Feds stop public disclosure of many serious hospital errors

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by 13News Now

WVEC.com

Posted on August 6, 2014 at 10:24 PM

Updated Wednesday, Aug 6 at 11:07 PM

NORFOLK -- The next time you look up your local hospital's safety ratings and errors, you may not be able to find it. 

USA Today's report published morning revealed that Centers for Medicaid and Medicare Services are no longer posting hospital associated conditions on Medicare.gov/hospitalcompare

13NewsNow spoke with a Virginia Beach woman who is furious saying that people should know when hospitals do things like leave surgical gauze inside of patients. In fact, it happened to her in 2011 when she gave birth to her daughter. 

Dawn Clarke shares this picture of when baby Annabelle was born four years ago. She says it brings her back to her favorite memories, but it was a shortlived joy. She read off her medical record in 2011, "She has gauze foreign object on exam."
 
It happened during the procedure to stitch her vaginal wound at a major local hospital. One doctor left surgical gauze inside and a week later another doctor had to remove it. She developed sepsis as a result. Surgical gauze is no longer reported on the feds website. Sepsis is.  
She says, "You don't think it's possible. I'm so grateful for the doctor who told me because otherwise I would never know."
 
She took it upon herself to report it to CMS but that's when she learned that the hospitals were the ones that had to report it. 
 
And while they're still mandated to do so, the feds will no longer report it to you. 
In an email from Lorraine Ryan, CMS spokesperson for the Hampton Roads region, says via email that they wanted to make the reporting database better and that they would eventually report "hospital acquired conditions that represent some of the most common adverse events in hospitals."
 
But even the hospitals acknowledge this level of mistake is huge and potentially fatal. Riverside, Sentara, and Chesapeake all responded to our questions via email, except for Bon Secours. 
See their responses here. 
Chesapeake Regional showed us back in 2011 when they installed a new gauze detection system. In fact, if hospitals have violations like leaving surgical gauze in a person's body, they lose medicare reimbursement dollars for poor performance. 
 
Right now, the only way you can see detail information is through the Virginia Hospitals Association wesbite, vhha.com, but the CMS grant that funds this project expires in January of 2015. The VHHA spokesperson, Katherine Webb, says their staff that is funded by thie grant is trying to come up with a way to still report important data after the grant expires that will give more information on hospital performance despite CMS's ommission of eight of the HACs. 
 

Sentara Press Release

Our policy has always been to publicly report only the data mandated by CMS, so the data reported is consistent and comparable.  

I can say that foreign object prevention is a major focus in our surgical program. Stringent human processes for counting and accounting are augmented by RFID chips embedded in sponges.  Manual counting is backed up by electronic alerting through a sensor pad on the operating table under the patient and/or a sensor wand passed over the patient.

 

- Dale Gauding, Sentara Communications

Riverside Press Release

Riverside posts select quality information on our website (http://www.riversideonline.com/quality/index.cfm). There are also links to the publically reported information on this site as well. We are reviewing, as a company, how to show hospital acquired conditions to the public. The article stated that the most common surgical issue is leaving a sponge in the body. In 2011 we implemented RF Assure™ Detection System for use in our surgical suites. RF Assure is used at Riverside Regional Medical Center, Riverside Walter Reed Hospital and Riverside Doctors’ Hospital.  RF Assure helps the operating room staff detect and prevent the occurrence of retained surgical items (RSIs). RSIs are materials such as a piece of gauze or sponge that may inadvertently be left inside a patient post-surgery.

On another note, Patient safety is one of the most critical issues facing health care today. For that reason, and because it’s the right thing to do for patients and their families, Riverside has made a system-wide commitment to maintaining the highest levels of safety and quality for the people who entrust us with their care.

One way we demonstrate our commitment to patient safety is through a program called Team up for Safety.  This initiative is designed to make safety a priority in all aspects of the patient experience, and it involves specialized training for everyone from our office staff to our medical staff.

Along with training and educating our team members in every Riverside facility, we’re closely involved with adopting new technologies that enhance safety, developing blame-free reporting systems and educating patients and families on how they can take a more active role in creating a safe patient experience.

As part of keeping our focus on the personal wellbeing of each patient, we believe that a true culture of safety includes transparency and accountability. Toward that end we support sharing information about our performance and consider public reporting of our patient safety measures as something that reinforces our incentive to excel.

In this era of healthcare reform, Riverside is directing its full resources to patient-centered, quality care, and you can count on patient safety being at the forefront of that effort.

Peter Glagola

Senior Director Brand Management and Public Relations

Statement from the Centers for Medicare and Medicaid Services

 “CMS believes that transparency of patient safety information is critical for patients to be able to make informed choices about providers, including hospitals. After extensive public review and comment, CMS improved safety reporting for hospitals to those measures that are more comprehensive and most relevant to consumers. Hospitals are now responsible for achieving performance measures in these areas and could be penalized if they do not. We are working on additional measures of hospital acquired conditions that represent some of the most common adverse events in hospitals, and are committed to working with all stakeholders to identify the most important measures of quality for patients and families.”
 
The new measures received strong support from the National Quality Forum’s Measure Applications Partnership. CMS prefers to use NQF-endorsed measures, when possible, because they offer a rigorous and thorough review process. 
 
For some background: 
 
•    The Affordable Care Act authorized a new quality reporting program called the Hospital Acquired Conditions Reduction Program (HACRP), which requires the use of risk-adjusted measures of hospital-acquired conditions and a 1 percent downward payment adjustment for hospitals in the top quartile of hospitals for whom CMS calculates a total HAC score.
 
•    When visiting Hospital Compare, consumers can view hospital performance on multiple safety measures including central line-associated blood stream infections and catheter associated urinary tract infections.
 

 

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