ProPublica

Journalism in the Public Interest

Cancel

Why Patients Don’t Report Medical Errors

Patient safety flaws remain hidden if no one finds out about them. Now, a federal health care quality agency is planning a new effort to encourage disclosure of medical mistakes.

.

iStockphoto

I was recently browsing through the nearly 200 stories we’ve compiled with our Patient Harm Questionnaire, when I was reminded again of a troubling truth. Many of the people who suffer harm while undergoing medical care do not file formal complaints with regulators. The reasons are numerous: They’re often traumatized, disabled, unaware they’ve been a victim of a medical error or  don’t understand the bureaucracy.


That’s a problem for those individual patients and for the rest of us. There are many places to complain: a state licensing agency; a professional licensing board that monitors doctors or nurses; the Joint Commission, which accredits hospitals or a Medicare Quality Improvement Organization. But if there are no complaints, there are no independent investigations, and that means no outside accountability for providers who may have made mistakes, and no public inspection reports that documents the case -- assuming an agency makes reports public, which is not always the case. It’s a collective problem because patient safety flaws that remain hidden, if they are not corrected, may be repeated.

We have staggering estimates of the number of people harmed while undergoing medical treatment. A review of medical records by the U.S. Health and Human Services Department’s inspector general found that in a single month one in seven Medicare patients was harmed in the hospital, or roughly 134,000 people. “An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths,” the IG found, “which projects to 15,000 patients in a single month.”

But there’s no central system in place to tally and track these events. There’s no way to know when and where patients are being harmed or to tell if the problem is worse in one place than another.

It’s not like keeping track of patient harm is a new idea. More than a decade ago the Institute of Medicine’s landmark “To Err Is Human” report called for a national system to capture cases of serious harm to patients or death. The report said accurate reporting provides accountability and knowledge that leads to learning. That’s information that could save lives.

“You really can’t improve what you don’t measure,” said Dr. Julia Hallisy, president of the Empowered Patient Coalition. “How do you know where to focus your improvement efforts if you haven’t measured what’s happening in the first place?”

Efforts at the state level appear to be falling short, according to federal inspectors. In many states, hospital are required by law to file a report every time a patient suffers unexpected harm -- often called  “sentinel” or “adverse” events. But a July report by the HHS inspector general’s office found that only 12 percent of harmful events identified by the office even met state requirements for reporting them. Compounding the problem: Hospitals themselves only reported 1 percent of the harmful events.

We found something similar when I was a reporter in Las Vegas. We used hospital billing records to identify 3,689 cases of patient harm at the city’s hospitals in a two-year period. Each of those cases would fit the state’s definition of a “sentinel event,” meaning the hospitals were required by law to report them. Yet in the same time period they reported to the state only 402 sentinel events.

The federal Agency for Healthcare Research and Quality is now accepting public comment about a proposed program to encourage consumers to complain about harm suffered while undergoing medical care. The goals include collecting information in a common format, developing prototype methods for gathering information on the phone and Internet and creating a follow-up questionnaire for medical providers. Patients will be asked what happened, who was involved and for permission to follow up with the providers involved in the event.

I recently referred the 1,000 members of the ProPublica Patient Harm Facebook Group to a story about the proposal in The New York Times. Many members of the group have suffered harm firsthand and filed complaints, so the article created lively discussion: 
 

  • Robin Karr said that based on her experience, she’s skeptical about reporting harm directly to the government “but not without hope” about the proposed program.
  • Debra Van Putten said she knows many people who have filed complaints about harm they suffered, but little came of their efforts. Patients want more than mere acknowledgement, she said. They want accountability for whoever is responsible.
  • Martha Deed said there are so many barriers to a patient reporting harm -- emotional trauma and physical disabilities, feeling intimidated by providers, social pressure not to complain -- that a passive questionnaire is unlikely to elicit responses. Instead, the patient harm information should be gathered in a way that’s standardized, she said, like the national survey that’s administered to recently discharged hospital patients that has results publicly reported on Hospital Compare.


That’s food for thought for those developing the program. Official public comment is due Nov. 9 and can be sent to Doris Lefkowitz, the AHRQ reports clearance officer: doris.lefkowitz@AHRQ.hhs.gov.

We’d also love to hear your comments. How do those of you who work in the medical field feel about this type of reporting system? Patients, what do you think about it? And what would you recommend as characteristics that would be essential to such a program?

Its been said many times, but Medicine needs a no-fault system of reporting errors, similar to the airline system.
There is a large social bias against reporting. We don’t want our patients to be harmed, but we also don’t want to harm our colleagues.
If there was no “real” harm done to a patient, why report when you just might be getting your colleague in trouble, without any true change being effected.

