Turning Transparency into Patient Safety

Make public reporting of medical errors and harmful incidents mandatory.

Make full dis­clo­sure a cen­tral pil­lar of the health­care process

A safe patient is an informed patient. In today’s world, that means hav­ing the infor­ma­tion we need to make informed health­care choic­es. Right now, there are too many bar­ri­ers to trans­par­ent infor­ma­tion that place patients at risk. The Cen­ter for Patient  Pro­tec­tion is a cease­less cham­pi­on of greater trans­paren­cy of med­ical infor­ma­tion in all lev­els of our health­care sys­tems.


One of the alarm­ing facts about the epi­dem­ic of hos­pi­tal harm is that too many providers do not, and/or are not required to, report med­ical errors, harm­ful inci­dents or even deaths as a result of break­downs in patient safe­ty. In fact, a report pre­pared by the U.S. Depart­ment of Health and Human Ser­vices’ Office of the Inspec­tor Gen­er­al (OIG) in 2012 found that 6 out of every 7 hospital-based errors, acci­dents, and oth­er adverse events still go unre­port­ed.  Yet patient safe­ty experts rec­og­nize that dis­clo­sure of errors and trans­paren­cy in hos­pi­tal prac­tices is crit­i­cal in cre­at­ing and main­tain­ing an informed health­care pub­lic that can prop­er­ly assess the risks to their health, and in cre­at­ing a cul­ture of patient safe­ty as a result.  


From the Toron­to Star’s inter­view with Kath­leen Fin­lay, June 2019

I’ve been push­ing for greater trans­paren­cy at all lev­els of health care for some time — every­thing from hos­pi­tal safe­ty rat­ings and med­ical error dis­clo­sure to a nation­al data bank for dis­ci­pli­nary actions/decisions involv­ing pro­fes­sion­al mis­con­duct and, impor­tant­ly, sex­u­al abuse of patients.   

I’ve seen a real sea change in recent years in the atti­tudes of patients and fam­i­lies.  They know that being an empow­ered patient leads to bet­ter health care out­comes.  Infor­ma­tion is empow­er­ing. There is a thirst for much more infor­ma­tion at all lev­els of our health care sys­tem. 

No doubt a sun­shine law for physi­cian billings would help open the cur­tains and lead to a bet­ter under­stand­ing of costs and ben­e­fits for one of the largest out­lays of tax­pay­er funds at fed­er­al and provin­cial lev­els.  

But trans­paren­cy also needs to extend to the dis­clo­sure of mon­e­tary and oth­er ben­e­fits from drug com­pa­nies and med­ical device man­u­fac­tur­ers, which can be a sig­nif­i­cant moti­va­tor (from the patient’s per­spec­tive, at any rate) to doc­tors in terms of the deci­sions they make about patient care.

Too much in our health care sys­tem still oper­ates in the shad­ows and behind closed doors. Trans­paren­cy helps to build the trust the sys­tem must have if it’s going to meet the needs of patients and fam­i­lies.  And, to be hon­est, if we don’t get a bet­ter han­dle on where all our health­care dol­lars go — and every­one is able to mea­sure that return — the sys­tem at some point will become unsus­tain­able.  

Time and again, patients and fam­i­lies who encoun­tered med­ical harm report expe­ri­ences of decep­tion and stonewalling by the health­care providers involved.  Often, infor­ma­tion was not dis­closed before the harm occurred (for exam­ple, the risks asso­ci­at­ed with a par­tic­u­lar drug) or there were efforts to cov­er up what actu­al­ly hap­pened.  More gen­er­al­ly, too many hos­pi­tals hide behind a wall that deprives the pub­lic of impor­tant infor­ma­tion which they need to make informed deci­sions about their care and about the per­for­mance of their health­care facil­i­ties.  In every case, when a cur­tain of opaque­ness is allowed to sep­a­rate med­ical facts from those affect­ed, the health­care safe­ty of every­one is placed at risk.

