Electronic error tracking on call at hospitals

Amid growing concern over medical errors, a number of hospitals in Boston and other cities are installing "near miss" systems, hoping to catch dangerous patterns before they hurt patients.

Most hospitals have surprisingly antiquated systems for tracking medical errors and near misses, which must be reported to the state if they involve serious injury or death to the patient. Typically, nurses report incidents by writing a lengthy description on a paper form. But the forms can be so time-consuming and the fear of reprisal so pervasive that few doctors participate. And because the reports are scattered on hundreds of pieces of paper, hospital executives sometimes can't see patterns, such as widespread fatigue or heavy workloads among staff.

But a number of hospitals are bringing in new electronic systems that allow doctors and nurses to log onto any hospital computer, call up a form, and report a near miss or error by checking off various boxes. The computer immediately sends the report to hospital safety officials and department chiefs. Because the data is searchable, hospital supervisors can look for patterns.

"Our paper system has been adequate to pick up big things," said Dr. Gregg Meyer, medical director of the Massachusetts General Physicians Organization. But "there's probably important information that would improve the safety of our patients buried in some file boxes."

Staff at Massachusetts General Hospital, which will install an electronic reporting system this year, filed 7,000 paper forms last year detailing minor concerns, employee injuries, equipment failures, near misses, and actual medical errors. Only 100 or so reports came from doctors.

But the new tracking systems won't work unless hospitals are able to assure doctors and other staff that they will not be punished for reporting a mistake and that it's worth their time to participate. Some doctors worry that if they acknowledge a mistake in writing, it could become a factor in a malpractice lawsuit, even though the reports are protected as confidential under state law. Other physicians say they just weren't trained to be open about mistakes.

At Brigham & Women's Hospital, which installed a new electronic reporting system a month ago, Dr. Andy Whittemore, the chief medical officer, said the hospital is trying to create a more open environment. Reporting near misses and errors is voluntary. But if they involve serious injury or death to the patient, medical staff must report those situation and hospitals must inform the state.

"Physicians' reluctance to report events is kind of inbred in the culture," said Dr. Stuart Mushlin, a Brigham internist. "The culture was kind of shame and blame, and that's changing."

Hospitals have been increasingly concerned about medical errors since 1999, when The Institute of Medicine, a nonprofit nonpartisan advisory group, called medical errors one of the most pressing problems in medicine. Extrapolating from two national studies, institute researchers estimated that medical errors kill 44,000 to 98,000 Americans each year.

The group recommended radical changes in the industry, including improving internal reporting. But since then, many researchers who worked on the report and follow-up studies have been frustrated by how slowly the health care system has moved to make improvements.

"There is a certain resistance or blind spot on the part of physicians in particular," said Janet Corrigan, a senior board director for health care services at the institute. "We know there are a lot of people who die or are injured every day because of medical errors. It's important that we move very quickly. But there are cost and resistance issues."

For example, Brigham's Computer Physician Order Entry system -- which requires doctors to order drugs via computer to eliminate hand-writing errors, dangerous allergic reactions, and overdoses -- has reduced medication errors by more than 80 percent, according to one hospital study. Even so, just 5 percent of US hospitals have installed electronic drug-ordering systems.

There also are cost considerations. Brigham is installing a drug bar-coding system, which is designed to eliminate errors at the time the nurse administers the medication to the patient. The code on the drug must match the information on the patient's hospital bracelet. But to do so, the hospital is spending at least $6.5 million, including the cost of creating a repackaging center to code drugs in instances when the manufacturer has not done so. The hospital also must hire 50 temporary nurses for six months to help care for patients while the hospital trains its own nurses to use the coding system.

Despite these concerns, most hospitals are looking at near miss and error systems first, because they're cheaper and easier to install than electronic drug ordering systems.

Mass. General, which will install the same system as Brigham uses, estimates the cost of software, implementation, training, and two additional employees to help analyze reports at about $900,000, said Joan Fitzmaurice, director of quality and safety.

Children's Hospital has signed a contract with the manufacturer for the same system, while Beth Israel Deaconess Medical Center plans to install a similar near miss system by the end of the year. Tufts-New England Medical Center has been using another system since late 2001, during which time staff have reported 10,000 near misses, errors, and patient safety issues, from minor to significant.

In one instance, several nurses reported that the nutritional substitute they were giving to premature babies had leaked out of the intravenous tube and under the babies' skin, a problem that can cause infection. "The system helped us pick this up," said Greg Townsend, director of outcomes analysis and performance improvement at Tufts-NEMC. "We changed the medication; we changed the way the IV lines are managed and monitored."

Brigham had been using an older electronic system that had less capability to analyze trends. Staff reported 2,500 problems and potential problems during the last six months.

But Brigham executives expect the number to grow as much as tenfold, as other hospitals have experienced after installing sophisticated near-miss systems.

One such problem occurred within the last month at Brigham. A patient with gastrointestinal bleeding developed low blood pressure and needed a medication, vasopressin, to help stop the bleeding, Whittemore said. A physician ordered a dose that was too high for his condition, a dose that could have had dangerous side effects, such as interrupting his heart beat. A nurse caught the error as the medication was dripping and stopped it. Physicians adjusted the dose. The patient was fine, he said.

After the nurse reported the near miss, the patient safety department programmed an alert into its electronic medication ordering system. Now doctors who order a high dose of vasopressin are flashed a warning.

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