Merilee D. Karr

Sep. 25, 2012, 3:28 p.m.

Some patients refuse to report errors and adverse outcomes, because they feel (probably correctly) that they are still dependent on the providers who caused them harm, to repair the harm. This comes up especially after bad outcomes of surgery that require follow-up surgeries.
These patients feel like hostages to the providers who may have harmed them.

I reported a surgical nurse several years ago, who had put a drug that I am allergic to in my IV post-op. I had filled out the forms at least 5 times that day, and wore a red “alert” bracelet. Ultimately, they had to cut out my uvula in my room as it had swelled and was choking me. When I learned this was not her first time with this type of error, I reported it to the hospital, their “ombudsman”, and the Ohio State Board of Nursing. No one ever did a bloody thing. No acknowledgement, no apology, no sanctions- nothing. I suppose my mistake was in telling them that I would not sue, even though I am a lawyer; I just wanted to make certain that she didn’t kill someone, unfortunately, it appears likely to happen again. Sad, enraging, and disgusting.

Joel Selmeier

Sep. 25, 2012, 8:04 p.m.

Part of the problem is that there is no one you, a journalist, can call to get a coherent view of the interests of patients from someone who knows how to communicate that to a journalist. There are no professional advocates whose job that is. Medicine has lots of press agents. Just call a state medical board or a hospital and ask to speak to one.

Another part of the problem is that, as grateful as we are that you are asking patients and not caregivers about this, you are not asking the right patients. Talk to victims of crimes committed by caregivers. Those are people who tried hard to complain and got nowhere. I could point you to some.

There is no appreciation for what an imposing and unified monolith medicine is to a patient trying to complain. Even patients who were victims of murder attempts by their caregivers historically have not complained. They figure out that they are complaining to the same people who tried to kill them, or at least to loyal colleagues of the same. I can show you historical examples.

And your article is missing awareness of the fact that the places you said are available to take complaints are not places worth complaining to for patients. They are not on the side of patients. For instance, nothing comes of complaints made by patients to state medical boards. Those are lobbyists for caregivers and patients discover that right away.

Patients trying to complain cannot even get the police to take complaints about sex abuse or assault or any of the other crimes that caregivers commit against patients each year. I can lead you to people who have tried. Fear of defamation suits shuts up most of them. Some will talk, but not usually in an online forum where it can so easily be used to punish them.

Doctors can call state medical boards that are run by and for doctors. Nurses can call nursing boards that represent nurses. Hospitals have hospital associations. Patients have who to call? No one who is on their side. To complain about doctors they are supposed to call the agency that represents doctors. To complain about nurses, they are supposed to contact the agency that represents nurses.

You might want to glance at this study of a year of the disciplinary actions of the Ohio State Medical Board to get a better understanding of what complaining patients find:
http://patient-safety.com/osmb.htm

Or maybe call some of the now-grown women who were groped as adolescents by Dr. Vikas Kashyap in Ohio and tried to complain everywhere they could. No one did anything. Year after year. Finally when they grew up enough of them discovered each other socially to form a group. A group can get a lawyer (Barbara Bonar 859-431-3333) - the last hope of the injured patient. But, of course, even that is being taken away.

Sgt. Barefoot

Sep. 26, 2012, 9:51 a.m.

Gratitude to “Pro_publica” for providing a forumn for yet another contemporary dilemma.  One must not dismiss the prospect of foreign design upon domestic realms in the health care industry. When fiscal dynamics are questionable with a patinet, there are interests to obfuscate due process and institute “estate occupations”.  There is much ambiguity at the forefront of decision making, often at times during a stage that has progressed to the point of survivng and or remission, and are uniquely the design of executive adminisrators, outside or host of various “clinics” .  seeking to abridge insurance provisions that will limit payouts.
  The harm is not always attributed to the physical health status of the patient for the sppecific treatment at issue.

Michael H. Wilson

Sep. 26, 2012, 10:36 a.m.

In 1985 my wife had what was supposed to be a simple day surgery on her knee. She came out of surgery worse than she went in. She was left with what is known as Reflex Sympathetic Dystrophy. She lost her job, saving and retirement. We lost our home which we are still paying for. I filed a complaint with the state medical board. Some months later a lawyer who looked into it for me informed me there was no investigation nor had there been.

It took two years to get a diagnoses as to what the problem was and another two to find someone who would treat her and to get that treatment we had to move out of state. I was told that the doctor who did the original surgery had a drinking problem. He is still practicing today.

