How safe are you?

It's a question asked increasingly in the United States since the terrorist attacks on Sept. 11, 2001. But at that time, the same query was already echoing through hospitals across the country.

		Related illustration Keeping patients safe

That's because a landmark report by the federal Institute of Medicine in November 1999 declared that as many as 98,000 people die each year in hospitals due to medical errors.

With the report's five-year anniversary fast approaching, health-care experts are taking stock of whether patient safety has improved for all the talk. In Pennsylvania, the question is of particular interest at the Patient Safety Authority, an independent state agency created in the wake of the federal report that collects reports on medical errors and incidents that didn't harm patients, but could have.

So, are patients in Pennsylvania hospitals safer than they were five years ago?

"Yes, but we still have a long way to go," said Dr. Robert Muscalus, Pennsylvania's physician general and authority chair.

"Clearly not yet," countered Clifford A. Rieders, a Williamsport attorney who sits on the authority's board of directors. "Will they be in the future? I think that depends on whether the public gets on the back of the Patient Safety Authority -- starts pushing the Patient Safety Authority to do its job."

The authority was created with the passage in 2002 of the Medical Care Availability and Reduction of Error Act, a law that also changed the way doctors finance their medical malpractice premiums. The law called on the new authority to collect information on these incidents in hospitals, ambulatory surgical centers and birth centers. It would then provide information to health care providers to help them improve their quality.

Mandatory reporting through the Web-based system started in June in more than 400 health care facilities, although some hospitals started making reports in late 2003. So far, the authority has received about 50,000 reports, said its administrator, Alan Rabinowitz.

About half the reports fall in the broad categories of patient falls and medication errors. But the authority is less interested in aggregate numbers than in identifying specific areas for improvement, Rabinowitz said.

As an example, the authority on Oct. 28 issued an advisory about overdoses caused by confusion between syringes used to dispense insulin and those to treat tuberculosis. In one of the several reports, a nurse mistakenly used a TB syringe when administering insulin and gave the patient a 10-fold overdose.

The packaging for the TB syringe resembled that of the insulin syringe. The TB syringe is packaged in a white wrapper with black and orange print with an orange plunger tip -- the same color used for many years on insulin syringes.

A hospital worker e-mailed shortly after receiving the advisory to say that the information was already being put to use at her hospital.

Other problems submitted to the database had ready solutions; for example, how to avoid fires in the operating room and what could be done to prevent surgeons from amputating the wrong limb.

In one highlighted case, a medication error apparently occurred because a administered some drugs on the basis of patients' first names -- basically, one Jane got another Jane's medicines. The solution: Check wrist bands and, more broadly, think about using two unique patient identifiers such as last name, phone number or birth date.

"Our goal is to learn from these reports," Rabinowitz said. "The Patient Safety Authority is set up to identify trends and make recommendations about what facilities can do to improve their systems, so that events and errors don't happen again."

The bill that created the authority also had other provisions. For example, all hospitals were to designate a patient safety officer and to develop a safety plan.

Any time patients suffered from "serious events" involving care that resulted in death or compromised safety and resulted in an unanticipated injury, hospitals were to notify the patient in writing about what happened.

Serious events reported to the authority also would be reported to the state Department of Health, which regulates the quality of hospital care. This would effectively replace the "Chapter 51" requirements under which hospitals previously reported to the health department serious events and other problems -- critics maintained that hospitals had been slow to report under Chapter 51.

To fund its activities, the authority would assess fees that could total no more than $5 million per year to all facilities. Three fees have been assessed thus far, giving the authority $10 million to create its system for receiving reports.

The financial carrot for hospitals was an opportunity to receive a "patient safety discount" in malpractice insurance rates for facilities that showed improvements.

The authority, however, hasn't been without controversy.

Rieders, the lawyer on the authority's board, joined two other board members in voting against a decision this spring that allows hospitals to report less information about serious events that result in temporary harm. He viewed this as a "watering down" of the reporting requirements that primarily served the interests of hospitals.

But Muscalus, the physician general, said hospitals would still be required to answer 21 questions about these incidents. Department of Health officials could then follow up to learn more about these problems if they raised a regulatory issue. This decision could be revisited down the road, he added.

More recently, Rieders questioned whether hospitals were complying with the law's requirement that patients be informed about serious events. He noted that some hospitals have not reported any serious events or incidents to the system.

"When this law was passed, we knew we were giving up a lot of rights for people, but we thought it would be worthwhile if there was more patient safety," he said. "I'm disturbed and I'm distressed that that bargain has been breached."

But Dr. John Combes, the senior medical advisor to the Hospital & Healthsystem Association of Pennsylvania, said hospitals are complying.

In the wake of the Institute of Medicine's 1999 report, the Joint Commission on Accreditation of Healthcare Organizations called on hospitals to disclose medical errors to patients and they have worked hard to comply, he said, adding he believes patients are safer today because of reporting requirements.

Combes is not aware of any hospital that has received the safety discount. Apparently, that's because the state hasn't yet worked out how hospitals could win this discount.

That's a shame, said Ken Segel of the Pittsburgh Regional Healthcare Initiative, which is working to improve quality here. Hospitals need financial incentives to share information about quality problems because there are so many reasons not to share -- namely, the threat of malpractice lawsuits.

But Segel said the authority has made important progress. That point was seconded in a conference call last week among patient safety experts discussing what's happened in the five years since the IOM report.

"I think we're going to see in the Pennsylvania model a way to use mandatory reporting in a positive way that will make a difference," said Dr. Lucian Leape, an expert on patient safety at the Harvard School of Public Health. "We ought to watch that."