Why are surgical errors on the rise in Massachusetts hospitals?

Expanded definition of 'surgery' may be to blame, experts say

Topics: Performance Improvement, Quality, Medical Errors, Never Event

July 11, 2013

Despite a decade-long campaign to reduce preventable surgical errors at Massachusetts hospitals, state data reveals that they are on the rise, Liz Kowalczyk writes in the Boston Globe.

According to state data obtained by the Globe, hospitals are projected to report 94 never events in 2012—a 65% increase over 2011. This would make 2012 the year with the highest number of reported surgical errors since the state began collecting data five years ago.

Reported errors in 2012 included guidewire being left inside a patient's leg, putting a catheter into a patient that did not need one, and surgical items being left inside patients.

Despite the increase in surgical errors in 2012, overall errors—which include patient falls and bedsores—decreased.

Are more errors actually occurring?

Some health experts say that the increase is caused by a change in reporting requirements. In October of 2012, the state expanded the definition of surgery to include invasive procedures, such as colonoscopies, biopsies, and electroconvulsive therapy.

Meanwhile, Health Care Safety and Quality Director Madeleine Biondolillo told the Globe that it is unclear whether hospitals are simply noticing more errors or whether more errors are actually occurring.

Former CMS chief—and Massachusetts gubernatorial candidate— Don Berwick told the Globe that, because of expanded reporting requirements, "[h]ospitals will look worse before they look better."

"When safety becomes a serious central concern as it should, reporting does go up," Berwick said, adding that the increase may be "good news because they are noticing things that previously went below the radar."

Several hospital safety officials worry about the how the shift toward outpatient settings will impact patient safety. They note that hospitals generally are more vigilant about implementing safety protocols required for surgery or invasive procedures than outpatient clinics (Kowalcyzk, Boston Globe, 7/7).

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