The Cen­ter for Patient  Pro­tec­tion notes that in one land­mark case with which it is famil­iar, an elder­ly Cana­di­an patient was sub­ject­ed to more than 4,000 con­firmed med­ical errors at two Cana­di­an hos­pi­tals over the course of a con­tin­u­ous six-month hos­pi­tal­iza­tion. This is a record for med­ical errors in a hos­pi­tal set­ting which has no par­al­lel in patient safe­ty lit­er­a­ture.  

Yet the hos­pi­tals involved, includ­ing one of Canada’s most promi­nent teach­ing cen­ters in Toron­to, denied that a sin­gle error ever occurred and insist­ed that “all care was appro­pri­ate.” And although the fam­i­ly involved nev­er com­menced or threat­ened legal action, both hos­pi­tals resort­ed to lawyers to con­duct their com­mu­ni­ca­tion.

In Cana­da, hos­pi­tal report­ing of med­ical errors is gov­erned by a patch­work quilt of uneven reg­u­la­tions and prac­tices.  It is impos­si­ble to know, for instance, how many pres­sure ulcers are occur­ring in hos­pi­tals across Cana­da or whether there is a super­bug out­break.  In many cas­es where report­ing is required, hos­pi­tals get to pick and choose what areas they want to report on. There is the added fact, as not­ed pre­vi­ous­ly, that Canada’s hos­pi­tal data — when and where it is made avail­able — is based strict­ly on self-reporting. There is no inde­pen­dent ver­i­fi­ca­tion.

The idea that Cana­da would have an offi­cial sim­i­lar to the U.S. Inspec­tor Gen­er­al for Medicare and Med­ic­aid who could con­duct a review that found sub­stan­tial under­re­port­ing of harm­ful inci­dents in the hos­pi­tal set­ting, and that those find­ings would attract the atten­tion of nation­al leg­is­la­tors, is unthink­able to pol­i­cy lead­ers. The idea that Cana­di­an hos­pi­tals could be finan­cial­ly penal­ized for fail­ing to fol­low cer­tain safe­ty prac­tices, which hap­pens reg­u­lar­ly in the U.S., is equal­ly beyond their com­pre­hen­sion.

It would not be tol­er­at­ed if gov­ern­ments sud­den­ly stopped report­ing pas­sen­ger air­line dis­as­ters, or nev­er required them to be report­ed in the first place.  Do we rely on air­lines or rail­road com­pa­nies to deter­mine what went wrong lead­ing up to a crash or derail­ment, or to decide what infor­ma­tion the pub­lic has a right to know?  Even near-misses must be report­ed in a pub­lic forum.  Such trans­paren­cy is con­sid­ered to be in the pub­lic inter­est.  Between the U.S. and Cana­da, the num­ber of hos­pi­tal deaths from avoid­able harm takes a toll equiv­a­lent to sev­er­al ful­ly loaded jum­bo jets crash­ing every week.  Yet no one real­ly knows pre­cise­ly how many deaths or injuries occur, or why.

All juris­dic­tions need the health­care equiv­a­lent of the U.S. Nation­al Trans­porta­tion Safe­ty Board, which inves­ti­gates major acci­dents that cause death or seri­ous injury involv­ing planes, trains and sur­face trans­porta­tion vehi­cles. Such a body would look into sys­temic risks and sit­u­a­tions involv­ing out­breaks of infec­tions in the hos­pi­tal set­ting. Recur­ring types of med­ical errors would also be sub­ject to inves­ti­ga­tion. Too much harm to patients occurs in the shad­ows and behind closed doors, inhibit­ing the safe­guards that pub­lic aware­ness can pro­vide. 

Patient safe­ty and trans­paren­cy go hand in hand.  A hos­pi­tal that will not acknowl­edge that a med­ical error has occurred, or worse, tries to cov­er it up, is one that will not learn from its mis­takes. And that is a very dan­ger­ous hos­pi­tal. The pub­lic has a right to such infor­ma­tion in order to make an informed deci­sion about what may be life and death mat­ters — and to deter­mine which hos­pi­tals might be con­tribut­ing more to their life, or death.

