Hospital ownership and preventable adverse events

Incidence and risk factors of adverse events in pediatric hemato-oncological patients: A cohort study

BACKGROUND

Pediatric hemato-oncological (HO) patients are highly susceptible to the occurrence of adverse events (AE), nevertheless few research has been done in this field. Our aim was to describe the incidence, type, severity and preventability of AE in these patients, including bone marrow transplant (BMT) patients, and to identify patient's risk factors for having an AE.

METHODS

Retrospective cohort study. Children under 18yo hospitalized at the HO or BMT ward in 2016 were eligible for the study. Type of AE, severity and preventability were described as absolute and relative frequencies. Cumulative incidence of patients with at least one AE (CI_AE) and the rate of occurrence of all AE were calculated. Risk factors (sex, recovery probability, comorbidities and being a BMT patient) were analyzed using logistic regression.

RESULTS

114 patients were included, 58% were male, average age was 8.7yo and 25 were BMT patients. 44 had at least one AE, with CI_AE of 38.6% (95%CI 29.7-47.5). Overall rate of occurrence of AE was 2.5 cases per 100 patients-day (95%CI 2.15-2.98). For BMT and non-BMT patients they were 2.8 (95%CI 2.2-3.6) and 2.5 (95%CI 1.98-3.1) respectively. Healthcare related infection was the most frequent AE. Most AE were moderate and with high preventability. Being a BMT patient was the only independent factor associated with the occurrence of at least one AE (OR=11.5, p<0.001).

CONCLUSIONS

Our findings suggest that AE tend to be moderate and preventable in HO pediatric patients. BMT patients seem to be at greater risk of having an AE. Strategies focused on patient safety need to account for their specific characteristics.

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.

CONTEXT

The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.

METHODS

Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.

FINDINGS

Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.

CONCLUSIONS

Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis

BACKGROUND

The interpretation of the results of prior studies on the association of hospital teaching status with surgical outcomes is limited by selection bias. We investigated whether undergoing surgical operations in teaching hospitals is associated with improved outcomes.

METHODS

We performed a cohort study of all patients undergoing spine and cranial operations who were registered in the New York Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of teaching status (defined as academic affiliation for the primary analysis) with inpatient case fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and to simulate the effect of a randomized trial.

RESULTS

During the study period, 186,483 patients underwent surgical operations that met the inclusion criteria. Instrumental variable analysis demonstrated that hospitalization in teaching hospitals was associated with higher rates of case fatality (adjusted difference, 25%; 95% confidence interval [CI], 4%-46%), discharge to a facility (adjusted difference, 5.7%; 95% CI, 4.5%-7.0%), and longer LOS (adjusted difference, 31.4%; 95% CI, 16.0%-46.1%) in comparison with nonteaching hospitals. The same associations were present in propensity score adjusted mixed effects models. These persisted in prespecified subgroups stratified on particular operations and for different definitions of teaching hospitals.

CONCLUSIONS

Using a comprehensive all-payer cohort of surgical patients in New York State, we identified an association of treatment in teaching hospitals with increased case fatality, rate of discharge to rehabilitation, and longer LOS. Further research into the factors contributing to superior outcomes in nonteaching institutions is warranted.

The impact of complications and errors on surgeons

Do surgeons need support – and, if so, what kind?

Adaptation and validation of an adverse drug reaction preventability score for bleeding due to vitamin K antagonists

