Government Proposes New Patient Reporting System

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If you’re a doctor, nurse or healthcare practitioner, you’ve probably seen the alarming statistics of medical errors. A brief overview as reported by Answer My Health Question serves as a sobering reminder:

 

  • Every year, 7,000 patients die due to sloppy handwriting.
  • Over 7.5 million unnecessary medical & surgical procedures are performed annually.
  • More than half of the US population has received unnecessary medical treatment.
  • Over 42% of people have been directly affected by a medical mistake, procedure or drug.
  • Over 106,000 people die each year from adverse drug reactions to prescription drugs.

 

To stem the tide of injuries and deaths due to medical mistakes, the government has proposed a new patient reporting system. A recent New York Times article suggests that such a reporting system will put a brighter spotlight on doctors, nurses, pharmacists and other medical practitioners.

 

Under the new reporting system, patients and their relatives would report medical errors through a website and in telephone interviews. The report would ask respondents what happened; details of the event; when, where, whether there was harm; the type of harm; contributing factors; and whether the patient reported the event and to whom. The questionnaire would even list possible reasons:

 

  • A health care provider did not communicate well with the patient or their family.
  • A health care provider didn’t respect the patient’s race, language or culture.
  • A health care provider didn’t seem to care about the patient.
  • A health care provider was too busy.
  • A health care provider didn’t spend enough time with the patient.
  • Health care providers failed to work together.
  • Health care providers were not aware of care received  elsewhere.

 

Proponents argue such reporting could reveal how a drug mix-up occurred, why a surgery was performed on the wrong body part, or how a patient received too much radiation.

 

Hospitals, doctors and nurses say the proposal has merit. “It’s a great concept. The idea is welcome,” said Nancy E. Foster, a vice president of the American Hospital Association. Many doctors agree. Dr. Carolyn M. Clancy, the director of the federal Agency for Healthcare Research and Quality said, “Currently there is no mechanism for consumers to report information about patient safety events. Patient reports could complement and enhance reports from providers and thus produce a more complete and accurate understanding of the prevalence and characteristics of medical errors.”

 

If the pilot project is cleared by the White House, questionnaires would start popping up at kiosks in hospitals and doctors’ offices as early as May 2013. Information about the project would available at pharmacies and mailed to patients. Reporting is voluntary, and the information would be kept confidential.

 

The goal is to determine if the mistake involved the wrong medicine, the wrong dose of medicine or reactions to a drug; the wrong test or procedure, the wrong diagnosis or surgery on the wrong body part; or blood clots, infections, problems with anesthesia or “unclean or unsanitary care.” 

 

