Deadly and hidden mistakes: Hospital error reports often elude the public

Hospitals across Orange County and around the country are making mistakes that can be harmful, even deadly, to patients, but the public rarely finds out about them.

Details of conditions inside Mission Hospital – which temporarily closed its 14 operating rooms last fall because of a small outbreak of infections associated with orthopedic surgeries – were hidden by the federal government for six months.

Its inspection report became available under the Public Records Act in May. That was one year after four patients got sick during surgeries and six months after regulators visited the Mission Viejo and Laguna Beach campuses and found the hospital’s infection control department was understaffed and that in at least two instances, an insect had gotten into an operating room.

“These kinds of inspections are the checks and balances to make sure the hospital is doing what it’s supposed to be doing, but there’s a lack of awareness on the part of the public,” said Lisa McGiffert, director of Consumers Union’s Safe Patient Project. “Part of that is because this type of information is kept secret.”

Hospitals are required to report their infection rates, which are published online by the California Department of Public Health and by the federal Centers for Medicare and Medicaid Services. The published rates make it easier for consumers to compare hospitals.

But the figures don’t tell the full risk. A Register review of inspection reports for five large hospitals in Orange County over the past five years found they were not following simple protocols for hand washing and sterilizing surgical tools and operating rooms. There were rusty procedure tables at one facility and a dirty diaper on the floor of a neonatal intensive care unit at another, problems which could cause infections, the reports showed.

“These problems are extremely serious,” said Leah Binder, CEO of Leapfrog Group, which rates hospitals for patient safety using public data but does not review infection reports.

A hospital might have an infection rate comparable to or better than state and national averages, but still might get cited for a number of deficiencies.

“Unfortunately, tens of thousands of patients die each year from medical errors. By bringing these reports into public view, we can encourage the kinds of improvement that will save lives,” said Len Bruzzese, with the Association of Health Care Journalists, which publishes details from inspection reports since 2011 online.

The association does not publish results of routine inspections, which are typically conducted by The Joint Commission, which accredits most hospitals in the U.S. for Medicare funding. The Joint Commission’s surveys are not made public.

If patients know about certain violations, they could be on alert. Patients should feel comfortable second-guessing their providers, if, for example, they have not washed their hands, said Dr. Douglas Merrill, chief medical officer of UCI Medical Center.

“Doctors are human beings; we will make mistakes,” he said. “We shouldn’t be dependent on the patient, but they do have a unique interest in us doing our jobs.”

The reports, however, only provide a snapshot of what’s going on inside a hospital on a particular day.

In January, a patient was burned in a fire in an operating room at St. Joseph Hospital in Orange. The patient was undergoing a melanoma removal procedure when oxygen accumulated under a surgical drape and ignited. The fire triggered an inspection Feb. 26, but it was never mentioned in the report that followed.

Rufus Arthur, of the survey and certification division of the Centers for Medicare and Medicaid Services, said St. Joseph was not cited for the fire because “it had already taken measures to address the incident to the satisfaction of the surveyors.”

That inspection report was released three months later.

The reports are only available under a Public Records Act request. They are released after the Centers for Medicare and Medicaid Services approve the hospital’s plan to fix problems for which it was cited.

“Inspectors don’t send out a news release and say, ‘We just inspected this hospital and this is what we found.’ In a perfect world, that would happen. They work for us. We depend on them,” Consumers Union’s McGiffert said. “This is not a private matter. You or I might end up at one of these hospitals.”

[This story was originally published by The Orange County Register.]

Photograph by Nick Agro/The Orange County Register.