TUESDAY, DECEMBER 21, 2010


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Health Focus on patient safety hasn’t succeeded BY MANOJ JAIN Some years ago, I got a call at 3


a.m. from the hospital because a patient ofmine had spiked a high fever. Suspecting an infection, I called in some antibiotics. A few hours later, a frantic nurse called to saymy patient had turned red andwaswheezing, likely froman allergic reaction. I rushed to the hospital and


sawmy own note in the patient’s chart stating that the patientwas allergic to the antibiotic I had ordered. I had made a prevent- able medical error; so had the nurse who had missed the aller- gy wristband on the patient and the pharmacist who had neglect- ed to check the patient’s allergy drug list. Last weekend when I was on


call and seeing my sixth consult, I inadvertently ordered a penicil- lin-family drug for a patientwith a penicillin allergy. This time the pharmacy’s software flagged the potential error. Despite the best of intentions,


errors are common in hospitals even with new safeguards. A decade ago the Institute ofMedi- cine published its landmark re- port “To Err Is Human: Building a Safer Health System,” which estimated that 44,000 to 98,000 deaths occur annually because of preventable medical errors in U.S. hospitals. Over the past decade as a


hospital-based physician, I have noticed great efforts to improve patient safety. The software at my hospital’s pharmacy is just one example of progress. So I was surprised when a


report on hospitalized Medicare patients released last month found that one in seven of the patients experienced an adverse event such as excessive bleeding, a hospital-acquired infection or


aspiration pneumonia. Those events, both preventable and not preventable, led to about 180,000 deaths a year. A study published last month


in the New England Journal of Medicine of 10 North Carolina hospitals found that “harms re- main common, with little evi- dence of widespread improve- ment” from2002 to 2007. For me, these findings raise


two critical questions: Why do adverse events happen in the first place, and why are we not able to lower the number of adverse events in the hospitals after a decade of effort? An analogy may help. Adverse


events in the hospital are much like car accidents.The problemis complex, and the solutions re- quire massive system redesign and significant behavioral changes by individuals. To reduce car accidents, sys-


tem changes might include in- stalling reflectors between lanes and redesigning dangerous in- tersections. Similarly at hospi- tals, checklists and electronic medical records are system changes designed to reduce ad- verse events. On an individual level, drivers


reduce road fatalities when they do not text or drink while driv- ing. Similarly, in hospitals, doc- tors and nurses reduce adverse events when they dutifully per- formhand hygiene andwatch for drug interactions. The major reason so many


deaths occur on the roads and in hospitals, of course, is that both are inherently hazardous places. I amdisturbed that 1.5 percent of hospitalized Medicare beneficia- ries who experience an adverse event die each year. But I also recognize that many elderly pa- tients are so ill that they might well die if not hospitalized. At times, I see the adverse


EDEL RODRIGUEZ FOR THE WASHINGTON POST


Whydo adverse effects happen in the first place, and why are we not able to lower the number of them after a decade of effort?


events at hospitals as collateral damage. As one director of quali- ty improvement told me about hospital care, “There is no other situation where people from so many diverse backgrounds and skill levels come together every day to carry out a common mission with so much stress, so many high-tech processes, rely- ing heavily on low-tech manual interventions,which are regular- ly influenced by the human fac- tors that manifest mistakes. Un- less, of course, you count war.” That said, why have the re-


ports not shown any reduction in adverse events in the hospitals over the past decade? I called up Carolyn M. Clancy,


the no-nonsense internist who has been the director of the federal Agency for Healthcare Research andQuality since 2003. I asked her if our hospitals are any safer now than they were 10 years ago. She acknowledged the chal-


lenge of reducing the high num- bers of adverse events but added that some of the more recent numbers are the result of better


tracking and expanded defini- tions of which events are pre- ventable. For example, a decade ago certain hospital-acquired in- fections were considered side effects to usual care, but now we know that nearly all can be eliminated. “We are safer,” Clan- cy said. I see what shemeans. A detailed look at the North