Image by nattavut / freedigitalphotos.net

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  • Patsy H
    Patsy H
    I am a Registered Nurse , and I agree the prblem needs to be fixed but this project can bring about many more problems and alot of law suites that are are unnecessary. I agree with Kimberly S. never leave a family member alone. Always make sure you are aware of the family members medications. Ask alot a questions .  Write time date and names down.  Remember the saying " If it isn't written down it wasn't done."  
  • Tristan F
    Tristan F
    Hi, I am still living with the results of a medical mistake done by a doctor who perforated my intestine and then refused to treat me for 10 days. Another dr put me in the hospital, but the hospital and drs refused to treat me. The original dr who did the damage gave me iodine knowing I was highly allergic and I went into septic shock. He then paralized me during another surgery where I believe he was trying to kill me. My bills were over 1 million and I lost my home, income and I still suffer with illnesses. I now have a PhD and worked in a detox center where nurses regularly gave wrong medications. I told my supervisor and I was forced out. This has been common for me as agencies get rid of whistle blowers and work to the lowest common denominator being mre focus on billing and getting their money, than good and responsible care of the client. I think this is a great idea. I would love to give talks to support this program.
  • Robert H
    Robert H
    I think this is a very good idea
  • Barbara J
    Barbara J
    If this were taken seriously, it may indeed stimulate some changes, however in the current system, when an incident is reported to Joint Commission, the person reporting never receives any information about the outcome of the incident and is lead to believe that unless one has hard evidence about a situation, nothing is done. With lawsuits having the punch taken out of them by high costs and the low judgements, we need some better mechanism for those who are not doing their job to be held accountable. There have been too many times where as an RN I have heard supervisors who thought it was ok to verbally abuse their staff members, staff members who are required to work overtime but NOT compensated for it (Gentiva Healthcare and Odyssey Healthcare) and patients in hospitals and skilled nurse facilities that are left for many hours at a time unattended in pain or with other maladies. In one situation, a doctor refused to treat a patient who had severe chronic pain, offering no assistance for future care. This was reported to the AMA, the hospitals where this physician was practicing, and every individual passed the buck, unwilling to confront a man who was unwilling to help because he had decided the patient was a drug addict, without any evidence at all. Such abuses must stop somewhere.
  • Lisa B
    Lisa B
    This is a good idea and can only go so far. Lay persons have limited knowledge of medical symptoms, medication and their reactions/side affects and most know little to nothing about hospital procedures. Without knowledge of such things the lay person can only insure a constant vigil in the patients room therefore creating a more conscious environment the hospital staff will work in. On the other hand there are home care givers and family members who deal with immediate family meds and have knowledge of what they are for and what the dosage should be and for that knowledge may be able to prevent a medication mishap. But I really think the system should not hold unknowledgeable individuals accountable for the wreckless and negligent behavior of trained personnel. It may be better to reassess a medical persons qualifications more often than the present renewal time making the standards higher on the tests and insuring all necessary upgrade classes have been attended. Medical personnel should be held responsible for maintaing high standards of care---it is their job.
  • Kathleen N
    Kathleen N
    I was auditing a doctor's note and noticed that the patient was already taking scheduled Tylenol and aspirin.  An ortho consult recommended ibuprofen for the patient's joint pain.  It was added to the medication list, again on a scheduled basis.  I pointed this fact out to the doctor, who was the patient's PCP, and he thanked me for my concern. The orders remained standing.This patient was living in an assisted living facility and had Alzheimer's disease.  My personal PCP had given me a strict warning to NEVER take different over-the-counter pain medications due to the high possibility of GI bleeding, or even causing a hole to open in my stomach.  Very scary for an elderly patient who is not aware of his muliple medications.
  • samson n
    samson n
    A health care provider didn’t respect the patient’s race, language or culture.??am shocked this issue exist ...when will this stop !!!!!!!
  • Sue H
    Sue H
    Is anything mentioned about the long hours that healthcare professionals are requested to work?What about that causing fatique and resulting in medical errors?
  • Jeffrey f
    Jeffrey f
    I think it is ABOUT TIME!! I recently had a bad experience at Piedmont Newnan Hosp. ER and, it does no good to complain to the person who conducts the survey of your stay, as they are hospital employees.  
  • Betty E
    Betty E
    This sounds like a very good idea because there certainly are mistakes made and definite problems with many drugs. There will need to be, however, a way to determine if the patient is just a complainer or likes to sue. There has been a direct correlation between a doctor's bedside manner and a patient's perceived wrongdoing. Some of the worst and most incompetent doctors I've worked with are rarely called to task because they are "nice", while some very fine doctors run into problems due to  misunderstandings with patients because they don't have the Dr.Welby bedside personality.  
  • Armando S
    Armando S