Although drug therapy is inherently associated with the risk of adverse drug reactions (ADRs), some of these events are preventable. The estimated proportion of preventable ADRs varies from one study or clinical context to another. Bleeding caused by antithrombotic agents (and particularly vitamin K antagonists, VKAs) constitutes one of the most frequent causes of ADR-related hospitalization.Hence, the objective of the present study was to adapt and validate an ADR preventability score for bleeding due to VKAs and evaluate the preventability of bleeding in 906 consecutive hospitalized, VKA-treated adult patients with a risk of major bleeding (defined as an international normalized ratio ≥5) over a 2-year period. A specific preventability scale for VKA-associated bleeding was developed by adapting a published tool.Overall, 241 of the 906 patients in the study experienced at least 1 VKA-associated bleeding event. The scale's reliability was tested by 2 different evaluators. The inter-rater reliability (evaluated by calculation of Cohen's kappa) ranged from "good" to "excellent." Lastly, the validated scale was used to assess the preventability of the VKA-associated bleeding. We estimated that bleeding was preventable or potentially preventable in 109 of the 241 affected patients (45.2%).We have developed a useful, reliable tool for evaluating the preventability of VKA-associated bleeding. Application of the scale in a prospective study revealed that a high proportion of VKA-associated bleeding events in hospitalized, at-risk adult patients were preventable or potentially preventable.

Mortality, length of stay, and inpatient charges for heart failure patients at public versus private hospitals in South Korea

PURPOSE

This study compared in-hospital mortality within 30 days of admission, lengths of stay, and inpatient charges among patients with heart failure admitted to public and private hospitals in South Korea.

MATERIALS AND METHODS

We obtained health insurance claims data for all heart failure inpatients nationwide between November 1, 2011 and May 31, 2012. These data were then matched with hospital-level data, and multi-level regression models were examined. A total of 8406 patients from 253 hospitals, including 31 public hospitals, were analyzed.

RESULTS

The in-hospital mortality rate within 30 days of admission was 0.92% greater and the mean length of stay was 1.94 days longer at public hospitals than at private hospitals (mortality: 5.18% and 4.26%, respectively; LOS: 12.08 and 10.14 days, respectively). The inpatient charges were 11.4% lower per case and 24.5% lower per day at public hospitals than at private hospitals. After adjusting for patient- and hospital-level confounders, public hospitals had a 1.62-fold higher in-hospital mortality rate, a 16.5% longer length of stay, and an 11.7% higher inpatient charge per case than private hospitals, although the charges of private hospitals were greater in univariate analysis.

CONCLUSION

We recommend that government agencies and policy makers continue to monitor quality of care, lengths of stay in the hospital, and expenditures according to type of hospital ownership to improve healthcare outcomes and reduce spending.

Assessment of surgical training

BACKGROUND

The patient safety imperative has raised expectations regarding the responsibility of medical educators and decision makers to ensure that physicians are competent. Ensuring that trainees are ready for independent practice upon graduation is challenged by reduced work hours such that trainees spend less time in the OR and perform fewer cases than desirable.

METHODS

The literature on the assessment of technical and non--technical operative skills and professionalism was reviewed in order to make recommendations to identify barriers to evaluation.

DISCUSSION

Barriers to documenting performance deficiencies include uncertainty as to what should be documented, and concerns about the negative impact of critical evaluations on faculty popularity. Additional challenges include a lack of clear standards for performance and effective remediation options.

CONCLUSIONS

Trainee performance should be evaluated in a rigorous, reliable and meaningful way to ensure that graduates have the skills necessary for safe, independent practice.

Characterization of municipal solid waste temporary storage sites: risks posed to surrounding areas as a consequence of fire incidents

In this study temporary storage sites of municipal solid waste were characterized based on their potential social, health and environmental impacts as a consequence of spontaneous fires, by employing Boolean as well as weighted-linear-combination approaches in connection with various fuzzy set functions of population density around the storage sites. Sweden was used as the case study and data from 105 storage sites were analysed; of these, 38 were identified to be posing high risk for downwind residing population. Furthermore, during the past 10years, the fire frequency and the average population residing within a radius of 1, 2, and 3km were found to be comparatively higher for storage sites owned by private companies than for those owned by municipalities. The study provided first-cut information of poorly sited temporary storage sites and can help in formalizing the comprehensive risk analysis in the future.

