When the patient falls out of bed, who pays?

Abstract

Patient safety advocate Sue Sheridan learned about hospital errors the hard way. She recalls how, in 1995, her newborn son suffered severe brain damage when the hospital failed to run a 'ten dollar' blood test, which would have revealed neonatal jaundice. In 2002, her husband died after the hospital failed to notify him of a diagnosis of cancer. were simple Sheridan, now based in Boise, Idaho in the USA, says: They happened not because anyone was in a hurry or because this was so complex. In other words they were mistakes that should never have happened. Beginning in October 2008, Medicare, the US-government-administered social insurance programme providing health coverage to people aged 65 and over, stopped reimbursing hospitals for specific instances of this kind of error. The Centers for Medicare & Medicaid Services (CMS) drew up a list of 'reasonably preventable' mistakes, termed 'never-events', based on consultation with a variety of stakeholders and the recommendations of the National Quality Forum, a non-profit organization in the USA mandated by law to bring together people from across the health-care spectrum on measurement issues. In quantitative terms it is unclear what 'reasonably preventable' means exactly, and there is no clear guidance in the statute on which CMS policy is based. [ILLUSTRATION OMITTED] The list features major blunders such as operating on the wrong body-part or leaving surgical instruments inside the patient's body, it also includes complications, such as severe bedsores, and certain injuries caused by patients' falls. Dr Edward Kelley, head of strategic programmes at the World Health Organization (WHO) Patient Safety Programme, notes that the 'never-events' concept has been enthusiastically supported by the business community in the USA and has also been picked up by several European countries active in WHO's Patient Safety Reporting and Learning Community of Practice. For Sheridan, the initiative makes sense in so far as it improves patients' safety, her approval is nuanced. As a widow and the mother of a boy disabled due to medical error, it is hard to understand hospitals being paid for such blatant disregard of guidelines and communication procedures. On the other hand, I understand the possible long-term negative effects of non-payment for a 'never-event'. So this has to be looked at very thoughtfully. Dr Robert Wachter, chief of medical service at the University of California, San Francisco Medical Center, also believes the concept needs careful examination particularly the issue of reasonable preventability. Originally, the 'never-events', which came out of National Quality Forum deliberations, referred to things like cutting off the wrong leg or leaving a sponge in someone's belly, he says. That those things should never happen is self-evident. But the list of 'never-events' has expanded to now cover things like bad bedsores. But do we really know how to prevent bedsores 100% of the time? No, we don't. Professor Peter Pronovost, a critical care specialist at Johns Hopkins Hospital in Baltimore, concurs: Certain complications, like an object being left inside a patient after surgery are clear-cut, he says, but there are conditions such as air embolism and pressure ulcers (bedsores), that are not so straightforward. This being the case, one might think that impartial adjudication to separate preventable from non-preventable would be a key part of the policy. It isn't. On the patient's admission to hospital, a form is filled out noting the presence or absence of certain conditions, including pressure ulcers. These forms are coded. There is no opportunity to offer nuance (e.g. the patient is 98-years-old, the patient is morbidly obese) for the simple reason that assessment is not done on a case-by-case basis. CMS has made efforts to improve the coding, allowing the examining doctor the option of replying 'don't know' for example, the coded forms remain a necessarily blunt instrument. …