You might want to go to the facebook page for injured patients and post your story there: http://www.facebook.com/pages/One-Thousand-Injured-Patients/236181953372

You might also want to read about why people with iatrogenic injuries commonly have a similar story to tell, at this link:
http://patient-safety.com/blacklisting_patients.htm

What happens if I report egrecious physician error to a hospital (and its Board of Directors) requesting an apology, compensation for costs associated with the error, and a review of hospital policies re: safety still remains unanswered a year later?  One year, no response other than a quick phone call requesting access to medical records (provided).  I don’t know if they did anything, but I want to help avoid similar, potentially fatal, errors for other patients.  We did not suffer physical harm—only emotional and financial—but hope to help protect others.  Any ideas on next steps?

Marshall Allen

Sep. 26, 2012, 1:59 p.m.

Hi Joel, Chris and others. Thanks for your insightful comments on my story. I’m familiar with a lot of these issues and unfortunately there are not a lot of easy answers.

What I would encourage you to do is join our Patient Harm Facebook group, which is now over 1,000 members, and provides a forum for patients to share their stories and offer ideas, comfort and resources. Ask your questions to that group and I’m pretty sure you’ll get some direction.

I would also encourage you to complete our Patient Harm Questionnaire, if you’ve been directly affected by this problem. That’s a method we have for identifying stories and themes that we and other journalists can pursue with our reporting.

And last but not least, I know there are many providers—doctors, nurses, hospital officials, insurance executives, case managers, etc.—who care deeply about these problems. We are asking these folks to share their ideas and contact info with us by completing our Provider Questionnaire.

Links to the Facebook group and the patient and provider questionnaires, are on the right side of this page, where it says “Share your story” and “Join the discussion.”

You will note that many states including my home state florida,are restricting malpractice suits by law, while at the same time are not proactive in protecting patients and what is even funnier,not reducing health care costs,the claimed reason to restrict malpractice! Try asking a hospital about their rate of error as well as cross infection and they will refuse to provide the data even if you have to be admitted there! What is neaded is legislation that requires ALL medical providers provide this data to patients and let the “free market”(HA HA)work!!

When a doctor tells you that you will have to take the drug for the rest of your life,they know what is wrong with you when you have to go back ten years later and tell this same doctor something is not right.The side affects of such drug is going to cause an organ shut down or something else to go wrong.All these drugs people are taking really don’t do anything but make matters worse.Pain pills destroy livers but do make pain easier to live with even though you don’t really need as many as most people take.A doctor diagnosed me with fibromyalgia and told me i would have to be on some kind of medication until a cure was found.I haven’t haven’t had the condition now for two years.I made something,used it and it worked.I had no resaon to thnk the process wouldn’t work.Aything a doctor gives you that is synthetic won’t work near as good as the non synthetc medicine.There are entirey to many people that think they have to be fixed by a doctor when they don’t in a lot of situations.Numerous countries have cures for illness’s that we never will have because there is to much greed in the treatment end of health,not the curing end.We keep chasing better ways to use chemo and radiation.Both these treatments need to be kicked off the table.Humankind should be able to use what ever they want to treat and cure their own illness’s no matter what is it without gettng arested.All the medical marijuana patients are learning how to take care of themselves if they want to listen.Some won’t ever listen because they are to lazy,Call the doctor.Most of you could live if you would just listen to what is going on outside the rim.Stop listening to the doctors and use that thing on top of your heads thats called a brain.Liquoir company’s,drug company’s,AMA,federal government,congress,the senate and payed trolls are doing their dambdest to keep you from learning about a cure for everything that ails the human body.Our scientist need to be working with cannabis.There are hundreds of ways to us this plant.They know it kills cancer cells with no side affects and n certain country’s it is being used for a cure,and you know wat,the US will not here about it use because the US say’s no one can use it.As soon as these country’s have enough people who aren’t afraid to use something that works and really gives a dam about their people they will use it to.In the mean time do what you do best.CALL THE DOCTOR.

R RAMESH NAIK

Sep. 27, 2012, 2:46 a.m.