Hospital ownership type and treatment choices

In the face of increasing health care costs, taxing not-for-profit hospitals may be seen as the right choice to increase government revenues if not-for-profit hospitals are not different from their for-profit counterparts. This study investigates how hospital ownership type affects treatment choices to show whether ownership type and teaching status are correlated with choosing a procedure as the treatment and how these choices relate to patient insurance type. Not-for-profit hospitals significantly differ from for-profits in terms of treatment choices of less profitable patients and all hospitals are more likely to accord the procedure when the patient is privately insured than uninsured though teaching government hospitals are the most likely to accord the procedures for all insurance types. Considering treatment choices, not-for-profit hospitals have different objectives than for-profit and government hospitals and in terms of profit-seeking behavior, not-for-profit hospitals seem to lie between for-profit and government hospitals.

Cost implications of ACGME's 2011 changes to resident duty hours and the training environment

BACKGROUND

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates.

OBJECTIVES

To estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs.

DESIGN

A decision-analytical model represented direct costs and PAE rates, mortality, and costs.

DATA SOURCES

Published literature and publicly available data.

TARGET POPULATION

Patients admitted to hospitals with ACGME-accredited programs.

TIME HORIZON

One year.

PERSPECTIVES

All teaching hospitals, major teaching hospitals, society.

INTERVENTION

ACGME's 2011 Common Program Requirements.

OUTCOME MEASURES

Direct annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society). RESULTS OF BASE-ANALYSIS: Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2-25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be -$523,000 (95%-confidence interval: -$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society.

RESULTS OF SENSITIVITY ANALYSIS

The total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes.

LIMITATIONS

The effect on PAEs is unknown. Data were limited for some model parameters.

CONCLUSION

Implementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.

A systematic review of the extent, nature and likely causes of preventable adverse events arising from hospital care

BACKGROUND

Understanding the nature and causes of medical adverse events may help their prevention. This systematic review explores the types, risk factors, and likely causes of preventable adverse events in the hospital sector.

METHODS

MEDLINE (1970-2008), EMBASE, CINAHL (1970-2005) and the reference lists were used to identify the studies and a structured narrative method used to synthesise the data.

RESULTS

Operative adverse events were more common but less preventable and diagnostic adverse events less common but more preventable than other adverse events. Preventable adverse events were often associated with more than one contributory factor. The majority of adverse events were linked to individual human error, and a significant proportion of these caused serious patient harm. Equipment failure was involved in a small proportion of adverse events and rarely caused patient harm. The proportion of system failures varied widely ranging from 3% to 85% depending on the data collection and classification methods used.

CONCLUSION

Operative adverse events are more common but less preventable than diagnostic adverse events. Adverse events are usually associated with more than one contributory factor, the majority are linked to individual human error, and a proportion of these with system failure.

Medication error reporting and the work environment in a military setting

This study examined nurses' reasons for medication errors, reasons for not reporting errors, and perceived unit-reporting practices. It compared nurses' anonymous reports of medication errors with those from institutional reporting mechanisms. Qualities of the work environment, staffing, and workload were evaluated to determine associations with perceived error-reporting practices. The study findings have immediate applicability as a baseline for system improvements.

Cost implications of reduced work hours and workloads for resident physicians

BACKGROUND

Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.

METHODS

We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.

RESULTS

Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.

CONCLUSIONS

Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.

Physician-attributable differences in intensive care unit costs: a single-center study

RATIONALE

Variation in practice and outcomes, not explained by patient or illness characteristics, is common in health care, including in intensive care units (ICUs).

OBJECTIVE

To quantify within-ICU, between-physician variation in resource use in a single medical ICU.

METHODS

This was a prospective, noninterventional study in a medical ICU where nine intensivists provide care in 14-d rotations. Consecutive sample consisted of 1,184 initial patient admissions whose care was provided by a single intensivist. Multivariate models were constructed for average daily discretionary costs, ICU length of stay, and hospital mortality, adjusting for patient and illness characteristics, and workload.

MEASUREMENTS AND MAIN RESULTS

The identity of the intensivist was a significant predictor for average daily discretionary costs (p < 0.0001), but not ICU length of stay (p = 0.33) or hospital mortality (p = 0.83). The intensivists had more influence on costs than all other variables except the severity and type of acute illness. Average daily discretionary costs varied by 43% across the different intensivists, equating to a mean difference of 1,003 dollars per admission between the highest and lowest terciles of intensivists.