Carolina hospital study shows that although the total number of harm cases remained the same, there was a decreasing trend over five years in the number of preventable harms. And in a paper I published in


2006 with Donald Berwick, who is now head of the federal Cen- ters for Medicare and Medicaid Services, we showed how we reduced hospital-acquired infec- tions at my hospital by 50 per- cent. (This was in collaboration with the nonprofit Institute for Healthcare Improvement, then led by Berwick.) Take another example: inva-


sive hospital-acquired MRSA in- fections. MRSAis a staph bacteria high-


ly resistant to antibiotics that spreads through hospitals and nursing homes. The Centers for Disease Control and Prevention recently reported that since 2005 the rate of such infections in hospitals has declined, on aver- age, by 10 percent per year. Yet another study, conducted


between October 2007 and Sep- tember 2008, showed that the use of checklists led to a decline in surgical complications. We are seeing pockets of suc-


cess in arenas of patient safety where there is intense, focused activity, such asMRSA and surgi- cal infections prevention. At the same time, patient


safety activity has broadened with newtools and policy. Clancy told me that her agency has


developed “Common Formats,” which provide uniformreporting standards for hospitals that tally adverse events. We can improve only what wemeasure. Also, many states now require


hospitals to publicly report cer- tain adverse events, such as hos- pital-acquired infections. This gets the attention of the consum- er advocacy groups. There is also pressure to prevent drug compa- nies from giving new drugs names that are confusingly close to drugs that are already on the market, another common source of error. And lastly, as of September


2008, the Centers for Medicare and Medicaid Services has stopped paying hospitals for “never” events — adverse events that should never occur, such as surgery on the wrong limb or infections from urinary-tract catheters. This has many heads of hospitals following rates of bloodstream and urinary-tract infections as closely as they fol- low their budget line items. But, to make hospitals really


safe, we need to take a leap. We need to build a culture in which patient safety is the priority not just for the quality improvement director but also for every nurse, doctor, administrator, aide, housekeeper, dietary worker and hospital boardmember. Drivers still make mistakes


with dreadful consequences, but over the past decades we’ve created a culture that is verywell aware that traffic safety is imper- ative. Likewise, a culture — not just a strategy—of patient safety is amust. health-science@washpost.com


Jain is an infectious-disease specialist in Memphis and an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta.


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Program for frail seniors may be coming to D.C. area 6


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arrangement, PACE sponsors — for example, Johns Hopkins — get a set monthly amount from the state and federal government to provide seniors with all the medical and other services they need, not just what is covered under traditional Medicaid and Medicare. For ElderPlus, the payment is


an average of $5,600 per person a month shared about equally by Medicaid and Medicare. In re- turn, ElderPlus, which can serve up to 150 people and has been in operation for 14 years, is respon- sible for every aspect of partici- pants’ medical treatment, in- cluding nursing home care and hospitalizations. ElderPlus operates a clinic, a


pharmacy, an adult day-care cen- ter, a dining hall and a fleet of eight vans to ferry participants to and from home. Hospital care is provided by Johns Hopkins. Seniors are served breakfast


and lunch in a spacious, L- shaped dining room adjacent to a patio where some grow toma- toes and flowers. Down the hall are a physician, nurse practitio- ner, social worker, pharmacist and physical therapist, available for regular appointments. A dentist, an optometrist, an


optician, a psychiatrist and a podiatrist visit several times a month. A part-time dietitian tries to persuade participants it’s never too late to improve their eating habits and hasmade a few converts. Participants can get physical or occupational therapy beyond the normal Medicare limits, as well as dentures, eye- glasses and hearing aids—items that aren’t covered by traditional Medicare — at no cost. The extra care extends to


home when needed, usually on a temporary basis. Doctors or nurse practitioners


make home visits, and home health aides may help with light housekeeping and other chores. When home inspections have found safety hazards, ElderPlus has installed staircase railings, handheld showers and wheel- chair ramps. It also has bought home air conditioners for people with breathing problems. One of PACE’s biggest boosters


is Donald Berwick, a physician who heads the federal Centers for Medicare and Medicaid Ser- vices, or CMS,which oversees the PACE sites. “I think expansion of PACE is a


great idea, and evenmore impor- tant is building PACE principles,” he says, adding that its multidis- ciplinary approach, unified funding stream and other pio- neering techniques could help


