In perhaps the first wind of change in the cultural climate surrounding medical errors, two hospitals stepped forward last week to take full blame for mistakes that led to tragic consequences.
The hospitals' candid-some say forthright-disclosures came less than one month after a new policy was put in place by the Joint Commission on Accreditation of Healthcare Organizations requiring hospitals to tell patients when their care has not measured up to standards (June 25, p. 4.) They also come on the heels of two highly publicized Institute of Medicine reports that rang alarms concerning patient safety and quality of care in hospitals and a third study released just two weeks ago that attempted to downplay the severity of the problem (July 30, p. 16).
In Valhalla, N.Y., at 996-bed Westchester Medical Center, an oxygen canister that shouldn't have been in the room when the magnetic resonance imaging scanner's 10-ton magnet was turned on flew toward the MRI and struck in the head a 6-year-old boy undergoing a scan. The boy died two days later on July 29.
On July 30, the hospital released a written statement to newspapers describing the "unspeakable tragedy" and taking full responsibility for the accident. The one-page statement was attributed to Edward Stolzenberg, Westchester's president and chief executive officer.
"Our sorrow is immeasurable and our prayers and thoughts are with the child's family. The medical center will do anything it can to ease the family's grief," Stolzenberg said in the statement.
Meanwhile, on July 31 in Philadelphia, officials at 172-bed St. Agnes Medical Center released a written statement to the news media to report that two patients may have died because of a miscalculation in coagulation studies related to administration of the blood-thinning drug Coumadin. Hospital officials said the error affected 932 patients who had the laboratory tests performed at St. Agnes from June 4 to July 25, and all the patients had been notified.
"Members of the St. Agnes Medical Center hospital family are deeply troubled and saddened," the statement said.
That same afternoon, the hospital's President and CEO Sister Marge Sullivan held a news conference.
Both hospitals notified their respective state health departments as required by law and said they also are conducting their own investigations. They are in touch with the Joint Commission and are working on root-cause analyses as required under the JCAHO's sentinel event policy, said Charlene Hill, a Joint Commission spokeswoman.
Just a few years ago such candor was almost unheard of in most hospital public relations offices. But as much as the Joint Commission would like to take credit for the change of heart, the prominent place medical errors have taken in the nation's newspapers probably played a larger role, said Joe Cappiello, vice president of accreditation field operations for the Joint Commission.
"I think it's raising awareness of the public that hospitals do commit errors and people are injured in our healthcare facilities, and that has put pressure on medical centers to be more forthcoming when errors occur," Cappiello said.
Still, the hospitals went the extra mile by notifying the news media, not just the patients and their families, Cappiello said.
"The (JCAHO) standard would never require them to do this because it's such a complicated thing to stand up in front of the press," Cappiello said. "They really did the right thing and stepped forward."
In Westchester's case, CEO Stolzenberg went further, speaking on Aug. 1 with reporters from the local newspaper for a story published the next day. "We failed miserably with regard to this child," he said.
Westchester's public airing is hardly the norm in New York. Last February, State Health Commissioner Antonia Novello, M.D., called all hospitals to task for failing to report adverse events as required by state law. Compliance was dismal, she said. In one category-reporting patient deaths within 48 hours of surgery-the rate of hospitals complying statewide in 1999 was only 16%. Novello vowed that the state health department would work with hospitals that promptly report their errors, but for those that did not, "we will identify you, single you out and sanction you in a public forum."
Still, public disclosure is "certainly not a requirement for us. We are pleased and (Westchester) has been very cooperative with us," said Robert Kenny, a health department spokesman.
Last week, both hospitals declined to comment beyond the facts.
"We're so in it, we don't have the time to reflect on it," said Carin Grossman, a spokeswoman for Westchester.
Cappiello predicted the hospitals would be rewarded for their forthrightness. Published studies indicate that hospitals' admitting their errors defuses anger, frustration and even legal claims, he said.
"I think only time will tell as to whether this brings the proverbial swarm of trial attorneys down on (St. Agnes)," said Andrew Wigglesworth, president of the Delaware Valley Healthcare Council of the Hospital and Healthsystem Association of Pennsylvania. "At least from some comments I heard from the trial bar, they have begrudging respect for the fact that St. Agnes has come out and said this and been so open and forthright."