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Empty Promises:
The Failure of the New York State Health Department to Monitor Medical Errors
New York State's Failure to Adequately Protect Patients
Executive Summary
It has been a little over five years since the release of the National Academy of Sciences’ Institute of Medicine’s (IoM) landmark report, To Err is Human. Authored by a prestigious group of national experts in patient safety and quality improvement, the report documented for the first time the staggering number of medical errors occurring in the nation’s hospitals. The IoM estimated that between 44,000 and 98,000 patients die each year in U.S. hospitals as a result of medical errors, many of which are preventable. The report also stated that the nation spends as much as $29 billion in treating those injured by medical mistakes.
The IoM recommended that the nation work to cut in half the number of medical errors in hospitals within five years. On January 24, 2000, Health Commissioner Novello pledged to meet that goal in New York State.
Five years later, there is no evidence that such progress has been made, and in fact, the Department has no program in place that measures the frequency and severity of medical errors occurring in the licensed healthcare facilities it oversees. It is that failure to monitor the safety and quality of the New York State health care system that is at the heart of our criticism of the Department.
During the past five years the medical and hospital lobbies have ratcheted up their rhetoric over what they claim is a “malpractice crisis” that purportedly is putting health providers out of business. While there is little or no evidence to back up these claims, policymakers continue to be deluged by dire warnings of the impact of this “crisis” on New Yorker’s access to health care. As recently as last week, at hearings on reauthorization of the Health Care Reform Act (HCRA), legislators were besieged with “doom and gloom” predictions of hospital closures and loss of health care services.
In their efforts to advance legislation that would limit the legal rights of the most seriously injured patients, it is noteworthy that there is no mention of the health care system’s failure to make patient safety a priority. A safer health care system would substantially reduce the amount of malpractice that occurs – reducing harm and the cost of insurance – a “win-win” for both patients and providers.
Billions of public dollars are spent on the delivery of health care services through HCRA funding mechanisms; yet as the state begins to debate how to allocate HCRA funds for the next few years, it does not have oversight programs that would ensure that the public’s money purchases safe, high-quality care. It is simply inexcusable that five years after the IoM report and Commissioner Novello’s empty promise, New York is poised to once again spend billions of dollars on health care, while ignoring an epidemic of medical errors.
This report examines the state of hospital patient safety in New York and the action (or more accurately, inaction) of the New York State Health Department to safeguard consumers. This report finds that the Health Department has failed to deliver on the Commissioner’s promise in 2000 to reduce medical errors and, in fact, cannot even tell New Yorkers whether they are any safer today than five years ago.
Specifically, this report finds:
- • The New York State Health Department has apparently failed to meet its goal of a 50% reduction in hospital medical errors. Sadly, it still has no program to adequately track such errors.
In January 2000, Health Commissioner Novello pledged to cut medical errors in half in five years. The Department has no proof of success in this area and has not yet developed a program that comprehensively tracks such errors. Indeed, there is no reference to medical error harm reduction on the Department’s website. Obviously, it is impossible to cut the number of errors in half if the state does not even know how many are occurring in the first place!
- • Between 3,000 and 7,000 hospital patients in New York are killed annually due to medical mistakes—an estimated total of between 15,000 and 35,000 since 2000. The 1999 Institute of Medicine (IoM) study estimated that between 44,000 and 98,000 American hospital patients were killed each year due to medical mistakes. Assuming that such errors are spread evenly across the nation, this translates to between 3,000 and 7,000 patients killed by medical mistakes in New York hospitals each year. During the five years since Health Commissioner Novello pledged to cut medical errors in half, it is likely that between 15,000 and 35,000 New York hospital patients have been killed by medical errors.
- • Between $1 billion to $2 billion are spent each year as a direct result of patients’ injuries caused by medical mistakes in New York hospitals. The IoM estimated that the nation spent between $17 billion and $29 billion annually to cover the additional health costs resulting from treating injured patients. In New York, this translates into an additional $1 billion to $2 billion spent annually to treat these injuries. Since 2000 this means that an additional $5 to $10 billion was spent to treat preventable injuries in New York hospitals.
- • New York State hospitals fail to adequately report “incidents” to the Health Department. According to a 2004 audit by the New York State Comptroller’s office, four years after the Department’s pledge to cut medical errors in half, hospitals were not fully complying with requirements to report “incidents” that occur in hospitals – such as injuries that occur due to medical mistakes.
- • One-third of New York hospitals may have violated federal law by failing to report to the federal government limitations imposed on any physicians’ clinical privileges between 1990 and 2003. Hospitals’ failure to adequately report incidents to state authorities is matched by an apparent failure to report as required by federal law. According to the federal government, one-third of New York State hospitals have not reported taking any disciplinary action against any physician in the years from 1991 through 2003! Either these hospitals have had no problems with their physicians (which given the huge number of errors seems unlikely), they are not reporting the ones that do occur, or they are not punishing medical misconduct. In any case, this data shows an apparently careless approach to patient safety.
- • Despite the large number of medical mistakes, very few New York State physicians were reported to have had their clinical privileges restricted to the federal government. There are very few reports sent to the federal government by New York State hospitals and other health entities that have taken serious disciplinary actions against physicians. According to this report’s analysis, since 1991 health care entities have not punished more than 105 physicians in any one year. Typically, only between 40 and 79 physicians were sanctioned in New York.
- • The Health Department has failed to comply with a 1996 law and release hospital “report cards” to document the quality of medical care in New York. Not only have too many of New York’s hospitals failed to follow state and federal laws, but also the Health Department itself has ignored a requirement in patient safety legislation passed in 1996. That law required the Department to develop hospital “report cards” that would have provided policymakers and the public with information on the quality of medical care at each institution. Eight years later – and despite repeated assurances by the Department that such “report cards” would soon be released – no such program exists.
There can be no better indicator of the Department’s indifference to aggressively monitor hospitals’ health quality than its failure to follow the Legislature’s statutory directive in this area.
- • The hospital and medical lobbies argue that increasing malpractice premiums reduce patient access to care. However, New York State has one of the highest per capita number of doctors in the nation, with the pool of doctors growing at a significantly higher rate than the state’s overall population. From 1980 through 2003 the per capita number of active physicians practicing in New York increased 51%. During the period 1980 through 2003, the state’s population grew a mere 9%.
- • National data shows that New York’s number of physicians percapita is increasing at the national rate and at a rate faster than California. According to data obtained from the American Medical Association, New York’s increase in its per capita number of physicians matched the national average and far exceeded that of California – the state held up as a model of “reform” by the medical and hospital lobbies.
- • New York State significantly outpaces California, where malpractice insurance rates are lower (because of the enactment of Proposition 103 rate-making reforms), in the number of practicing physicians per capita. The AMA and other liability cap advocates consider California a model for medical malpractice “reform,” but lower insurance rates aren’t enough to keep doctors in practice there. New York ranks 3rd in the number of overall doctors per 100,000 people, but California only ranks 18th.
Read the full report here.
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