Discharge Summaries Grossly Inadequate at Documenting Pending Test Results

A study in the September edition of the Journal of General Internal Medicine found that "discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers."

The study found that only 13% of discharge summaries document all pending tests. And only 25% of discharge summaries mention some pending tests. Follow-up providers information was included in 67% of discharge summaries. "The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return." The study evaluated discharge summaries at two academic medical centers for patients that had pending test results.

This adds to the communication challenges referring physicians face coordinating care in follow-up to a hospital visit. Yet communications issues are accountable for over half of all preventable errors. And communications issues are twice as likely to be related to deaths as compared to "clinical inadequacy".

The study reported that approximately 41% of patient are discharged with pending test results and 9% of these test results affect patient care management.

"How American Health Care Killed My Father"

David Goldhill chronicles in How American Health Care Killed My Father the problems in the healthcare system leading to his father's death by a preventable hospital-borne infection. It's an excellent survey piece, whether or not you agree with the consumer- and market-centered policy conclusions.

Goldhill's comments extend to Healthcare Technology:

"Consider information technology, for instance. Of course the health system could benefit from better use of IT. The Rand Corporation has estimated that the widespread use of electronic medical records would eventually yield annual savings of $81 billion, while also improving care and reducing preventable deaths, and the White House estates that creating and spreading the technology would cost just $50 billion. But in what other industry would an investment with such a massive annual return not be funded by the industry itself? (And while $50 billion may sound like a big investment, it’s only about 2 percent of the health-care industry’s annual revenues.)

Technology is effective only when it’s properly applied. Since most physicians and health-care companies haven’t adopted electronic medical records on their own, what makes us think they will appropriately use all this new IT? Most of the benefits of the technology (record portability, a reduction in costly and dangerous clinical errors) would likely accrue to patients, not providers. In a consumer-facing industry, this alone would drive companies to make the investments to stay competitive. But of course, we patients aren’t the real customers; government funding of electronic records wouldn’t change that."

Dead By Mistake

Preventable medical errors and hospital acquired infections are still the largest causes of accidental death in US. The number of preventable deaths is approaching 200,000. There has been little change in the number of deaths from preventable medical errors since the seminal report on preventable medical errors, "To Err is Human".

Dead by Mistake, by a group of Hearst journalists, reports that "ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half — within five years. Instead, federal analysts believe the rate of medical error is actually increasing. In its 2008 annual report to Congress, the Agency for Healthcare Research and Quality, a part of the Department of Health and Human Services, reported that preventable medical injuries are growing each year by 1 percent, the first time it had reported such an increase."

As a result of this and other evidence, the Hearst journalists found that, since the original Institute of Medicine (IOM) study, there was no reason to believe that the 98,000 deaths per year attributable to preventable medical errors had declined. And the Center for Disease Control and Prevention found that 99,000 deaths were due to mainly preventable hospital infections.

The report "found that the the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago." For example, the IOM report

• Recommended national reporting of medical errors. Strong resistance from the AMA and the AHA effectively shelved this recommendation. Of the 20 states that have mandated reporting, "evidence shows that even in those mandatory-reporting states, hospitals report only a tiny percentage of their mistakes."
• "Recommended the creation of a national patient safety center. The center is underfunded and has fallen far short of expectations.
  
• Urged that hospitals improve the level of safety within their walls. Hundreds of hospitals responded, a few of them comprehensively pursuing safer care. Thousands did much less.
• Advocated a voluntary system for hospitals to report and learn from errors. Five years later, Congress approved legislation for 'patient safety organizations' to serve this role, then took four more years to create rules to govern them. But the new organizations are devoid of meaningful oversight and further exclude the public."

New Never Events

In a sobering reminder of the challenges in eliminating preventable errors, on January 15 CMS issued three national coverage determinations (NCD) to protect patients from preventable surgical errors. These "never events" apply to surgical or other invasive procedures (sometimes collectively called "wrong site errors") including:

• performed on the wrong body part
• performed on the wrong patient
• the wrong procedures

CMS referenced a 2007 article estimating that wrong site errors might occur “once each year in a 300-bed hospital' and "surgeons who work on symmetrical structures may have a 1 in 4 chance to be involved in a wrong-site error during their careers." A 2006 study reported finding these errors in 1 of 112,994 operations. Finally, the 2006 AHRQ study reported that these errors "are extremely rare and major injury from them is even rarer."

To put the study's definition of "extremely rare" in perspective: the FAA's operational error rate (i.e., allowing two planes to be too close together) is 31% better (1 in 149,074 operations).

Effective immediately, Medicare does not cover these events, which apply to hospitals, doctors and "any other health care providers and suppliers involved in the erroneous surgeries. " This is a change in coverage limitations from some other 'never events', which had applied to hospitals only.

CMS, in an apparent moment of dark humor, stated that "instructions for processing such claims will occur at a later date." Yet CMS is quite serious about this, as only 11 states prohibit wrong-site billing.

Stories involving wrong site procedures regularly make the news such as this three time occurrence of wrong site brain surgery in Rhode Island (link on the picture):



References

Clarke J, Johnston J and Finley E. Getting Surgery Right. Annals of Surgery. 2007;246:395-405.

Kwaan M, Studdert D, Zinner M and Gawande A. Incidence, Patterns and Prevention of Wrong-Site Surgery. Archives of Surgery. 2006;141:353-358.