    Totally agree, whom else but the patient should let us know after a treatment the responses of it. We should follow up patient' s healing process even after has left the clinic for any treatment. As Nurse we should make sure all the information about our patients is received by all members of the healthcare team to prevent more errors!
  • Jeffrey V
    Jeffrey V
    this is not the answer, there has to be some filter to avoid any and everyone that's disgruntled and or not happy with there health outcome,  There are better ways to address many perspectives or a percieved mistake, at the time of the occurance with communication to a supervisor, an office clerk, director and most hospitals already assess patients view, concerns and complaints as a routine dailt or at discharge.  We don't need yet another complaint hotline or agency, that duplicates the already standing ability to open their mouth and ask, say, or claim some harm or concern,  I can see it now, a telephone line or huge stacks of forms that's collecting in huge rooms / whearhouses from anyone that thinks they can make a dime or get a nurse, doctor or even a MHT or Aid fired, just because their bell wasn't answered to move a bedside table or change the TV station fast enough.  Where is common sense and honesty, accuracy and priority going to be injected into the equation?  Who is going to read, file and prioritize all these form or listen to all these phone calls/  There are alread reporting agencies, AMA, Crisis, 911 and Civil courts full of melingerers,fraud and wannabe claimants, Do you think this is going to improve care due to yet another stressor that any activity, action or percieved contact may generate a call to this HOTLINE and EXECUTIONER mentality?  Who is going to want patient contact without some sort of protection and outlined parameters or what NOT to report?  This is a pandoras box.
  • Tamara B
    Tamara B
    I am an LVN and have worked as a nurse for thirty three years in the State of Texas. I have worked mainly in home health, but in other areas of nursing as well. I believe that the employees are given a much bigger load than they can handle for the sake of profit, and the patient is the one that suffers in the long run. I am concerned that the nurses are assigned to take care of more patients than they possibly can ...and still do a good job and take care of the patient as they should. This also causes undue errors and mistakes due to the emotional stress on the caregiver. Maybe there should be a quota or limit imposed on the number of patients that can be assigned to a nurse, therapist , aide or medical worker to allow them the time they need to do a better and more accurate job for the patient.
  • Flavia M
    Flavia M
    I think this is very practical.  It would integrate care provided to a patient by a primary care physician plus other specialty doctors involved with the same patient.  It would narrow down the number of medications especially those that would interact adversely with each other either increasing or decreasing effects.  Hopefully by then, I will be in my internship learning more about and at firsthand the new reporting system.
  • Ruth S
    Ruth S
    I think its a great concept in theory, but I believe it leaves the door open for the consumer(pt. or family) to make false reports or make attempts to use it to try and get something by holding it over the healthcare workers head
  • PHIL G
    PHIL G
    SOUNDS LIKE A NO WINNER FOR HEALTH CARE PROVIDERS
  • camille c
    camille c
    I think is a great idea. As a health unit coordinator I myself find many errors by both other h such as...hospital personnel such as. Labeling patient reports with the wrong patient sticker, I've had faxes arrive that are not the correct patient! I think the questionnaires are a good start to help stop deadly mistakes...
  • Cindy S
    Cindy S
    I believe this is already in place by the facility.    When someone has a complaint, it needs to go directly to the facility top brass.  Not to some "created Agency" who, with more bureaucracy, will clog up the system.  The KISS method works.  No one should step in from outside the place where the error was made and pass any judgements.  "If it ain't broke, don't fix it".  If it is take it back to the origination.  NO MORE BUREAUCRACY.   
  • John G
    John G
    it will be as important as medicare and social security it needs to be put into law, now if a doctor or hospital make a mistake in most cases it is sweep under the rug  because a doctor will not say if another made a mistake.
  • Rhonda E
    Rhonda E
    In the medical field most have gone to electronic processing however this is done by udertrained individuals who are sopposed to read their own dr handwritinig. I know because as a pharmacists I now spend hours waiting for the office responses
  •  Teresita T
    Teresita T
    This is a very good proposal. The reason for having this reporting system is to minimize the performance of surgeries which will not really help the patient instead will just make the patient's condition worst, but not all kinds of surgery  but some just want to make money without giving patients the the effects, side effect or possible prognosis.
  • Opal M
    Opal M
    I think this is a wonderful idea. My sister passed away on December 2, 2011. As of today, I still do not know why she died. All I know is that she died from an accidental overdose of prescription medication. The problem with this is the family don't know who or why the doctor was treating her with a medication called methedone. My sister was not an intravenous user, she did not use heavy drugs she just took pain medications her doctor prescribed. I don't understand why her doctor was prescribing her norcos, soma, promethazine cough syrup, valium, diazepam all at the same time. When the doctor was asked if he ever prescribed her methedone he said no. Nevertheless, her autopsy showed she had a large amount of the drug in her system at the time of death. I have not been able to put closure on her death and probably never will until I am able to find the truth of what conspired during the time I talked to her around 3:30 pm December 2, 2011 and she sound fine and made no mention that she was not feeling well, however, she was pronounced dead around 11:30 pm that night. I hope someday I will find the real reason behind her death.Opal McDanielopalmcd@comcast.net
