Disagreement On How To Stop Serious, Preventable Medical Errors in NH Hospitals

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Below is an excerpt of Part 2 of InDepthNH.org’s three-part series on reducing preventable medical errors in hospitals that cause serious injury or death. They are called “never events” because they are never supposed to happen.

You can link to the full story below.

Part 1 Serious Medical Errors Plague Hospitals in NH

Hospitals are required by law to conduct a root cause analysis on never events to formulate plans to stop them from happening again. But some experts say these types of analysis don’t dig deeply enough.

 Part 3: InDepthNH.org will post How To Protect Yourself on March 2. 


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In 2010, New Hampshire’s hospitals and ambulatory surgery centers reported 42 adverse events and 73 in 2014. They are also called “never events” because they are never supposed to happen.

The 29 reportable events include serious or fatal preventable errors such as surgery on the wrong person or body part, objects left inside a patient after surgery, falls, burns, pressure sores, assaults and sexual assaults.

Dr. Roger Resar, an assistant professor at the Mayo Clinic who also works with the Institute of Healthcare Improvement (IHI), has pioneered ways to reduce or eliminate such errors.

“When it comes to (hospital) patient safety, we are not much better off than we were 10 or 15 years ago,” Resar said.

He was critical of the kinds of typical root cause analysis used in New Hampshire and many other states. By law in New Hampshire, the 29 adverse events must be reported along with a reduction plan to the state Bureau of Licensing and Certification.

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Dr. Roger Resar

“Root cause analyses are a waste of time,” said Resar.

Resar, who still works occasionally as a consultant to hospitals, is a proponent of IHI’s Global Trigger Tool.

The trigger tool is described as “an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time.”

Michael Fleming, the director of the state Bureau of Licensing and Certification and oversees the adverse events reporting, disagreed with Resar on the quality of hospital care today.

“If somebody said to me that hospitals are not safer than they were 10 years ago, that’s not the case,” Fleming said.

Click here for the rest of the story on InDepthNH.org, and to read the DHHS full 2014 Adverse Event Report.


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Nancy WestAbout InDepthNH: Nancy West founded the nonprofit New Hampshire Center for Public Interest Journalism in April. West is the executive editor of the center’s investigative news website, InDepthNH.org. West has won many awards for investigative reporting during her 30 years at the New Hampshire Union Leader. She has taught investigative journalism at the New England Center for Investigative Reporting’s summer program for pre-college students at Boston University. West is passionate about government transparency. The New Hampshire Center for Public Interest Journalism is a member of the Institute for Nonprofit News, formerly called Investigative News Network, which is also InDepthNH.org’s fiscal sponsor. Click here to read about INN to learn more about the mission of nonprofit news.

About this Author

Carol Robidoux

PublisherManchester Ink Link

Longtime NH journalist and publisher of ManchesterInkLink.com. Loves R&B, German beer, and the Queen City!