Law to Rein In Hospital Errors Is Widely Abused, Audit Finds

Hospitals routinely violate a New York State law requiring that they tell the state promptly about medical errors that harm patients, an audit released yesterday said. The audit found that hospitals often delay for weeks or months reports that might be critical to a timely investigation, and sometimes never report the mistakes at all.

The audit, conducted by the state comptroller, Alan G. Hevesi, found thousands of instances in which hospitals failed to turn over prompt information concerning episodes as serious as patient deaths and mistaken surgery. But the State Health Department punished the hospitals for the lapses only on a handful of occasions, the audit concluded. In fact, Mr. Hevesi said the department had failed to draw up and follow rules detailing when and how to discipline the hospitals for violations of the law.

In all, Mr. Hevesi said, the accident reporting system, which had been hailed as a crucial tool for improving medical safety and as a model for other states to follow, has been badly weakened by the failures of both the hospitals and the state.

"The purpose of these reports is to find problems, to correct them, and to save lives," he said. "You can't do that very well if you have incomplete or inaccurate information."

Dr. Antonia C. Novello, the state health commissioner, whose office had a chance to review the audit before it was made public, released a statement yesterday pledging to correct some of the problems raised by the audit, including lax enforcement of reporting deadlines.

A department spokesman, William Van Slyke, said, "We welcome, of course, any critique by the comptroller's office, but to paint this as anything other than an already excellent program would be a mischaracterization."

Since the 1980's, New York State law has required that hospitals and health clinics tell the state whenever their actions harm patients, and a 1999 report on medical errors by the Institute of Medicine, a nonprofit organization affiliated with the National Academy of Sciences, said other states should adopt similar systems. All the information is supposed to be entered into a computer database that the state and the hospitals can analyze to compare error rates and identify problems. The public can see annual summaries of the database, but not individual entries.

Concerns about how well the state's rules were being followed are not new, as Dr. Novello acknowledged four years ago when she warned that her department would get tough with violators. The warning contributed to a 62 percent increase in the number of reports filed about mistakes. But a more aggressive use of penalties - the state can levy a fine of up to $2,000 for each reporting violation - has not occurred.

Mr. Hevesi's office looked at a period from January 2001 to May 2003, when almost 66,000 mistakes were reported, almost all of them by hospitals. Though there were thousands of violations of the law in that time, the audit said, the department fined only 2 hospitals and issued citations against 37.

Mr. Van Slyke said the department preferred working with hospitals to correct their problems, rather than resorting to punishment. Mr. Hevesi replied, "Coaxing is the first step, but it's often not enough."

The audit found that the department had no rules on when to fine or cite hospitals, and that each of its seven field offices used a different approach. The department has now pledged to draft a policy on enforcement that will result in more penalties.

Jeannie Cross, a spokeswoman for the Healthcare Association of New York State, a statewide hospital group, rejected the notion that hospitals are persistent violators of the law. "But we agree that improvements have been needed to clarify definitions and requirements," she said. "A central reporting mechanism is a good thing, and we want to make it work, but it really should not be punitive."

The Health Department found more than 300 mistakes in the period studied that should have been reported to the state but were not.

The audit states that many more probably could be found if the department were more aggressive, and criticizes the department for failing to uncover the most serious cases that hospitals may be covering up or mismanaging. The department contested that claim, but said it was working to improve its searches for unfiled reports.

For episodes classified as "most serious," including patient deaths or performing surgery on the wrong part of the body, the hospital or clinic is supposed to notify the state within 24 hours. Since early 2003, the law has also required 24-hour notice for certain other errors. Requiring the hospitals to report quickly is meant to help the state investigate the incidents effectively.

The audit covered more than 5,000 cases that should have been noted to the state within 24 hours, but it found that 84 percent of those were reported late - an average of 40 days late. One was reported more than two years late.

"This was the most troubling thing," Mr. Hevesi said. "There might be some circumstances in the hospital that led to this, and you need to find the problem immediately so it's not repeated."

In the most serious cases, the hospital is supposed to investigate and file a thorough report to the state within 30 days (45 for a clinic), and the law allows for a 15-day extension. But the deadlines were missed in more than half the cases, Mr. Hevesi reported, 11 percent of the investigative reports were never filed at all, and those that were filed were often woefully incomplete.

The state made little attempt to check the accuracy of those reports, the audit said, and when it did try, it once again focused on the less serious cases.

Hospitals file their reports electronically, but clinics still file on paper to the regional offices. The comptroller's audit found that three of the seven regional offices - for Long Island, the Hudson Valley and Buffalo - simply do not enter those reports into the computer, "because they either do not have enough staff to perform this function," or because the database "has not been programmed to include data on certain clinics."

The reason why hospitals (and their mistakes) come under the supervision of the state controller is that hospitals find it profitable to make mistakes, and provide shoddy (and sometimes injuring or deadly) care. After all, to fix things would require measures and procedures that would raise costs, and therefore kill profits.

No, it's more profitable to pay lawyers and settlements for those few cases that actually get prosecuted.

Besides, patients that whose health is compromised need to be treated, treatment that (you guessed it) they can bill for.

I know it's blastphemy to praise malpractice lawyers in this forum, but they make their living (a really nice one) collecting on that cost savings. What they do is to reverse that trend - to make it unprofitable to do things half-a&&ed. For that I am grudging grateful.

In the absence of a drastic change by those being regulated, the alternative to massive lawsuits is to introduce state regulators - or horribly, to live with bad care.

What are the Comptroller's Responsibilities?

The only information is the story of missed administrative deadlines, largely due to a lack of administrative resouces. The report from the Institute of Medicine cited in the article has already been criticized as badly overestimating medical errors. This is doing nothing to improve the delivery of healthcare in NY, just trying to grab headlines to further his career. Ping me tomorrow if you want the criticism of the Institute of Medicine article.

I think it boils down to what the government can do and cannot do well --- manage health care is one of those things it can't do well --- but I think the number of errors is under-estimated and it can be helpful to know about errors that occur so others can try to study their own procedures and policies to try and prevent them.

I know it's blastphemy to praise malpractice lawyers in this forum

I suspect there is a ring of hell where doctors and tort lawyers will spend eternity together.

We keep being porpagandaized about how great medical care in the U.S. is. That is only true is you shop for the elite doctors. The average is pretty crappy.

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