Hiding mistakes is a bad idea, and definitely contrary to any type of lean or other improvement strategy. You can only improve if you know what you are trying to improve, which means having complete and accurate information about the current process and the problems that are occurring.
Not long ago I wrote about a positive trend among some hospitals to admit mistakes – to patients, amazingly enough – and try to learn from them.
But on the heels of that information comes a disturbing report from the Hartford Courant that information about “adverse events” in Connecticut hospitals is now rarely available, thanks to revisions lobbyists obtained in state law.
The legislature in 2002 ordered hospitals to disclose all serious patient injuries "associated with medical management." But after the first reports were made public, hospital lobbyists persuaded lawmakers to rewrite the statute in 2004, limiting the types of adverse events that must be divulged and promising to keep reports secret unless they led to an investigation.
State health officials had given assurances that the new law would shed more light on serious medical errors. But an analysis of health department records, death certificates, medical examiner reports and lawsuits shows it has had just the opposite effect.
Since the law was revised:
· The state has investigated dramatically fewer adverse-event cases, with about three out of four reported events now closed without a formal inquiry — keeping them hidden from the public — including more than 50 cases in which patients died.
· Narrower reporting requirements have allowed hospitals to keep more medical mistakes secret even from state regulators, with reports to the state immediately dropping by more than half.
· Even after lobbyists pushed for more narrowly defined reporting rules, some believe hospitals still are not reporting all incidents mandated by law, but the state has never attempted to determine whether or not hospitals are complying.
The article, written by Matthew Kauffman and Dave Altimari, notes that mistakes are indeed taking place.
The details of more than a dozen sexual assaults are concealed in the health department's files, along with at least 30 cases in which sponges or other objects were left in patients' bodies after surgery, a Courant analysis has found. Information on hundreds of serious falls is also kept under wraps by the department, as are the particulars of at least half a dozen cases in which newborns died or were seriously injured during childbirth.
I hope the Courant’s article will help prompt a reversal of the changes to the law.