Five hospitals release data on inspections

Five large Boston teaching hospitals that were inspected by a national oversight organization in the past eight months have taken the unusual step of releasing the normally confidential results, and several said more problems were found than in the past under a revised inspection system.

The system includes surprise visits and delves more deeply into the care actually provided to patients in the hospital at the time of the inspection -- a shift that has led to more safety concerns being turned up at hospitals nationwide.

One of the most common problems -- found at three of the local hospitals and at about 1 in 3 nationwide -- is failing to ask some patients being admitted to list their medications. This is done to ensure patients are not given drugs or treatments that could cause dangerous reactions, or to "reconcile" their medications as they are transferred or discharged. Massachusetts General and Brigham and Women's hospitals and Boston Medical Center all were cited for this shortcoming.

At Mass. General, in nine instances inspectors found that doctors and nurses inserting intravenous tubing or performing other procedures either did not take a "time out" to verify a patient's identity and procedure, or did not document that they had. The Brigham and Boston Medical Center said they need to improve the way nurses and doctors handle "critical test results," such as low red blood cell counts, that indicate a patient needs an immediate intervention.

All of the hospitals have been or will be reaccredited and have made improvements or have plans in place. But hospital executives said the newer safety standards are challenging to follow consistently because they require a change in the very culture of medicine and in how busy doctors and nurses do their jobs. They require caregivers to adopt standardized procedures for every patient in a workplace that has valued individual decision-making.

"Health care puts a high priority on individual autonomy," said Dr. Richard Croteau, executive director of patient safety initiatives for the Joint Commission, the private organization that inspects hospitals. "Some of this goes against the traditional culture."

The results for the Boston hospitals are similar to the national picture, according to Joint Commission data. About one-quarter of hospitals nationally did not always perform verification before surgery and other procedures, or quickly respond to critical test results, or they failed to record these actions.

Boston hospital executives said they do not believe patients were harmed in the instances where the Joint Commission found flaws in their procedures. But the potential for harm exists, they said, which is why they are working to improve the way they provide care.

"Medical errors are happening everywhere all the time," Croteau said. "This is a high-risk field that has a long way to go in reducing the risk inherent in what we do."

Based on the inspections and subsequent hospital improvement plans, the commission awarded accreditation to Mass. General, the Brigham, Dana-Farber Cancer Institute and Children's Hospital Boston. Boston Medical Center said it has not received the commission's final report, but was told after its inspection that it could expect to be reaccredited.

When hospitals do not meet one of the commission's roughly 250 standards, they are issued a "requirement for improvement" in that category. Mass. General received 10 requirements for improvement; the Brigham, nine, Dana-Farber, which does not have overnight patients, three; and Children's Hospital, three. Boston Medical Center initially received eight requirements for improvement but has disputed two as allowed by the commission's policy; in addition, the hospital's residential mental health program received three and is appealing one.

Neither hospitals nor the commission usually release detailed results for individual organizations. But Mass. General president Dr. Peter Slavin wrote an e-mail to employees in December, soon after inspectors left, indicating that he was disappointed with the hospital's results, describing them as a wake-up call and promising immediate improvements. The hospital promised to release the final report. Following that, the Globe requested the findings from other Boston teaching hospitals, which agreed to either release their reports or describe the commission's findings in detail. Mass. General and the Brigham plan to post similar information on their websites.

"We're not trying to hide the fact that we have things we need to fix," said Dr. Andy Whittemore, the Brigham's chief medical officer.

The Illinois-based Joint Commission evaluates more than 15,000 healthcare organizations and is the country's primary inspector of hospitals, nursing homes, and other medical institutions and programs. The organization has been criticized in the past for being too easy on hospitals, which financially support the commission by paying a fee for inspections. As a result, the organization has made several changes in the past few years.

Four years ago, the commission began requiring hospitals to comply with a set of national patient safety goals, which include tracking patients' medications, time outs before procedures, and communicating critical test results quickly. Three years ago, it began following patients through their hospital stay, rather than just reviewing hospital policies and meeting with executives, as it had done previously. Last year, the commission switched from scheduled visits to surprise visits.

Hospitals are still adjusting to the revised system. Many Massachusetts hospitals began tracking patients' medications during transitions in care -- an emergency room visit, admission to the ICU, transfer to a patient floor, or discharge -- far sooner than institutions in other parts of the country, and much of the research about the potential harm of not doing so originated in Boston.

At Mass. General, inspectors also found that caregivers did not always document at set intervals whether patients on pain medication had improved or that they had quickly assessed patients for pain -- one surgery patient had no record of pain assessment for 22 hours after admission. And several patient records lacked information about whether they had signed "advance directives," which indicate whether patients want aggressive medical care if they can not communicate their wishes.

Dr. Gregg Meyer, senior vice president for quality and patient safety at Mass. General, said that the hospital is monitoring all areas where the commission found problems and has improved. He said that when the hospital fully switches to computerized medical records, it will drive improvement in many areas, because the system has automatic reminders built in and because computers at patients' bedsides make it easier for caregivers to note their actions.

Among the Brigham's problems, inspectors found that caregivers did not always re-evaluate every 24 hours the reasons for putting patients in restraints; and some pharmacies did not check all physician medication orders to ensure they were safe for patients. The hospital has an improvement plan in place.

At Children's Hospital, the commission discovered incomplete or illegible medical records, among other findings.

At Boston Medical Center, the commission's findings included cases where doctors had used dangerous and prohibited abbreviations that can easily be misunderstood. The hospital has started an education campaign.

"That's like trying to beat back 200 years of indoctrinated language in health care," said Peter Healy, vice president of professional services. "It's really hard to do all of these things perfectly all the time."

Liz Kowalczyk can be reached at kowalczyk@globe.com.