Navigating the Health Care System

AHRQ Director Carolyn Clancy, M.D., has prepared brief, easy-to-understand advice columns for consumers to help navigate the health care system. They will address important issues such as how to recognize high-quality health care, how to be an informed health care consumer, and how to choose a hospital, doctor, and health plan. Check back regularly for new columns.

Dr. Clancy, a general internist and researcher, is an expert in engaging consumers in their health care.

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Dr. Clancy's columns and other health information also are available from AARP.

Payment Change Puts Spotlight on Preventing Hospital Errors

By Carolyn M. Clancy, M.D.

October 21, 2008

Patients don't go into the hospital thinking they might get sicker because of the care they've received. But medical errors or lapses in care that harm patients happen. They occur despite the hard work many doctors, nurses, and hospitals have done to develop better ways of delivering care.

Medical errors take a big toll and can happen anywhere. One study found that mistakes cost insurers $9.3 billion in extra charges and caused 32,600 patient deaths each year. Medical errors happen in small hospitals and in big ones, including some of the best-known medical centers in the United States.

To address this problem, the Federal Government created a new rule. Starting October 1, it will no longer pay hospitals for the extra costs they charge when patients who are covered by Medicare (the Government health plan for people 65 years and older) develop some conditions as a result of the hospital's care. Patients cannot be billed for the costs of these conditions, either.

This first-ever list of "hospital-acquired conditions" includes events that can be sharply reduced or even eliminated, according to research by my Agency, the Agency for Healthcare Research and Quality. They are:

• Infection following certain kinds of surgery, including some orthopedic surgeries and surgery for obesity.
• Blood clots or embolism that develop after knee and hip replacement procedures.
• Mixing up blood types.
• Air embolism (an air bubble in the blood stream).
• Serious pressure ulcers (or bed sores caused by infrequent changes of position for bed-ridden patients).
• Some falls and traumas.
• Signs of poor blood glucose sugar control.
• Urinary tract infections caused by catheters.

This new rule follows a trend that many private insurers are also putting into place. In 2007, for example, hospitals and insurers in Minnesota agreed that patients and health plans should not pay for any care described as a "never event" by a major health group. Two examples of these events are surgery performed on the wrong patient or on the wrong body part. Soon after, the national Blue Cross and Blue Shield group said that its 39 health plans will work to end payments for these serious patient events.

Because medical errors still occur, you may wonder if we know enough about how to prevent them from happening. I believe we do.

Let me give an example. About 1 million cases of urinary tract infections that are due to catheters (often used during and after surgery) occur each year in U.S. hospitals. These infections can cause longer hospital stays, more serious infections, and even death. Research my Agency supported has shown that limiting the use of catheters to 3 days can sharply reduce the risk of these infections. Computer-based reminders about the 3-day timeframe are an effective way to help doctors and nurses follow this practice.

Another example is preventing a type of blood clot that forms in deep veins in the body, called deep vein thrombosis (DVT). A DVT can be deadly if it breaks off and blocks blood flow. Hospitals and clinicians can prevent many DVTs by taking specific steps.

A new guide from AHRQ helps hospitals and clinicians put procedures in place that can prevent dangerous blood clots. It explains how to start, evaluate, and maintain a prevention program and offers examples of successful ones that are already in place.

A new booklet for patients on how to prevent and treat blood clots is also available. In clear, easy-to-read language, the guide explains the symptoms of blood clots, offers tips on how to prevent them, and describes what to expect during treatment.

For many years, I have argued that following scientifically tested procedures can reduce or even eliminate many medical errors or lapses in care. It's time that we put our knowledge into our day-to-day care for patients.

I'm Dr. Carolyn Clancy, and that's my advice on how to navigate the health care system.

More Information

Agency for Healthcare Research and Quality
Preventing Hospital-Acquired Venous Thromboembolism
http://www.ahrq.gov/qual/vtguide/
AHRQ Publication No. 08-0075. Rockville, MD. August 2008.

Agency for Healthcare Research and Quality
Your Guide to Preventing and Treating Blood Clots
http://www.ahrq.gov/consumer/bloodclots.htm
AHRQ Publication No. 08-0058-A. Rockville, MD. August 2008.

Agency for Healthcare Research and Quality
10 Patient Safety Tips for Hospitals
http://www.ahrq.gov/qual/10tips.htm
AHRQ Publication No. 08-P003. Rockville, MD. Revised October 2007.

Centers for Medicare and Medicaid Services
Hospital-Acquired Conditions
http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp

National Quality Forum
Serious Reportable Events: Transparency and Accountability are Critical to Reducing Medical Errors
http://www.qualityforum.org/projects/completed/sre/fact-sheet.asp

Current as of October 2008

Internet Citation:

Payment Change Puts Spotlight on Preventing Hospital Errors. Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy, October 21, 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/cc/cc102108.htm