CONCLUSIONS

There are large differences among intensivists in the amount of resources they use to manage critically ill patients. Higher resource use was not associated with lower length of stay or mortality.

Patient safety problems in adolescent medical care

PURPOSE

This study estimates the annual incidence and describes the nature, types, and contributing factors involved in patient safety problems in adolescent medical care.

METHODS

This study uses data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents and "critical incidence analysis" data reported by pediatric clinicians to elucidate the nature, types, and contributing factors in adolescent patient safety problems.

RESULTS

The incidence of adverse events in adolescents in the Colorado and Utah Medical Practice Study was 2.74 (CI 95% = 2.62-2.86), significantly higher than all other age groups of children. The incidence of preventable adverse events in adolescents was 0.95 (CI 95% = 0.65-1.25), significantly higher than that of children 1-12 years old, but not significantly different than infants. Diagnostic events were most common, followed by medication events. Services associated with the highest frequency of events were pharmacy and Family Practice. In the critical incident analysis, adolescent-specific factors contributed to 54.8% of the described patient safety problems. Discomfort with adolescents, a factor not described for other age groups of children, contributed to 17% of the adolescent patient safety problems.

CONCLUSIONS

Adolescents experience relatively high rates of patient safety problems compared with other age groups of children. Adolescents represent a defined population with a patient safety risk profile that differs from adults and younger children. The substantial contribution of adolescent-specific factors suggests that patient safety improvements, to be effective, should address adolescent-specific risks.

The postoperative hemorrhage and hematoma patient safety indicator and its risk factors

This study employed a retrospective cohort analysis using New York State's Statewide Planning and Research Cooperative System (SPARCS) to improve the Patient Safety Indicator (PSI) definition of postoperative hemorrhage/hematoma (POHH) and to identify patient risk factors associated with POHH. Study participants were nonobstetric, inpatient surgical admissions in SPARCS and readmissions within 30 days with a principal diagnosis of POHH. The main outcome measures were mortality rate, length of stay, and readmissions. The mortality rates of events identified by a secondary diagnosis only and by the PSI were not significantly different. The number of POHH events increased by 9.3% when readmissions were captured. The PSI definition of POHH may need modification to capture events with no secondary procedure. The PSI misses events identified on readmission, but the consequences of these events are not as severe as those currently captured. A variety of patient and hospital characteristics are predictive of a higher risk of POHH.

Improving the ICU: part 1

ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.

Quality of care in teaching hospitals: a literature review

PURPOSE

To compare the quality of care in teaching hospitals with that in nonteaching hospitals.

METHOD

By performing a literature review via PubMed, the author identified and surveyed 23 studies that compared the quality of care in teaching hospitals with that in nonteaching hospitals. The studies were published from 1989-2004 and in all but one case dealt exclusively with U.S. hospitals.

RESULTS

The teaching hospitals studied had better-quality measures than did nonteaching hospitals in the predominant number of studies reviewed. Process measures were significantly better in teaching hospitals in seven of the eight studies where such measures were observed, and equal in the other study. Risk-adjusted mortality was lower in teaching hospitals in nine of the 15 studies using that measure, not significantly different in five, and significantly lower in nonteaching hospitals in one study (in pediatric intensive care units, even though the teaching hospitals had a better process of care). In nonmortality outcomes, teaching hospitals were better in one study using that measure; there were no significant differences in five other such studies. Major teaching hospitals had more favorable outcomes end points than did minor teaching hospitals in eight studies in which they were compared. Including only those six studies using clinical data for process analysis or risk adjustment, teaching hospitals had a better process in all six and lower adjusted mortality in five of seven studies where that measure was used.

CONCLUSIONS

Overall, the favorable results in teaching hospitals extended over a range of locations, conditions, and populations, including routine as well as complex conditions. However, the quality measured in these studies was not at target levels across the spectrum of hospitals. There needs to be a continuous and determined effort for improvement in all institutions. It is to be hoped that teaching hospitals will take the lead not only in continuously improving their own quality, but also in developing and evaluating ever improving methods of quality assessment.

