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Study finds adverse events follow patients home
All Minnesota hospitals to take Leapfrog's public survey
Study: Bilingual interpreters make about 31 mistakes per visit

Patient Safety Monitor Alert, February 7, 2003

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STUDY FINDS ADVERSE EFFECTS FOLLOW PATIENTS HOME

Tracking adverse events to patients in your hospital? Don't forget the ones you've already discharged. After they went home, nearly one in five patients experienced new or more extreme symptoms due to the treatment they received in the hospital, according to a new study published in yesterday's Annals of Internal Medicine.

Researchers, who conducted the study at one large, unidentified urban teaching hospital, found that out of the 400 hospitalized patients they contacted, 76 experienced adverse events after they went home, according to the Associated Press (AP). They considered 23 of the events preventable, while the other 24 could have been "less severe" if the hospital had provided better care.

Drug side effects caused most of the problems. Study authors cited the main issues as the hospitals' failure to communicate with patients and primary care physicians at discharge and failure to follow up quickly on symptoms of complications. Go to www.annals.org for more information.

ALL MINNESOTA HOSPITALS TO TAKE LEAPFROG'S PUBLIC SURVEY

Will the Leapfrog Group's three patient safety standards ever take a firm hold on hospitals? If you live in Minnesota, the answer is 'yes.' All 139 Minnesota hospitals have agreed to take the Leapfrog Group's hospital survey, which addresses the standards, the Minnesota Hospital Association (MHA) and the Buyers Health Care Action Group (BHCAG) announced last week. Minnesota is the first region in the country that has all of its hospitals participating in the survey, according to a press release from the MHA and BHCAG.

The three Leapfrog Group standards include the following:
- Computer physician order entry
- ICU physician staffing
- Evidence-based hospital referral

Leapfrog will use data from the survey to educate enrollees, as well as to reward providers that meet the standards, according to Leapfrog's Web site. Officials will begin to post Minnesota's survey information online Consumers may be able to view it as soon as February 7, 2003. Go to www.leapfroggroup.medstat.com for more information.

STUDY: BILINGUAL INTERPRETERS MAKE ABOUT 31 MISTAKES PER VISIT

Even professional interpreters aren't fail-safe when it comes to communicating between patients and clinicians, a recent study found.

Study researchers analyzed transcripts from 13 doctor-patient visits involving Spanish-English interpreters--about half of whom were employed by the hospital. The other half included untrained family members, friends, or other people at the hospital. They found that the interpreters made an average of 31 mistakes per visit. Nineteen of those mistakes could have had a negative impact on the patient, according to Reuters. The visits all occurred in a Massachusetts hospital's urban outpatient clinic.

Though non-professional interpreters were more likely to make serious mistakes than professional interpreters, researchers still found that more than half the professional interpreters' errors could have caused harm.

Medical insurers should cover the cost of an interpreter because errors increase medical bills, Dr. Glenn Flores of the Milwaukee-based Medical College and Children's Hospital of Wisconsin, the lead author, told Reuters. He cited a case in which one misinterpreted word in the emergency room ended in a court award of $71 million to the patient.

The study was published in the January 2003 issue of Pediatrics.

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