An Ounce of Prevention Is Worth a Pound of Cure hellipas Well as a Pound of CashJulie Niezgoda MD

On November 291999 the Institute of Medicine(IOM) released a report that concluded that medi-cal errors may be responsible for as many as 98000

deaths annually at costs up to $29 billion with most of thiscost being shifted to outside payers such as Medicare1

Research conducted by the Harvard School of PublicHealth2 found after examination of 14732 discharge re-cords from 24 hospitals in Colorado and Utah that theaverage cost per injury was $58766 for all adverse eventsand $113280 for negligent injury When evaluating theimpact of medical errors Mello et al2 took into account allcosts that hospitals might be required to bear through thetort liability system inpatient and outpatient care expenseslost income and household productivity future medicalexpenses burial costs for fatal injuries and noneconomiclosses (ie pain and suffering) Mello et al stated that 78of costs associated with all injuries and 70 of costs fornegligent injuries were externalized to outside payers Theyconcluded that there was little financial incentive for hos-pitals to invest in patient safety interventions due to thesmall portion of medical error costs that they had to bearThe authors stated that both medical payment and legalreforms allowing injured parties to pursue compensationfor errors could considerably bolster incentives for hospi-tals to improve safety2

The government responded to the IOMrsquos landmarkreport on medical errors with the Deficit Reduction Act of2005 a that President Bush signed on February 8 2006requiring the Secretary of Health and Human Services(HHS) to identify at least 2 hospital-acquired conditions(HACs) that would be subject to adjustment in payment Asdefined by HHS ldquohospital-acquired conditionsrdquo are thoseconditions that (1) an individual acquires during a stay inthe hospital (2) have a high cost or high volume or both (3)result in the assignment of a case to a diagnosis-relatedgroup that has a higher payment when present as a

secondary diagnosis and (4) could reasonably have beenprevented by adoption and implementation of evidence-based guidelines The conditions were selected from a listof ldquonever eventsrdquo or conditions that had been identified bythe National Quality Forumb in 2002 Never events areserious reportable events that should never have occurredthat could be prevented and that a patient who is a victimof the event should not have to pay forc The Centers forMedicare amp Medicaid Services agreed that never eventswere indeed avoidable and denied reimbursement to hos-pitals for any additional care as a result of these eventsd

The Joint Commission on Accreditation of Healthcare Or-ganizationse supported withholding payment for adverseevents if the following conditions existed (1) evidence thatthe bulk of the adverse events in question could have beprevented by wide spread adoption of achievable practices(2) the events are accurately measurable and auditable and(3) it is possible through chart reviews to differentiate theadverse events that began in the hospital from those thatwere ldquopresent on admissionrdquo

As of July 1 2012 the Centers for Medicare amp MedicaidServices extended Medicarersquos no-pay policy for avoidablehealth conditions to the Medicaid programf The 10 categoriesof preventable medically acquired conditions that Medicaidreduced hospital reimbursement for include the following

bull Foreign object retained after surgerybull Air embolismsbull Blood incompatibilitybull Stage III and IV pressure ulcersbull Falls and traumas that produce fracture dislocations

crushing and other injuriesbull Catheter-associated urinary tract infectionbull Vascular catheterndashassociated infectionbull Manifestations of glycemic control

From the Department of Pediatric Anesthesia Cleveland Clinic ClevelandOH

Accepted for publication July 12 2012

Funding None

The author declares no conflict of interest

Reprints will not be available from the author

Address correspondence to Julie Niezgoda MD Department of PediatricAnesthesia Cleveland Clinic 9500 Euclid Avenue Cleveland OH 44195Address e-mail to niezgojccforg

Copyright copy 2012 International Anesthesia Research SocietyDOI 101213ANE0b013e3182699902

a Deficit Reduction Act Sec 5001 Hospital Quality Improvement Availableat httpwwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalAcqConddownloadsDeficitReductionAct2005pdfb The National Quality Forum (NQF) is a not-for-profit organization createdto develop and implement a national strategy for health care qualitymeasurement and reporting Available at httpwwwqualityforumorgprojectssre2006aspxc The Leapfrog Group ldquoFact Sheet of Never Eventsrdquo Washington DCAvailable at httpwwwleapfroggrouporgmediafileLeapfrog-Never_Events_Fact_Sheetpdf (Internet Document)d CMS Office of Public Affairs ldquoEliminating Serious Preventable and CostlyMedical ErrorsmdashNever Eventsrdquo Thursday May 18 2006 Available athttpwwwcmshhsgovappsmediapressreleaseaspCounter1863

October 2012 bull Volume 115 bull Number 4 wwwanesthesia-analgesiaorg 743

EDITORIAL

bull Surgical site infections following coronary arterybypass grafts bariatric surgery and orthopedicprocedures

bull Deep vein thrombosis or pulmonary embolism aftertotal knee or hip replacement (with pediatric andobstetric exemptions)

Further reductions are slated for 2015 for inpatienthospitals with high volumes of HACs Payments for dis-charges will be reduced to 99 of the amount of paymentthat would otherwise apply to such dischargesg The pay-ment reductions will be applied to hospitals that are in thehighest quartile of national risk-adjusted HACs (ie thosewith the worst performance) This penalty comes on top ofthe existing case-by-case nonpayment for treatment ofHACs or conditions that were not present on admissionThis 1 penalty is intended to provide an incentive forhospitals to reduce HACs

