Surprising Dangers in the Hospital

When you're admitted to a hospital, you probably don't stop and wonder what your chances are of getting out alive. But the odds are worse than you might imagine-and you can literally save your own life (or that of a loved one) by knowing how to investigate a hospital's record before you're checked in.

Frightening statistics: An estimated 98,000 hospital patients die from medical errors in the US annually. That's more than twice the number of Americans killed in car crashes each year. Many other hospital patients will suffer from serious and preventable-complications. Examples: About one of every 20 hospital patients will develop an infection...and surgeons operate on the wrong body part up to 40 times a week.

Getting the information you need: Because few hospitals publish statistics about their performance, it's difficult for patients to know which ones are worse-in some cases, much worse than average

For advice on avoiding the most common threats to hospital patients, we spoke to Marty Makary, MD, MPH, one of the country's leading experts on hospital safety.

What You Can Find Out

When I've asked patients why they chose a particular hospital, they typically say something like, "Because it's close to home." Others might say, "That is where my doctor has privileges." But those are bad answers. Before you get any medical care in a hospital, you should find out everything you can about the track record of the hospital. Five clues to consider…

Clue #1: Bounceback rate. This is the term that doctors use for patients who need to be rehospitalized within 30 days. A high bounceback rate means that you have a higher-than-average risk for postsurgery complications, such as infection or impaired wound healing. Patients also can look up bounceback rates for conditions such as heart attacks and pneumonia. The rate for a particular procedure should never be higher than the national average.

Why this matters: A high bounceback rate could indicate substandard care or even a lack of teamwork in the operating room. It could also mean that the hospital is discharging patients too soon or that patients aren't getting clear discharge instructions that tell them what to do when they get home.

What to do: Check your hospital's rating on the US Department of Health and Human Services Web site Hospital Compare (www. hospitalcompare.bbs.gov), where the majority of US hospitals are listed. You can see if the bounceback rate is better than, worse than or the same as the national average for the procedure you need.

Hospitals that are serious about reducing readmissions go the extra mile. For example, they will provide patients with detailed instructions on such issues as medication use and proper wound-cleaning procedures. Some even give patients a 24-hour hotline number to call if they have symptoms that could indicate a problem.

Clue #2: Culture of safety. My colleagues and I at Johns Hopkins recently surveyed doctors, nurses and other hospital employees at 60 reputable US hospitals and asked such questions as, "Is the teamwork good?" "Is communication strong?" "Do you feel comfortable speaking up about safety concerns?"

We found a wide variation in the "safety culture" at different hospitals and even within different departments at the same hospital. At one-third of the hospitals, the majority of employees reported that the level of teamwork was poor. Conversely, up to 99% of the staff at some hospitals said the teamwork was good.

Why it matters: Hospitals with a poor safety culture tended to have higher infection rates and worse patient outcomes.

What to do: Few hospitals that have conducted this type of survey make the findings public. Patients have to find other ways to get similar information. To do this, I suggest that before you choose a hospital you ask employees-including nurses and lab technicians-if they'd feel comfortable getting medical care where they work. Even if some hospital employees put a positive spin on their answers, you can generally tell a lot from their demeanor and comfort level when they respond.

Clue #3: Use of minimally invasive procedures. Compared with "open" surgeries, minimally invasive procedures such as knee arthroscopy and "keyhole" gallbladder surgery-require shorter hospitalizations. They're also less painful, less likely to result in an infection and less likely to lead to the need for subsequent surgery.

In spite of this, some surgeons still prefer open procedures. During my training, for example, I worked with a surgeon who was not skilled at minimally invasive surgery. His procedures were always open and involved large incisions-his wound-infection rate was about 20%. But his colleagues, who had trained in the newer minimally invasive techniques, had infection rates that were close to zero.

Why it matters: For the reasons above, you should usually choose a minimally invasive procedure if it's appropriate for your condition.

What to do: When discussing surgery, ask your doctor if there's more than one approach...the percentage of similar procedures that are done in a minimally invasive way...and the percentage that he/she does that way versus the percentage done each way nationwide.

What Your Hospital Knows That You Don't

Here are six things your hospital might not tell you that could hurt you…

• Your surgeon has experience-just not with the operation you require.
  

What to do: Ask your doctor how many times each year he/she performs the operation you need. Be cautious about the surgeon who performs it far less than the average specialist in the field would.

• You can't trust marketing claims.
  

What to do: The hospital's advertised "number-one ranking might be restricted to a very specific measure or malady that has little to do with your needs. Go to www. hospitalcompare.hhs.gov for unbiased info. .You might be better off going to your local community hospital than a prestigious research hospital.

What to do: Lean toward prestigious reSearch hospitals if you have a high-riek or complex condition such as cancer or a high-risk pregnancy...but toward well-regarded community hospitals for routine conditions.

• You're probably better off with a doctor who doesn't seem omniscient.
  

What to do: Raise the topic of seeking a second opinion with your doctor. It's a good sign if he encourages this...a bad sign if he becomes defensive.

• Doctors recommend the procedures that they know best, not the ones that are best for you.
  

What to do: Do a Web search for the name of the operation you require, along with the words "minimally invasive." If there is a minimally invasive alternative that your doctor didn't mention, ask him/her about it. Seek a second opinion (see CLUE #3 on this page).

• The hospital's plastic surgeons may have little or no training in plastic surgery.
  

What to do: Confirm that a plastic surgeon is certified by the American Board of Plastic Surgery (www.abplsurg.org).

Important: Get a second opinion before undergoing any ongoing or extensive treatment, including surgery. About 30% of second opinions are different from the first one.

Clue #4: Volume of procedures. "See one, do one, teach one is a common expression in medical schools. The idea is that new doctors have to start somewhere to learn how to perform medical procedures. Don't let them start on you.

Why it matters: Surgical death rates are directly related to a surgeon's experience with that procedure. The death rate after pancreas surgery, for example, is 14.7% for surgeons who average fewer than two procedures a year. It is 4.6% for those who do four or more. A survey conducted by the New York State Department of Health found that hospitals with surgeons who did relatively few procedures had patient-mortality rates that were four times higher than the state average.

What to do: Ask your doctor how often he does a particular procedure. For nonsurgical care, ask how many patients with your condition he treats.

Helpful: If 50% or more of a doctor's practice is dedicated to patients with exactly your condition, he will probably be a good choice.

Clue #5: The availability of "open notes." Doctors make detailed notes after every office visit, but many patients have never seen these notes. Hospitals may not make them easily available, or the office/hospital can make it difficult (or expensive) to get copies.

Why it matters: Transparency builds trust. Patients who know what's in their medical records will not have to wonder what the doctor is writing about them.

Patients who read the notes will remember details about treatment advice...ask questions if they are confused.. and often correct errors that can make a difference in their diagnosis and/or treatment. Also, these records are needed for a second opinion.

I purposely dictate notes while my patients are still in my office sitting next to me. Once, I was corrected when I said that a prior surgery was on the left side- it was actually on the right side. Another patient corrected me when I noted a wrong medication dose. Another reminded me to mention a history of high blood pressure.

What to do: Get copies of all of your medical records, including test results. If your doctor or hospital refuses to share them, ask to speak to an administrator. The records are yours-you have a right, under federal law, to see them and get copies. Fees range from a few dollars for a few pages to hundreds of dollars for extensive records.

Extra Help When Picking a Hospital

When you meet hospital workers in your community, ask which hospital they would choose if they needed care. A recent survey conducted at 60 reputable US hospitals found that in one-third of them, half or more of health-care workers would not feel comfortable receiving medical care in the unit in which they work.