Claire* was detained by security at the airport when the metal detector went off. Guards couldn't figure out why. Eventually, they let her board the flight, but when she arrived home she immediately asked her doctor to order an X-Ray. The result: There in Claire's abdomen, clear as day, was a retractor, a surgical instrument the size of a crowbar, somehow left behind from her recent surgery.
This story is not as unusual as we would all hope. Indeed, the story is instructive enough that it appears in the leading textbook on patient safety, "Understanding Patient Safety" by Bob Wachter. There's even a well-vetted medical term for this kind of error: "foreign objects retained after surgery," one among many scary mishaps labeled as "serious adverse events." The Leapfrog Group, my nonprofit which represents employers and other purchasers of healthcare, has another name for these outrageous errors: "never events" -- mistakes that should never happen, no excuses. Surgical never events -- Claire's experience, plus some other errors you don't want to hear about during lunch, occur about 39 times a week, according to a study from Johns Hopkins. There is a host of grisly mishaps known to happen beyond the surgical suite in the walls of a hospital, from excruciating and fully preventable Stage 3 or 4 bedsores to collapsed lungs. When you count all the non-surgical and surgical never events, they happen about 200 times a day to Medicare beneficiaries alone.
Here's the kicker: Though I don't know Claire, I bet the offending hospital billed her for the surgery to remove the crowbar. They probably weren't brazen enough to bill her to replace the missing retractor in the operating room, but stranger things have shown up on hospital bills.
Employers and other purchasers have long been outraged by these astonishing misadventures in hospitals, and they are tired of paying for them. In recent years, they've adopted a set of purchasing principles that include refusing to pay for never events and demanding an apology to the patient. It's amazing that we even needed to establish such guidelines in the first place. But according to the Leapfrog Hospital Survey, while the majority of reporting hospitals committed to adhere to our guidelines, hundreds more refused.
A few years ago, after many battles, Medicare finally started requiring hospitals to publicly report on some of them, including the following nine events:
1. Foreign object retained after surgery
2. Air embolism
3. Pressure ulcers, Stage 3 and 4
4. Trauma and falls
5. Collapsed lung due to medical treatment
6. Breathing failure after surgery
7. Postoperative PE/DVT (a preventable and often deadly blood clot)
8. Wound split open after surgery
9. Accidental cuts or tears from medical treatment
We used these nine measures in our Hospital Safety Scores -- letter grades assigned to more than 2,500 general hospitals warning consumers of their propensity for deadly mistakes. We found that some hospitals have many more of these never events than others. And the public deserves to know which hospitals protect patients best.
But the American Hospital Association (AHA) and its lobbyists disagree. They did not want hospital data on these never events, as well as some other terrible measures, publicly reported. They acknowledge these events happen, but they say the government wasn't measuring them in a way that's perfectly fair to hospitals.
Purchasers continually fight this effort to suppress reporting. The best-known and most well-respected national coalition of employers, unions and consumer advocates, the Consumer-Purchaser Disclosure Project, pleaded in a letter last year to Secretary of Health and Human Services Kathleen Sebelius, "When it comes to patient safety, we simply cannot afford -- in either human or financial terms -- to delay or derail progress toward greater transparency and accountability. Nor can we wait until the arrival of perfect measures before addressing patient safety gaps in our health care system."
The hospital lobbyists nearly won suppression of never events. Last fall, the Centers for Medicare & Medicaid Services (CMS), the agency that runs Medicare, announced they would stop reporting the never events listed above, plus other key measures. However, the agency recently told us they do, indeed, plan to continue reporting these measures, at least through 2013, so we'll keep working with them to continue the level of transparency the public deserves.
The good news is that the administration has taken steps to identify other measures of patient safety for public reporting and pledges to tie Medicare payment to performance on those measures in the future. These are new measures of infection, errors and accidents. Just last month, CMS put out for public comment a proposed rule to make a number of important new safety measures public.
Last week, the hospital lobby submitted a 58-page comment letter complaining (among other things) that these measures aren't perfect enough, but consumer and purchaser organizations responded, saying the measures, in fact, meet the requirements of good science and give the public the information we need to protect ourselves and our families.
Our advocates ask for reporting on more critical measures, faster and with more detail. AHA asks for fewer measures, reported later instead of now, and reported in generalities so you can't discern among hospitals using the data. For instance, Leapfrog wants to end the exemption of Maryland, Puerto Rico and Guam from public reporting. We ask for data to be reported for each and every facility that calls itself a hospital; currently, CMS only reports data by hospital system, and a system can have several hospitals in a wide geographical area. (Patients care about their individual hospital, not what corporate system it belongs to. And we have found major differences among hospitals in the same network).
Meanwhile, before the ink was dry on its letter to CMS complaining about the imperfection of measures and requesting delays, AHA was quick to submit testimony to the Senate about its commitment to public reporting -- as long as it's on its own terms. AHA's testimony asks for fewer measures to be publicly reported, and although the lack of progress nationally on patient safety is well established, the testimony reports glowing achievements by some of its member hospitals in improving on several important measures of performance. Ironically, the important measures it touts to Congress are among the same ones it tells CMS aren't good enough for public reporting.
We can only hope for bipartisan common sense to prevail when hospitals ask to suppress information from the public that they themselves use to improve their performance. While we're hoping for the right response from Congress, consumer and purchaser advocates will need all the support we can get to protect patients -- and protect our right to know.
This post first appeared on Forbes.com