For this rea­son, and because of the numer­ous expe­ri­ences of harm that have come to its atten­tion, as well as the life-altering per­son­al expe­ri­ence that result­ed in its found­ing, The Cen­ter for Patient  Pro­tec­tion is a vig­or­ous cham­pi­on of changes both in hos­pi­tal cul­ture and in the law that will make health­care sys­tems more trans­par­ent and account­able, includ­ing those that sup­port manda­to­ry report­ing of med­ical errors and harm­ful inci­dents. 

In that regard, we strong­ly urge that providers make health­care records of hos­pi­tal stays avail­able, with­out charge, to patients or appro­pri­ate family-member sub­sti­tute decision-makers.  Research shows that med­ical charts often miss impor­tant events, espe­cial­ly from the patien­t’s per­spec­tive. Informed feed­back from patients and fam­i­lies can serve as a vital learn­ing tool that can sig­nif­i­cant­ly ben­e­fit con­sci­en­tious health­care providers and, ulti­mate­ly, all patients. 

A safe patient is an informed patient. It is tru­ly time for the health­care sys­tem to come out of the shad­ows.

RELATED:

Less to Canada’s “Nev­er” List Than Meets the Eye

Cana­da Needs a Nation­al Hos­pi­tal Rat­ing Sys­tem

How Safe is Your Hos­pi­tal? Canada’s Health­care Sys­tem Should Be More Trans­par­ent Like the U.S.

It’s Time For A Shake­up In Our Health-Care Com­plaints Sys­tem

Kath­leen Fin­lay inter­viewed in the Toron­to Star inves­ti­ga­tion series on doc­tor billing in Ontario.

 

  1. Shin­ing a Light

    From  a  report pre­pared by the Nation­al Patient Safe­ty Foun­da­tion

    From the pub­lic pol­i­cy per­spec­tive, trans­paren­cy is essen­tial for account­abil­i­ty. With­out full infor­ma­tion, nei­ther pol­i­cy mak­ers nor patients can know whether clin­i­cians and their orga­ni­za­tions are deliv­er­ing safe, appro­pri­ate, cost-effective care.

    From the qual­i­ty and safe­ty per­spec­tive, trans­paren­cy is foun­da­tion­al for learn­ing from mis­takes and for cre­at­ing a sup­port­ive envi­ron­ment for patients and health care work­ers. Trans­paren­cy of all safe­ty, qual­i­ty, and cost data is also essen­tial to the effec­tive func­tion­ing of the health care deliv­ery sys­tem. To make informed and cost effec­tive deci­sions, all stakeholders—patients, clin­i­cians, pay­ers, providers, and policymakers—need to have full infor­ma­tion in a form that is use­ful and under­stand­able. If health care sys­tems and clin­i­cians don’t know about fail­ures, they can’t fix them.

    Not only does trans­paren­cy pro­mote account­abil­i­ty and improve­ment, but it lies at the heart of the rela­tion­ship between a patient and his or her clin­i­cian. How can patients ful­ly trust the clin­i­cians and orga­ni­za­tions from which they receive care if these clin­i­cians and orga­ni­za­tions are not ful­ly trans­par­ent?

    With­out trans­paren­cy, informed choice is impos­si­ble for either patients or pay­ers. With­out full, hon­est, open com­mu­ni­ca­tion, patients can­not make informed deci­sions about their care or man­age the result­ing emo­tion­al and phys­i­cal chal­lenges when things go wrong. More­over, trans­paren­cy iden­ti­fies best per­form­ers, allow­ing them to reap the rewards of their strong per­for­mance and allow­ing oth­ers to emu­late their best prac­tices. Patients have a right to full infor­ma­tion about every aspect of their care. With­out it, opti­mal care is an elu­sive dream. 

 

 

 

 

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