Concord
State law requires New Hampshire to track 29 rare errors that are often called “never events” because they are never supposed to happen in hospitals.
They include burns, falls, surgery on the wrong patient or body part, items left inside a patient after surgery, assaults and pressure ulcers, among others. The Centers for Medicare and Medicaid Services defines never events: “According to the National Quality Forum, ‘never events’ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.”
Adverse events in New Hampshire hospitals decreased 12 percent in 2015 from the previous year, but are still higher than they were from 2010 to 2013.
Dartmouth-Hitchcock Medical Center, the largest hospital in the state, has reported the most adverse events for each of the six years that the state has required such reporting. In 2015, Dartmouth-Hitchcock reported 16 overall events, which accounted for 25 percent of all 64 adverse events in the state, up from 14 in 2014.
Lebanon-based Dartmouth-Hitchcock also had the most surgical events in 2015 with two surgeries on the wrong body part and two incidents in which objects were left inside a patient after surgeries, according to the report. The other 2015 events at Dartmouth-Hitchcock included eight pressure sores, three falls and one burn.
In 2014, Dartmouth-Hitchcock had 14 overall events with one surgery on the wrong body part, one surgery on the wrong patient, two foreign objects left inside a patient after surgery, five pressure ulcers, four falls, and one that was lab-related.
Dr. George T. Blike, chief quality and value officer at Dartmouth-Hitchcock, said in an email that the report lacks critical information about the severity of events, from minor and temporary to serious and permanent.
“For example, of the 16 Dartmouth-Hitchcock events reported, all but one were minor and temporary. Of course, saying that these cases were minor and temporary certainly doesn’t diminish the events. Even a minor temporary event has impacts on our patients and their families, and our goal remains zero events,” Blike said.
“When looking at the total number of events at Dartmouth-Hitchcock or any other hospital, it is important to take into account how many patients the hospital sees and how sick those patients are. Dartmouth-Hitchcock sees the most and the sickest patients in the state,” Blike said.
The 2014 adverse event report said that in 2014, there were 74 adverse events in New Hampshire, but the 2015 report says there were 73 that year. The difference wasn’t explained. The number of events declined about 12 percent from 2014.
Most of the 2015 New Hampshire numbers in the various categories remained the same or were slightly lower, with some exceptions.
One area of increase was in the category of death or serious injury to a newborn during low-risk pregnancies, labor or delivery, but it doesn’t specify if the newborn died. Four newborn events were reported in 2015 and only two events total in the previous two years. The report said two newborn events were reported by Alice Peck Day Memorial Hospital, one reported by Cheshire Medical Center, and one by Wentworth-Douglass Hospital in 2015.
Lebanon-based APD also reported two other care-management events, one a medication error and the other a fall.
“Unfortunately adverse events eventually occur at most hospitals. In that context, we believe that it is crucial for hospitals to have a systematic method of reporting and learning in order to ultimately improve patient safety,” Dr. Sue Mooney, APD’s president and CEO, said in a statement through a hospital spokesman. “When these events occur at APD, we report them to the state of New Hampshire as well as the APD Board of Trustees. We then conduct a thorough analysis to understand why this harm occurred and what we can do as a hospital to make sure these events do not occur again.”
Elsewhere in the Upper Valley, New London Hospital reported one event, a fall.
“For New London Hospital, even one such event is regrettable and does not match with our goal of 100 percent excellence in patient care. On the very rare occasion of an adverse event, we do all we can to mitigate any harm to that particular patient as well as to systematically learn from the situation how to better prevent any future similar occurrence,” New London Hospital President and CEO Bruce King said through a spokeswoman.
Valley Regional Hospital in Claremont and Cottage Hospital in Woodsville reported no adverse events in 2015.
Hospitals and ambulatory surgical centers must notify the Health Facilities Administration-Certification at the New Hampshire Department of Health and Human Services within 15 days after the discovery of an event.
After an event is reported in New Hampshire, within 60 days the facility must submit a root cause analysis and a plan to correct the action.
A 2013 study estimated the number of premature deaths nationwide associated with preventable harm at more than 400,000 a year.
The 2013 study by John T. James said: “The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed.”
James went on to say, “Fully engaging patients and their advocates during hospital care, systematically seeking the patients’ voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.”
The 2015 New Hampshire report released last week said after completing a root cause analysis, the hospital may find that harm occurred even when it was using best practices.
“Upon completion of a detailed root cause analysis, (hospitals) may occasionally find that, despite adoption of evidence based protocols and strict adherence to established standards of care, an optimal outcome is not achieved and harm still occurs.
“Individuals may have clinical conditions that can create a complex set of processes that lead to an event, despite providing the best prevention and/or treatment known,” the report said. “The goal of patient care is to do all that is possible and learn from all events, whether or not a reported event was considered unavoidable.”
Dartmouth-Hitchcock’s Blike said the hospital works to eliminate adverse events by learning from past ones and improving procedures.
“The safest hospitals reduce the harm that patients suffer from any given event by learning from those events to improve processes and procedures and patient safety,” Blike said.
“I am very proud of our safety systems at Dartmouth and the job we have done at reducing the harm our patients suffer from these events,” Blike said.
The state’s 2015 report summarizes New Hampshire goals. “The continued goal for the New Hampshire hospitals and (outpatient surgical centers) is to utilize their root cause analyses and to make corrective action plans that can enhance patient safety.
“The Hospitals and the (outpatient surgical centers) remain committed to educate their personnel and professional staff about patient safety to promote the best outcomes for their patients,” the state report concludes.
Valley News staff writer John Gregg contributed to this report. InDepthNH.org is a nonprofit news site published by the New Hampshire Center for Public Interest Journalism. Nancy West can be reached at nancywestnews@gmail.com.