It has traditionally been the ldquogold standardrdquo in medicalspecialties to identify and learn from medical errorsthrough morbidity and mortality conferences after an eventhas occurred These were often ldquoclosed-doorrdquo presenta-tions and subsequent process improvement polices re-mained in the confines of the specialties The outcomeswere not disseminated hospital wide because health careprofessionals had difficulty discussing or admitting toadverse events for fear of administrative blame lawsuitsprofessional censure or personal feelings of self-doubtThis has come full circle to more ldquotransparentrdquo hospitalreporting systems that include internal safety systems thatreduce the likelihood of errors occurring and responding tothe publicrsquos right to know about patient safety Morerecently safety rounds to inquire of hospital personnelldquoWhat in your work place could harm the next patientrdquohave been proactive in standardizing and simplifying sup-plies processes and procedures to ensure safety Physi-cians nurses therapists and pharmacists have becomemuch more alert to safety hazards and are committed tomaking improvements Evidence-based medicine of thesafe practices include 81 reduction of medication errorswith physician computer order entry3 78 reduction ofpreventable adverse drug events with pharmacistsrsquo in-cluded in floor rounds4 cardiac arrests decreased by 15by rapid response teams5 and 90 reduction in medicationerrors by reconciling medications with patients upon hos-pital discharges6

The article in this issue of Anesthesia amp Analgesia byKeidan et al7 is a small randomized clinical trial using a

diluted solution of sodium bicarbonate to confirm IVcatheter placement in 18 mechanically ventilated childrenby observing the increase in end-tidal carbon dioxide Thecomplications of extravasation of both peripheral IV cath-eters and central lines meet the definition of a HAC asdefined by the Department of Health and Human ServicesKeiden et al have described a technique that could reason-ably prevent the complications of a nonfunctioning periph-eral IV line As suggested by the authors further studiesare needed to assess this technique for central venouscatheter placement when the consequences of a misplacedline are much more catastrophic leading to increasedlength of staycosts and decreased patientndashfamily satisfac-tion assessments

Even though anesthesiologists were recognized by theIOM in the report ldquoTo Err is Humanrdquo1 as among the firstphysicians ldquoto improve safety and outcomes for patientsrdquocontinued vigilance to this cause is paramount Futureprogress is needed for the establishment of a new field ofhealth care research a new taxonomy of error and newtools for addressing problems Efforts need to be focusedon multidisciplinary teams of researchers and health carefacilities that support projects aimed at achieving a betterunderstanding of how the environment in which care isprovided affects the ability of providers to implement safepractices There needs to be a paradigm shift from ldquomor-bidity and mortality conferencesrdquo where health care work-ers implement changes after mistakes have happened toldquoprevent and protect conferencesrdquo in which strategies andstudies are designed to recognize prevent and mitigateharm HACs need to be decreased to protect patientsdecrease costs increase patient satisfaction evaluations andultimately equating to improved reimbursements

DISCLOSURESName Julie Niezgoda MDContribution This author wrote the manuscriptAttestation Julie Niezgoda approved the final manuscriptThis manuscript was handled by Peter J Davis MD

REFERENCES1 Kohn LT Corrigan JM Donaldson MS eds To Err Is Human

Building a Safer Health System Washington DC NationalAcademy Press Institute of Medicine 1999

2 Mello MM Studdert DM Thomas EJ Yoon CS Brennan TAWho pays for medical errors An analysis of adverse eventcosts the medical liability system and incentives for patientsafety improvement J Empirical Legal Studies 2007 4835ndash60

3 Bates DW Gawande AA Improving safety with informationtechnology NEJM 20033482526ndash34

4 Kucukarslan SN Peters M Mlynarek M Nafziger DA Pharma-cists on rounding teams reduce preventable adverse drugevents in hospital general medicine units Arch Int Med 20031632014ndash8

5 Landro L The informed patient hospital form lsquoSWATrsquo teams toavert deaths Wall Street J December 1 2004

6 Rozich JD Resar RK Medication safety one organizationrsquosapproach to the challenge JCOM 2001827ndash34

7 Keidan I Ben-Menachem E White SE Berkenstadt H Intrave-nous sodium bicarbonate verifies intravenous position of cath-eters in ventilated children Anesth Analg 2012115909ndash12

e The Joint Commission Journal on Quality and Patient Safety ldquoMedicarersquosDecision to Withhold Payment for Hospital Errors The Devil Is in theDetailsrdquo Oak Brook IL Available at httppsnetahrqgovpublicWacher_JQPS_2008pdff Final rule on payment adjustment for provider-preventable conditionsincluding health caremdashacquired conditions for Medicaid Centers for Medi-care amp Medicaid Services Available at httpwwwfaetorgCMSpdfg The Affordable Care Act (ACA PL 111ndash148 and PL 111ndash152) establishesseveral major changes in Medicare hospital payment policy Available athttpswwwaamcorgadvocacymedicare153882selected_medicare_hospital_quality_provisions_under_the_acahtml

EDITORIAL

744 wwwanesthesia-analgesiaorg ANESTHESIA amp ANALGESIA