the widely
respected Cleveland Clinic –and that the Clinic didn’t report the fires.
In Ohio, as in many other states, hospitals are not required to tell
anyone about these adverse events. And patients who
receive compensation are often asked to sign confidentiality agreements.
(To be fair, when Medicare inspectors came in March, the Clinic
voluntarily talked about the fires that had occurred over
the previous 12 months. It is not at all clear that the Clinic was
trying to bury the information. It just didn’t have anyone to tell. That
is the problem. )
Surgical fires, like many accidents that hospitals
call “adverse advents” could be prevented. If more errors
and accidents were made public, medical professionals could analyze
causes and publish guidelines that would make patients safer, not only
at one hospital, but nationwide.
Under the new reform legislation, regulation is all
about transparency. Medicare will insist that hospitals report infection
rates. And my guess is that more and more states are going to require
that hospitals publicly disclose accidents and errors.
Meanwhile, groups such as the Empowered
Patient Coalition and the Consumers Union Safe
Patient Project are
providing new channels for patients to report these accidents.
Did you know that if there is a fire in the OR during surgery
hospitals in some states don’t have to report the event to anyone?
When I read a recent story in the Cleveland Plain Dealer
headlined, “Reporting Surgical Fires Could Improve Patient Safety
in Ohio, Experts Say, I was stunned. (Many thanks to Helen
Haskell, founder of Mothers Against Medical Error, for sending
the piece my way).
The piece begins:
fire breaks out and burns a patient during surgery in Pennsylvania, the
hospital is required by law to report the incident to the state Patient
“If a similar surgical fire ignites in New York or California, the
hospital must notify the state health departments there.
“And if the same thing happens in Ohio?
“The hospital doesn’t have to tell any state agency . . . .
“On April 30, officials at the Cleveland Clinic confirmed
six fires had broken out in Clinic operating rooms in the 12-month
period that ended in March.
“Patients suffered ‘superficial burns’ in three of the
fires,” they said. “And no one was harmed in the other three.”
Clinic didn’t report the incidents to any outside agency immediately
after it happened because it wasn’t required to,” said Dr. Michael
Henderson, the Clinic’s chief quality officer.
health officials showed up in late April to conduct an inspection for
the Centers for Medicare & Medicaid Services (CMS), the Cleveland
Plain Dealer’s Diane Suchetka reports, “the Clinic told them about
A few days later, Clinic chief executive Dr. Toby Cosgrove explained
that “the three injured patients suffered superficial burns
that resulted from ignition of flammable skin-preparation or other
chemicals used during surgery. . . .Each of the six
fires,” the hospital explained, “was started by an
electrocautery device which uses electricity to cut or destroy tissue.
“’In none of these cases was there serious harm,’ Cosgrove added.
‘And in no case did a patient sue the hospital.’”
Cosgrove said that the inspectors from CMS made two
recommendations: “That the Clinic remove all alcohol-based surgery
preparation solutions from operating rooms and that it train anyone who
enters an operating room in how to prevent fires and how to extinguish
them when they do occur.” Sounds like a plan to me.
“Those recommendations,” Cosgrove added, “were implemented within
I’m impressed that the response to the inspectors’ advice was so
swift. But I can’t
help but wonder: Why didn’t anyone at the Clinic see a pattern when six
fires, all related to the alcohol-based solutions, broke out in the ORs
in just twelve months? Perhaps no one person at the Clinic knew
about all six fires?
story confirms that even highly respected hospitals need help in
collecting information, recognizing hazards, and coming up with
guidelines to prevent future accidents. They should be reporting
“adverse events” to someone.
A Rare Accident
Before I say more about surgical fires, let me be clear: The
odds that you will become a burn victim while undergoing a
knee transplant are minuscule. According to an estimate by the
ECRI Institute, a nonprofit organization that researches how to improve
patient care, while 650
fires occur in health-care facilities in a given year, just one or two
kill patients; 20 or 30 result in disfiguring or disabling injury.
two dozen tragedies cannot be dismissed. ECRI’s Mark Bruley has been
publishing articles on the causes and prevention of surgical fires for
more than 30 years. He tells some harrowing stories—of a 2-week-old
baby who died after a surgical fire, of a pregnant woman who, after
doctors cut into her abdomen to deliver her baby, leapt off the
surgical table, because her body was in flames.