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions

PURPOSE

To identify the frequency and type of iatrogenic medical events requiring admission to an intensive care unit. To assess the consequences of iatrogenic medical events for patients and institutions. To assess the prevalence of disclosure of iatrogenic medical events to patients, surrogates, and institutions.

METHODS

The project on Care Improvement for the Critically Ill enrolled 5727 patients to 8 intensive care units at 4 Boston teaching hospitals. To determine the nature, consequences, and disclosure of iatrogenic medical events, we did a retrospective chart review on all patients whose admission to an intensive care unit was precipitated by an iatrogenic event.

RESULTS

Sixty-six patients (1.2 %) were identified by an intensive care unit's clinical team as having an iatrogenic medical event as the primary reason for admission to the unit. The majority (29, or 45%) of iatrogenic medical events were secondary to technical error, but a high percentage (21, or 33%) was due to iatrogenic drug events. Twenty-two (34%) cases were assessed by the investigators to have been preventable. In 60 (94%) cases there was no documentation in the patient's chart of communication to the patient regarding the reason for admission to the intensive care unit. In 11 (17%) cases there was documentation of a discussion with the surrogate about the reason for admission to the unit. In only 3 (5%) cases was there documentation that the patient or surrogate was informed that an iatrogenic medical event was the reason for admission to the intensive care unit. Incident reports or malpractice claims were filed in only 4 (6 %) cases.

CONCLUSION

The frequency of iatrogenic medical events resulting in admission to intensive care units is lower than previous studies have reported. Iatrogenic drug events continue to be an important source of error. A considerable percentage of iatrogenic events may be preventable. Health care professionals rarely document disclosure of iatrogenic events to patients and surrogates.

The evolving science of quality measurement for hospitals: implications for studies of competition and consolidation

The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. We describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.

Does the ownership of the admitting hospital make a difference? Outcomes and process of care of Medicare beneficiaries admitted with acute myocardial infarction

BACKGROUND

Concerns have been expressed about quality of for-profit hospitals and their use of expensive technologies.

OBJECTIVE

To determine differences in mortality after admission for acute myocardial infarction (AMI) and in the use of low- and high-tech services for AMI among for-profit, public, and private nonprofit hospitals.

STUDY DESIGN, SETTING, AND PATIENTS

Cooperative Cardiovascular Project data for 129,092 Medicare patients admitted for AMI from 1994 to 1995.

MAIN OUTCOME MEASURES

Mortality at 30 days and 1 year postadmission; use of aspirin, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers at discharge, thrombolytic therapy, catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft (CABG) compared by ownership.

RESULTS

Mortality rates at 30 days and at 1 year at for-profit hospitals were no different from those at public and private nonprofit hospitals. Without patient illness variables, nonprofit hospitals had lower mortality rates at 30 days (relative risk [RR], 0.95; 95% confidence interval [CI], 0.91-0.99) and at 1 year (RR, 0.96; 95% CI, 0.93-0.99) than did for-profit hospitals, but there was no difference in mortality between public and for-profit hospitals. Beneficiaries at nonprofit hospitals were more likely to receive aspirin (RR, 1.04; 95% CI, 1.03-1.05) and ACE inhibitors (RR, 1.05; 95% CI, 1.02-1.08) than at for-profit hospitals, but had lower rates of PTCA (RR, 0.91; 95% CI, 0.86-0.96) and CABG (RR, 0.93; 95% CI, 0.86-1.00).

CONCLUSIONS

Although outcomes did not vary by ownership, for-profit hospitals were more likely to use expensive, high-tech procedures. This pattern appears to be the result of for-profit hospitals' propensity to locate in areas with demand for high-tech care for AMI.

Analysis of errors reported by surgeons at three teaching hospitals

BACKGROUND

Little is known of the factors that underlie surgical errors. Incident reporting has been proposed as a method of obtaining information about medical errors to help identify such factors.

