When fire breaks out and burns a patient during surgery in Pennsylvania, the hospital is required by law to report the incident to the state Patient Safety Authority.
If a similar surgical fire ignites in New York or California, the hospital must notify the state health departments there.
And if the same thing happens in Ohio?
The hospital doesn’t have to tell any state agency.
That lack of reporting, experts say, hurts all of us.
That’s because getting the word out about medical errors keeps patients from being injured, cuts down on medical malpractice lawsuits and, in the end, reduces unnecessary health care costs.
“Medical error reporting, in general, helps change clinical practice for the better and helps improve patient safety,” said Mark Bruley, a researcher who has been publishing articles on the causes and prevention of surgical fires for more than 30 years.
On April 30, officials at the Cleveland Clinic confirmed that six fires had broken out in operating rooms in the 12-month period that ended in March.
Patients suffered “superficial burns” in three of the fires, they said. And no one was harmed in the other three.
The Clinic didn’t report the incidents to any outside agency immediately after they happened because it wasn’t required to, said Dr. Michael Henderson, the Clinic’s chief quality officer.
But when health officials showed up in late April to conduct an inspection for the Centers for Medicare & Medicaid Services, the Clinic told them about the fires.
The inspectors, said Clinic Chief Executive Toby Cosgrove, made two recommendations: That the Clinic remove all alcohol-based surgery preparation solutions from operating rooms and that it train anyone who enters an operating room in how to prevent fires and how to extinguish them when they do occur.
Those recommendations, Cosgrove said, were implemented within hours.
That was 12 months after the first fire occurred.
Cleveland Clinic spokeswoman Eileen Sheil says the hospital supports transparency when it comes to reporting errors.
“And the state of Ohio seems to be moving in that direction,” she said.
Ohio Department of Health spokesman Robert Jennings said requiring hospitals to report problems that occur during surgery is under discussion.
As of now, though, “Ohio is a state that does not license its hospitals, so there is no process for reporting surgical errors,” he said.
Surgical fires are not uncommon. As many as 650 occur in health-care facilities a year, according to an estimate by the ECRI Institute, a nonprofit organization that researches the best approaches to improving patient care. Twenty or 30 result in disfiguring or disabling injury, the report says. One to two — typically fires in the airway — kill patients, according to Bruley, ECRI’s vice president for accident and forensic investigation.
University Hospitals Case Medical Center has had one very small operating-room fire with minor injury in the past 12 months, officials said. MetroHealth Medical Center has had none in that time, according to a spokeswoman there.
Prevention is a major reason states require reporting, officials say.
“You can learn from others,” said Fran Charney, director of educational programs at Pennsylvania’s Patient Safety Authority. “That’s the beauty of the system.
“Smart people learn from their mistakes. Wise people learn from the mistakes of others.”
One of the best examples of how the system works, she said, involved a near-miss. Those too must be reported in Pennsylvania.
A patient in cardiac arrest almost died because he was wearing a yellow wristband. The hospital used yellow bands to indicate that a patient had a “Do not Resuscitate” order. In this case, though, the patient had been transferred from another facility that used yellow bands for other purposes. He did want to be resuscitated. And, in the end, he was.
The catastrophe that almost happened led to the creation of universal color coding for wrist bands at hospitals across the country, Charney said.
“That’s an example of how one near-miss in one hospital in Pennsylvania actually sparked a national movement to increase patient safety,” she said.
One reason that Pennsylvania’s Patient Safety Authority works, she added, is that it is not a regulatory agency — it can’t fine or otherwise punish a hospital and it does not identify individual hospitals or employees involved in the errors.
“I always describe us as the guys with the white hats,” Charney said. “We’re truly here to help, to look at the data, see what the data is showing and share it with other facilities, which I think is ideal.”
Pennsylvania hospitals must also report serious events to the state health department, which can investigate and take further action.
In California, the Department of Public Health can assess serious fines against hospitals that don’t take proper precautions to prevent operating room burns.
“We just cited a hospital and they didn’t even have a fire,” said spokesman Ralph Montano. The hospital was fined because the humidity was so low in an area where cesarean sections are performed that it increased the risk of fire, jeopardizing the health of three women and their babies.
The women were on oxygen during the surgery, and doctors used electrical equipment to make incisions and seal blood vessels.
The California health department fined the hospital $100,000.
But some medical safety experts say public announcement of errors is the best way to prevent them.
“We’ve done some research on this,” said Judith Hibbard, a professor of health policy at the University of Oregon. “And making it public makes a big difference.”
What her research found is that hospitals improved safety more when their mistakes were made public than when they were just reported back to the hospital or not reported at all.
“The hospitals were primarily motivated to improve because of their public image and reputation,” Hibbard said.
“Just knowing that they’re not doing great isn’t enough. Unless there’s something at stake, they’re not motivated to change.”
Another advocate of public reporting of errors is Lisa McGiffert, director of the Safe Patient Project of Consumers Union.
“Reporting is a form of accountability,” McGiffert said. “And hospitals should be accountable to the public they serve — to the communities that they serve. And that should include reliable information about how safe their hospital is, how safe their care is.”