Medical science is highly complicated and still not a perfect science and involves a very lengthy decision process.
When a person falls sick, he has to decide whether it requires a consultation. Some take spot decision. Some take delayed decision, some do not decide at all. The out come of treatment many times depends on the speed at which one decides. This is the first variable.
2. Ready availability of relevant services: Many have to wait endlessly to get the appointment.
3. The attending medical fraternity should have highest level of competence
.4.The level of treatment depends on paying capacity of patient- Inpatient or Out patient treatment or,symptomatic treatment, or treatment on basis of clinical diagnosis without investigations, or scientific treatment after different level of investigations, viz, routine investigations, or relevant primary investigations, or specialized investigations, or super-specialized investigations or high-fidelity investigations, and in certain rare cases subject to medical research.
5. How much time can one spare for all these procedures.
6. After diagnosis, again, one wants latest, costliest, and invariably most effective schedule of treatment, or moderately effectively treatment of moderate cost, taking a longer duration for relief,with moderate failure or prefer cheap medicines, which are less effective and accept a delayed relief, with a high level of failure.
7.Next comes, the regularity of consuming medicines.
8. And the most notorious of the variables- accept life style changes advised by the doctor,VIZ, stop alcohol consumption, smoking, substance abuse, wake up early in the morning and do exercises, control food intake, do meditation, stop worrying, stop junk food, take good amount of vegetables, fruits, and freshly prepared hot food, avoid preserved food,lead a systematic life and a long list of other life style changes. (Many retort-Then what is the purpose of living?)Many other variables decide the outcome.This, along with the issues raised by other learned readers discourages the offended party to complain against medical negligence EVEN IF HE A MEDICAL PRACTITIONER. This is not meant to discourage the victims or justify the crime against the humanity by medical fraternity, but to lay bare the intricacies faced by the Social activists to bring the delinquent to books!            MAY GOD HELP THE HUMANS IN NOT FALLING SICK!
MEDICAL SECRET REVEALED:
” LEAD A HEALTHY LIFE STYLE. YOU WILL NOT SEE THE FACE OF A DOCTOR”.
“ENJOY TODAY, AND SEE THE FACE OF A DOCTOR TOMORROW ” TAKE CARE TODAY AND ENJOY THE REST OF YOUR LIFE,”

Todd Miller, Ph.D. The Impartial Review News

Sep. 27, 2012, 5 a.m.

A survey would accomplish little IMO.  The methodology is wrong.  The first thing you have to do is understand what happens to patients who are harmed. 

Reporting a harmful event should never be sufficient.  Rather, you need to report and fix the problem.  However, some strongly suspect that most hospitals are spending too much money on insurance company paperwork and attorneys to have the resources or inclination to report and fix.  Health care reform only minimally addresses these issues. 

The correct methodology is to go in as if you were regulators doing an investigation and then you could document the extent to which regulators are not doing their jobs and to determine the extent to which hospitals are covering up.  You could find errors and report them to agencies and see what if anything they do. 

A patient survey in and of itself is simply a waste of time in my opinion.  We already know 1/3 of all patients report they’ve been a victim of a medical mistake.  More details from patient reports leaves out the appropriate medical data, the issues with regulators and how the hospitals respond to and attempt to prevent problems.

Joel Selmeier

Sep. 27, 2012, 7:48 a.m.

You say that you know there are many providers—doctors, nurses, hospital officials, insurance executives, case managers, etc.—who care deeply about these problems and you are asking these folks to share their ideas and contact info with you by completing your Provider Questionnaire.

You haven’‘t figured out what the fundamental problems are, and they will never tell you. It is not in their interest to know it themselves, so they don’t. Look up agnotology.

I defy you find a caregiver who knows what happens to patients after they injure them. I defy you to find a caregiver who even can give a sensible answer to what the least is that a patient should be able to expect in medicine. They have answers, but they are so far off the mark it irks, and the people who interview them accept their answers. Try asking a few of them those two questions and then call me to let me show you how self-interested their answers are: (513) 348-4744.

Failing that, perhaps read a few dozen pages of my website to find why you are not going indentify the problems, let along fine find the answers by talking to them. http://www.patient-safety.com

I reported a nurse once who was obviously abusing medication, wow, did I ever get backlash.  I think the real lesson with all of these articles Pro Publica has published is fairly simple.  If you know our medical community and hospitals are a mess, simply take care of yourself and avoid them…

“We have staggering estimates of the number of people harmed while undergoing medical treatment. “

What are those estimates and who made them and with what verificalbe statistics? My estimate is that .01% of medical procedures are willfully negligent. Do you have evidence that my considered estimate is in any way wrong?

If not, his article is bogus!

Joel Selmeier

Sep. 29, 2012, 6:57 a.m.

You could start by looking at the summaries of some of the studies listed at this link:
http://www.patient-safety.com/Preventable.Deaths.htm

Marshall Allen

Sep. 29, 2012, 9:21 p.m.

Hi Ed Bradford, thanks for your question about my article. I put those estimates in the sentences that follow the one you referenced. Here they are, from the story: “A review of medical records by the U.S. Health and Human Services Department’s inspector general found that in a single month one in seven Medicare patients was harmed in the hospital, or roughly 134,000 people. “An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths,” the IG found, “which projects to 15,000 patients in a single month.”