Lauren Wargo, a 19-year-old from Shaker Heights, Ohio, who went to an
outpatient surgical center where a plastic surgeon was going to remove
a mole from her eyebrow. The oxygen used during her surgery and an
electrical device used to seal blood vessels combined to create a
flash flame that left her face, neck and ear badly burned. Four years
later, the 23-year-old still has to wear make-up to cover the scars on
her face and is unable to completely close one eyelid.
could this happen? As is too often the case when hospital errors occur,
health care professionals weren’t communicating with each other.
court the doctor testified that he turned on the electrical device
after announcing that he was about to do so–and after he thought the
anesthesiologist assistant had turned off the oxygen Wargo was
receiving through a face mask.
The assistant testified that
she never heard the doctor say he was turning on the device. If she
had, she told the court, she would have repeated the statement to the
doctor and would have turned the oxygen off. The jury found the doctor
negligent and awarded Wargo $1.3 million in damages, according to court
documents. The doctor has appealed.
surgical fires are preventable, Bruley observes. “The use of
established techniques for proper skin cleaning and for safe delivery
oxygen-enriched gas to the patient can virtually eliminate the hazard.
In Wargo’s case, a simple change in procedure could have prevented
tragedy. Rather than telling the assistant that he was
turning on the device, the doctor should have been required to ask
the anesthesiologist if he or she had turned off the oxygen–
wait for a reply, and repeat the reply, before proceeding.
said, I don’t want to spread fear about fires in ORs.. If you are
going in for surgery, there are risks worth thinking about (infections
for instance). But fretting that flames will be licking at your toes
while you are having your appendix removed is like worrying that the
hospital will be hit by a hurricane or taken over by terrorists. In any
individual case, the chances are slim to none.
So why am I writing about surgical fires? Because they
represent just 650 of tens of thousands of hospital accidents that go
unreported each year. And, like surgical fires, a great many
Only 25 States Require Reporting “Adverse Events”
Cleveland Clinic’s excuse that it didn’t report six fires because
“it wasn’t required to” might sound lame—until you realize that it is
not at all clear who the hospital should have told. The Clinic was,
after all, willing to volunteer the information when talking to
Medicare inspectors at the end of the year. But someone should
about adverse events when they happen, so that they can investigate
causes, and come up with a plan of action to prevent future accident.
Such guidelines could be of great use to hospitals nationwide.
Ohio is not unique. While more than 25 states
have passed legislation or created regulations related to hospital
reporting of adverse events, roughly half of all states have no
Injured patients can try to broadcast
the news—but if they go to the media, they risk being sued. Moreover,
in most cases where a patient is harmed, the hospital is likely to
offer compensation that comes wrapped in a confidentiality agreement.
in all states should gather reports about hospitals accidents from
doctors, hospital workers and patients. But the Agency for Health Care
Research and Quality (AHRQ) reports that patients are rarely part of
the reporting process, and most hospitals fail to disclose many adverse
events. Reform legislation could change this. Medicare will be
calling for greater transparency, and hospitals that don’t
report errors are likely to find that Medicare will begin imposing
Perhaps more importantly, Medicare is likely to begin making
medical errors public, along with infection rates.
Experience shows that consumers often pay little attention to these
reports; they continue to go to the hospital closest to home, or the
one their doctor recommends. But hospitals and a hospital’s doctors do
not like to see their names listed in reports suggesting lapses in
patient safety. Putting the information on a website gives them an
incentive to take a closer look at errors and accidents.
Seven States Serve as Models—How Patients Can Help
In January an Office of Inspector General (OIG) report (“Adverse Events in Hospitals: Public Disclosure of
Information about Events”) reviewed 17 state adverse event
reporting systems , and noted that seven states (Maryland,
Massachusetts, New Jersey, Oregon, Colorado and Rhode Island
) disclosed “more extensive information than others (e.g., analysis of
the causes of adverse events, guidance for reducing future occurrences,
and information about improvements made by hospitals), which can serve
as models for other entities. “
Meanwhile, the Empowered Patient Coalition and the Consumers
Union Safe Patient Project are
making a joint effort to capture a snapshot of medical errors and
accidents from the patient’s point of view. They have designed a survey
covering various categories of adverse events. Patients can simply
check boxes, but they are encouraged to use the narrative sections to
share vital details, observations and suggestions. Personal
information remains completely confidential unless the patient gives
permission to use or share it.