  • Christine B
    Christine B
    Adequate staffing would solve this problem by at least 80%
  • Deloris T
    Deloris T
    There needs to be some type of reporting system. Not every case of neglect, unsanitary conditions or mistakes is severe enough to result in a law suit. Bear in mind, however that there are many frivolous lawsuits that add to the cost of malpractice insurance and higher medical cost. I am not defending those that cause harm. I am just saying that if there is a tracking system it needs checks and balances so that reports can be verified for accuracy. No one wants to see a medical professional slandered or unjustly reported. With that said, I have had four different cases of poor and potentially harmful medical care. 1. My mother had surgery to put a stint in her leg because of severe blockage. Her incision (from navel to pelvis) became infected and burst open two days after surgery while in the hospital. I witnessed nurses (more than one) checking her incision without washing their hands or putting on gloves. It took four months for her to heal and she had a scare two inches wide from her navel to the top of her pelvis for the rest of her life. Oh, I forgot. The night before she was hospitalized and had the emergency surgery for the blockage she was taken to the ER at the same hospital where we were told by the attending that her severe leg pain was just old fashion leg cramps, nothing to worry about. She was screaming in pain at the time and my mom had a high tolerance to pain. 2. My grandmother had skin cancer surgery on her face. The nurses checked her skin graphs and changed ice packs without washing hands. She got an infection, her graphs died and she was left with an open wound across the entire upper lip with the corner of her detached for two months while she healed and or course a bad scar for the rest of her life. Can you imagine going out in public and having to wear a mask or every time someone came to visit having to cover you face.3. My husband was in a VA facility with congestive heart failure, legs so swollen that fluid was seeping from his legs like rain. His primary care doctor on this visit was a gynecologist (all doctors too a rotation an whoever was there when you were admitted was your primary). This Dr. released my husband in this condition saying that blood work was saying he was dry. Get real. If left the VA and drove him directly to another hospital ER where he spent two weeks in ICU and I was told if I had not done as I did he would have died. Oh yes, he was literally drowning. After all this and after the death of all three of the above I returned to college and became a Certified Medical Assistant.4. The last event was recently and I must say as a medical professional myself I was embarrassed to see such treatment in what is claimed as one of the most modern teaching hospital in the state. My sister went to the ER with a rash and chest pain. She has a pacemaker and a record atrial fibrillation, high blood pressure and diabetes. She was sent home with an antibiotic (no reason for the rash). Five days later she is in route to a doctors appointment and has what appears to be a seizure. She is taken to the ER where they send her home again. During the night she becomes hostile and delirious; is taken by ambulance to a small local hospital where after about 6 to 8 hours of stabilization she is transferred back to the teaching hospital. They finally, reluctantly keep her. She is placed in a room where a family member is with her. She has no idea where she is, cannot feed herself, get off the bed, is tied down because she is hostile. She is there from Tuesday night until Friday afternoon, no bath, no bedding change and the only thing done to the room is emptying of the trash can (no cleaning). Her IV is changed from one arm to the other Friday morning. She is on blood thinners and bleeds on the sheets where she is left lying until late afternoon where she is taken to radiology for a CT and they change her gown and sheets before bringing her back to the room. Did anyone complain, yes, multiple times. We were told "I get it a few minute" six times. She is moved to the ICU where care improves but still no answers about what is going on, no cardio consult, no diabetic meds or diet. After multiple CT's, blood test, Ultrasounds, two lumbar punctures and Xrays she is placed on seizure med. All tests are reportedly fine, nothing physically wrong but the seizure meds seem to be working. Two days later she is discharged from ICU and sent home, unable to stand, with a heart rate of 140. And the best for last, her daughter gets 10 miles from the hospital and realizes that they did not take out her IV. She calls the nurse that did the discharge and he says "Can you take it out" then " bring her back out front of the hospital and I will come down to the car and take it out". Needless to say she was taken to another hospital to have it removed and documented and will never go to this hospital again. The sad part is that her family did talk to a lawyer but were told they had a case but it would cost ...
  • Christine S
    Christine S
    Reasoning questionnaire is right on target. As an RN, I hope medicare and government will take serious note of companies, most of them, do not adequately staff their facilities and that more than likely is where 80% of this problem stems from. Nurses want to give good care and that is why they (we) became healthcare providers. Lets make that possible.

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