Hawaii health care
addresses errors

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By Helen Altonn
haltonn@starbulletin.com

Many Hawaii health care facilities are using the aviation industry as a model in trying to address medical errors, says Richard E. Meiers, Healthcare Association of Hawaii president and chief executive officer.

He said many facilities "are following the aviation industry because they've been there and done this."

"They're studying the way the aviation industry monitors itself, how to get to the root cause of an accident."

All Hawaii hospitals and long-term care facilities have been working hard on error problems since a 1999 Institute of Medicine report estimating medical errors nationally kill up to 98,000 hospital patients annually, Meiers said.

The Joint Commission on Accreditation of Healthcare Organizations, a nonprofit group that monitors about 5,000 hospitals nationwide, now is requiring hospitals to tell patients when they are victims of medical errors.

Under new safety guidelines taking effect tomorrow, hospitals risk losing their accreditation if they do not discuss harmful mistakes with patients.

Three Hawaii health care industry representatives attended a federally funded conference last week in Nashville, Tenn., to look at how states are addressing error problems, Meiers said.

They were Cliff Cisco, Hawaii Medical Service Association senior vice president; Sister Alicia Damien Lau, immediate past chairwoman of the Healthcare Association board and chief executive officer of the Pearl City Nursing Home and Oahu Care Facility; and Rene McWade, corporate counsel, Hawaii Health Systems Corp.

Meiers said he will try to hold a meeting next week to discuss the possibility of establishing an association task force to deal with facility error issues.

He said Hawaii's facilities have "a real good record, but again, we are dealing with human beings.

There could be mistakes. We've got to keep them to a minimum, and when one does happen, we've got to identify what caused it and fix it immediately.

"There has been a tremendous increase in automation and computer online services to help prevent errors, particularly medication errors," he said.

"I'm sure there are errors made out there," he added. "You just want to keep them at ground zero if you can, but there are going to be mistakes."

He said he has not heard of any significant ones, but if any error occurs, "Our facilities are definitely telling patients about that."

They do a "root cause analysis" on any serious problem discovered to find how it happened and they try to determine if it is systemwide, he said. If so, he said, improvements would be made in the system.

"They will also check to make sure there is no domino effect there. Does this error cause two or three other errors to be made? This is a very important part of the process so other patients don't experience the same mistake."

The facilities all have quality councils or patient-safety teams that review errors, do cause analysis and recommend improvements, Meiers said. They also have overall quality councils to review all actions, he said.

"Another issue that's really important, they're trying to develop something within the health care system so people don't worry about getting punished if a mistake is made."

Meiers commended the Joint Commission on Accreditation of Healthcare Organizations for its safety guidelines. "Making it part of the accrediting process is very important. ... No one wants mistakes in the health care system."

Some states are mandating that hospitals report errors to a state agency, Lau said.

Others are considering developing a task force comprised of all acute hospitals, she said. "They're looking at voluntary reporting and making it more constructive, more meaningful, for hospitals ... to really assist each other, both in decreasing medical and medication issues and taking care of quality of care."