PHOTOS BY DOUG KAPUSTIN FOR THE WASHINGTON POST


Above, registered dietitian Sharmila Chakravarti meets with ElderPlus participant Bill Blankenship at the program’s facility in Baltimore. Below, Shelby, who engages patients in tugs of war and other physical therapy exercises at ElderPlus, awaits his next assignment.


many chronically ill people. To be eligible for PACE, people


must be at least 55 years old and qualify for Medicaid, Medicare or, in most cases, both. They must meet their state’sMedicaid criteria for requiring nursing home care, live within the PACE service area and be able to live safely at home with PACE assis- tance. Since PACE is a managed- care plan, the enrollees must agree to get their medical care only through PACE providers. These requirementsmay partial- ly explain while the program is still relatively small. PACE participants are among


the most complicated geriatric patients and often suffer from several concurrent chronic con- ditions such as diabetes, heart disease or hypertension, explains Matthew McNabney, medical di- rector at ElderPlus. They typical- ly also have some kind of physi- cal impairment; more than half of the enrollees have some de- gree of dementia. “The beauty of PACE is that


the incentives are all right,” says ElderPlus Director Karen Arma- cost. The staff provides aggres-


sive and creative preventive health care to keep seniors healthy and to avoid expensive hospitalizations or nursing home visits, goals that patients say they share. “We pretty much say that


PACE covers almost anything,” says Smith, the Virginia long- term-care director. Virginia has six PACE pro-


grams, and four more are planned, including the Inova site in Fairfax County. Virginia offi- cials estimate that the cost to the state of a person who has both Medicaid and Medicare through PACE is, on average, $4,200 less per year than that of a similar person gettingMedicaid services either at home or in a nursing home.


The health-care overhaul law provides funds to test similar non- institutional alternatives for people who need long-term care.


Expansion? Not so fast. Maryland officials aren’t look-


ing to expand PACE anytime soon, despite ElderPlus’s waiting list — 87 as of last week. One reason,Maryland officials


say, is a dearth of organizations willing to sponsor such a pro- gram. To assume that financial responsibility, sponsors must be


on washingtonpost.com A closer look


To learn more about the Program for All-Inclusive


Care for Elderly (PACE) and hear from participants, visit http://wapo.st/pacevideo.


large health-care organizations, such as Johns Hopkins, or have sufficient resources to form a partnership with a health-care provider, they say. Mark Leeds, the state director


for Medicaid long-term-care ser- vices, says ElderPlus is “a good service, and people benefit from their participation,” but he adds that before expanding PACE, the state would have “to make the numbers work.” In many parts of the country,


PACE seems to be gaining popu- larity. TheNational PACE Associ- ation reports that 57 percent of sponsors are planning to expand their services. And the health- care overhaul lawprovides funds to test similar non-institutional alternatives for treating people who need long-termcare. In the District, Capitol Hill


Village, which provides services to help its 350 members live independently in their own homes, has enlisted Volunteers ofAmerica Chesapeake, a region- al human services organization, as a potential PACE sponsor. Washington Hospital Center’s Medical House Call program is interested in becoming themedi- cal partner. In the PACE application that


Inova submitted to Virginia offi- cials, the hospital had to provide details about its business plan and medical services. But Inova also had to explain how it will cope with a problem Northern Virginia is famous for: daunting traffic that could compilicate getting seniors to a PACEsite and back home. “Someone could spend 50


minutes on a van and only go 10 to 15 miles,” says Robert Hager, assistant vice president for long- term services at Inova. Seniors will probably go home early to beat the traffic. health-science@washpost.com


Jaffe writes for Kaiser Health News, specializing in health-care policy and aging issues. This article was produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health- care-policy organization that is not affiliated with Kaiser Permanente.


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