METHODS

Between November 1, 2000, and March 15, 2001, we conducted confidential interviews with randomly selected surgeons from three Massachusetts teaching hospitals to elicit detailed reports on surgical adverse events resulting from errors in management ("incidents"). Data on the characteristics of the incidents and the factors that surgeons reported to have contributed to the errors were recorded and analyzed.

RESULTS

Among 45 surgeons approached for interviews, 38 (84%) agreed to participate and provided reports on 146 incidents. Thirty-three percent of incidents resulted in permanent disability and 13% in patient death. Seventy-seven percent involved injuries related to an operation or other invasive intervention (visceral injuries, bleeding, and wound infection/dehiscence were the most common subtypes), 13% involved unnecessary or inappropriate procedures, and 10% involved unnecessary advancement of disease. Two thirds of the incidents involved errors during the intraoperative phase of surgical care, 27% during preoperative management, and 22% during postoperative management. Two or more clinicians were cited as substantially contributing to errors in 70% of the incidents. The most commonly cited systems factors contributing to errors were inexperience/lack of competence in a surgical task (53% of incidents), communication breakdowns among personnel (43%), and fatigue or excessive workload (33%). Surgeons reported significantly more systems failures in incidents involving emergency surgical care than those involving nonemergency care (P <.001).

CONCLUSIONS

Subjective incident reports gathered through interviews allow identification of characteristics of surgical errors and their leading contributing factors, which may help target research and interventions to reduce such errors.

A national profile of patient safety in U.S. hospitals

Measures based on routinely collected data would be useful to examine the epidemiology of patient safety. Extending previous work, we established the face and consensual validity of twenty Patient Safety Indicators (PSIs). We generated a national profile of patient safety by applying these PSIs to the HCUP Nationwide Inpatient Sample. The incidence of most nonobstetric PSIs increased with age and was higher among African Americans than among whites. The adjusted incidence of most PSIs was highest at urban teaching hospitals. The PSIs may be used in AHRQ's National Quality Report, while providers may use them to screen for preventable complications, target opportunities for improvement, and benchmark performance.

Teaching hospitals and quality of care: a review of the literature

Because teaching hospitals face increasing pressure to justify their higher charges for clinical care, the quality of care in teaching and nonteaching hospitals is an important policy question. The most rigorous peer-reviewed studies published between 1985 and 2001 that assessed quality of care by hospital-teaching status in the United States provide moderately strong evidence of better quality and lower risk-adjusted mortality in major teaching hospitals for elderly patients with common conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. A few studies, however, found nursing care, pediatric intensive care, and some surgical outcomes to be better in nonteaching hospitals. Some factors related to teaching status, such as organizational culture, staffing, technology, and volume, may lead to higher-quality care.

Ethics and communication: does students' comfort addressing: ethical issues vary by specialty team?

Ethics education aims to train physicians to identify and resolve ethical issues. To address ethical concerns, physicians may need to confront each other. We surveyed medical students to determine if their comfort challenging members of their ward teams about ethical issues varies by specialty and what attributes of students and their teams contributed to that comfort. Compared to other specialties, students felt significantly less comfortable challenging team members about ethical issues on surgery and obstetrics/gynecology. We suggest that ethics education must address the atmosphere on ward teams and give students skills to help them speak out despite their discomfort.

Fatal distraction: finance versus vigilance in U.S. hospitals

Three decades ago, a now classic study on the sale of human blood defied conventional economic wisdom by demonstrating that a marketplace system for blood distribution was less efficient, less safe, and more costly. Emerging data, including the article by Thomas and colleagues in this issue, suggest the same may be true for hospitals. For-profit hospitals in Utah and Colorado had higher preventable adverse event rates than matched nonprofits. The author explores possible explanations, including the role of nursing care. While some claimed that a for-profit marketplace would stimulate efforts for improved quality, evidence is accumulating that report cards and profit-driven competition have failed to deliver on their promises. More promising is a series of not-for-profit initiatives to reduce errors that redirects our attention to patients and their need for better quality care. Rather than allowing competition to lower costs and avoid sick patients to distract us, our energies need to focus on better quality alternatives.