Transparency Can Lead to Prevention
errors should be made public, not so much to shame hospitals, or even
to spur them to improve, but so that “hospitals can learn from
others,” Fran Charney, director of educational programs at
Pennsylvania’s Patient Safety Authority told the Cleveland Plain
Dealer. “That’s the beauty of a reporting system.
“Smart people learn from their mistakes. Wise people learn
from the mistakes of others.”
One of the best examples of how the system works, she told the Plain
involved a near-miss. In Pennsylvania, near-missed must be reported
–just as airline pilots are required to share information on close
In this case, a patient in cardiac arrest almost died
because he was wearing a yellow wristband. The hospital used yellow
bands to indicate that a patient had a “Do not Resuscitate” order. In
this case, though, the patient had been transferred from another
facility that used yellow bands for other purposes. He did want to be
resuscitated. And, in the end, he was.
The catastrophe that
almost happened led to the creation of universal color coding for wrist
bands at hospitals across the country
Hospitals Should Begin to Implement Change Now
course not all hospital accidents are preventable—and in some cases,
the accident may not be the hospital’s fault. “We need more data,”
argue some hospitals and doctors.
But the truth is that we have a great deal of data, and much
information about what works to keep patients safer. Hospitals
don’t have to wait for Washington to begin publishing infection rate
and medical accidents.
As patient-safety expert Dr. Lucian Leape points out in a March 10 report for the Commonwealth Fund:
“Data from a large number of hospitals, gathered by several sources,
show wide variations in the incidence of one of the most lethal
hospital-acquired complications, central line–associated bloodstream
infections (CLABSIs). Compared with the evidence on how to prevent
other types of infections—and most other kinds of adverse events—the
evidence on how to prevent CLABSIs is quite strong.
Peter Pronovost demonstrated the potential for complete elimination of
central line infections in his intensive care unit at Johns Hopkins
Hospital seven years ago. In 2005, in a stunning display of
generalizability, Pronovost and his team taught staff in over 100
Michigan hospitals to implement his protocol for central line
insertion, and 68 hospitals completely eliminated CLABSIs for six
months or more.
Yet, five years later, “we still have significant rates of
CLABSI in most hospitals,” Leape writes, “and some are very
high. What is going on?”
He answer his own question: “What
is going on is that the vast majority of hospitals have not implemented
the Pronovost protocol because they have not made a meaningful
commitment to reducing preventable injuries, much less
eliminating them. Despite an avalanche of data,
exhortation from all kinds of experts, and impressive results by
some, most hospitals have in place programs to implement only a few of
the known safe practices,
and none has a strategic plan to implement all of the 34 evidence-based
safe practices endorsed by the National Quality Forum.”
How can we motivate hospitals to use what we already know about safe
most powerful method for reducing preventable injuries has been to
require physicians to provide data on their own performance and then
provide them with comparisons of their risk-adjusted complication
rates with those of their peers,” writes Leape.
We know this, because the Veterans Administration (VA) has
already done it.
“The VA pioneered this approach in the 1990s with its National Surgical
Quality Improvement Program, which has since been adopted and promoted
by the American College of Surgeons. Under this program, each
hospital’s surgical specialty department receives feedback on its
risk-adjusted complication and mortality rates, together with a
comparison with all of the other (unidentified) surgical departments in
the VA system. In response to these reports, below-average units made
substantial improvements, leading over several years to system-wide
declines in both complication rates and mortality.’
If the VA can do it, why can’t private-sector hospitals?
Maggie Mahar is an award winning journalist and author. A frequent
THCB, her work has appeared in the New York Times, Barron’s and
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
at the Century Foundation, Maggie is also the author the increasingly
blog, one of our favorite health
reads, where this piece first appeared.