If you click on the hyperlinks in the sentences (the hyperlinks in the article above) you’ll be taken directly to the source documents that provide those estimates. The estimates came from a review of medical records by doctors, as part of a study by the Office of Inspector General for the Department of Health and Human Services. Check out the methodology and tell me what you think. I believe it is sound.

This OIG estimate does not go into whether the harm is “willfully negligent.” The point isn’t whether it’s “willful” harm. The point is that patients are being needlessly harmed. They’re too often suffering preventable harm, and that’s bad whether it’s “willful” or not.

Kerry O'Connell

Oct. 1, 2012, 1:17 p.m.

Healthcare exists by the grace of those they harm. People are profoundly tolerant and forgiving when it comes to providers. It is a both blessing and an curse as there is little incentive for patient safety improvements. I feel that the only ethical provider response to patient harm is for the provider to become a tireless teacher showing his fellow healthcare workers how not to make the same mistake. It is the only way to truely heal the guilt and shame that comes with harm.

Joel Selmeier

Oct. 1, 2012, 7:49 p.m.

Then first tireless teacher might need to be the one who teaches fellow healthcare workers merely to recognize when harm is caused. The caregiving community has established a culture that shields itself from knowing most of the time. And it doesn’t know that about itself.

I think it is over-due that injuries to patients should be monitored in a data base and the root revealed. Is it the education process? Is it the greedy corporations? Is it a selfish nurse?  Are health care workers covering up injuries to patients? Are people that are really marginal being employed in the healthcare field because they obtain a license? Is their character, and honesty questionable? Is the a result of foreign labor that has not provided adequate background and proof of their education - are they frauds? How much do patients know, and how much is hidden or covered up by dishonest healthcare professionals, i.e. nurses? corporations?, etc..Are the Corporations greedy, and healthcare workers are injuring patients because they are not standing up for what is right, and not demanding adequate staffing at the facilities where they work?  Are CEO’s not appropriate in the healthcare setting, because they are greedy? Yes, the public should have all and any information about themselves, and their treatment. Nurses are trained NOT to document “everything” only limited information about something out of the “norm”. The reason the corporations have nurses “chart by exception” is information regarding errors can be hidden if a patients’ record is subpoenaed for a court action. There is so much the public doesn’t know, that they should know.

Joel Selmeier

Oct. 3, 2012, 8:02 a.m.

All of the reasons you mention could contribute to why 93% of adverse events do not get reported or recorded at any level (according to the same HHS study cited in the above article). But what might be the biggest one isn’t in your list. It is pointed out by the difficulty of finding anyone in medicine who believes statistics about how few adverse events get reported. It might be the most important problem in healthcare, but it is not one you can get healthcare workers to talk about or acknowledge.

Are you familiar with the experiments Solomon Asch did with groups of people showing how they come to agree on the interpretation of the evidence of their senses? Rather than type three paragraphs about that here, you can read about it in the first three paragraphs at this link:
http://patient-safety.com/white_wall_of_silence.htm

It suggests that we are spinning our wheels when trying arrange for healthcare workers to become honest and objective reporters. It suggests that the reporting will have to come from other sources. After all, can you find a healthcare worker anywhere who thinks anyone he/she knows in medicine doesn’t report 93% of what goes wrong? They don’t see it. They have a different interpretation of what needs to be reported than an objective third party would have.

This article is part of an ongoing investigation:
Patient Safety

Patient Safety: Exploring Quality of Care in the U.S.

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment.

The Story So Far

Too many patients suffer harm instead of healing in U.S. medicine. That’s why ProPublica’s reporters have investigated everything from deadly dialysis centers and dangerous hospitals to the failure of state boards to discipline incompetent nurses.


This page allows patients, providers and readers to join the patient safety conversation. Our goal is to find out why so many patients are suffering harm and highlight the best ways to solve the problem. Here you’ll find regular updates, and places to share your stories, views or expertise.

Read all of our posts on patient safety, and find out how to get involved.

Contact Us

Blair Hickman, Community Manager
@amandablair
Blair.Hickman@propublica.org

Got a tip? Fill out our form.

Share Your Story

Your input can help ProPublica's reporting.

Have you worked in health care? Tell us what you’ve observed about patient safety.

Have you or a loved one been harmed? Tell us about it.

Join the Discussion

Join the over 1,500 members of ProPublica's Patient Harm Group to learn, share your story and connect with others.

Icon graphics courtesy of the Noun Project.

Get Updates

Stay on top of what we’re working on by subscribing to our email digest.

optional