Now that we have Mandatory Disclosures of Medical Mistakes, Should not We Require Disclosure of Hospital Hazards?
A number of states have already passed laws requiring hospitals to disclose medical and nursing errors to patients or their next of kin. The Joint Commission on Accreditation of Health Care Organizations has instituted the post incident disclosure requirement as a standard of care in administrative policy. Although it is nice to see a trend away from covering up medical blunders, how does this help prevent them? What about disclosing conditions that are likely to cause injury such as a severe nursing shortage on a particular unit? Are there no "truth-in-advertising" laws that require full disclosure if the hospital administration knows in advance that it can not provide services in accordance with its representations?
Notwithstanding the fact that a full staff is no guarantee against mistakes, an unsafe staffing level is the most visible indicator of general deterioration in the quality of care. The following is a partial list of problems arising out of not having enough nurses on duty:
Patient calls for assistance remain unanswered;
Injuries from falling;
Failure to follow physicians orders;
Incompetent nursing care from lack of supervision;
Failure to report changes in clinical condition;
Narcotic overdose from patient controlled analgesia;
Fetal hypoxia during childbirth.
Hospitals have a standard number of staff required for each unit based on a full census. The actual numbers can be less when there are empty beds (except for labor and delivery units). However, there is a risk that the beds would fill up during a particular shift. For example, a twelve-bed surgical intensive care unit usually requires at least six nurses (one nurse for two patients). Sometimes more are needed for one-to-one nursing. If there are less patients at the beginning of the shift a fewer number of nurses would obviously still be safe unless the supervisor authorizes additional admissions without adding more nurses. In many hospitals where there are chronic shortages, having three to four nurses in a full twelve-bed unit is common and the staff nurses are sending unsafe staffing reports to the nursing office on every shift. Whenever such a situation exists, the patients and family members are not being given full disclosure and the hospital advertisement continues to give the impression that the hospital is fully capable of delivering the highest possible quality of care.
Case in point:
The following is part of an advertisement on the web site of a hospital in New York City
"The _______ Hospital has identified a number of clinical areas for which the provision of cutting-edge care depends upon superb coordination and the devotion of extraordinary institutional resources … Brings together the specialized doctors, staff, technology and support structures that are needed for delivery of care that is second to none anywhere. "
This well known institution does provide state-of-the-art technology and when the units are fully staffed they are usually well run. However, there have been many instances of unsafe staffing levels in all of the critical areas, regular floors and the labor and delivery unit. Additionally, the hospital employs a staffing coordinator who posts the staffing schedules two months in advance. Therefore, when a severe shortage exists for any shift the hospital administration knew about it two months earlier. Yet the advertisement makes the reader believe the best possible care is being provided and consumers are unaware that there is a problem.
Since the quality of care as advertised can only be upheld with a full compliment of nursing staff, severe shortages that were known in advance without disclosing the consequential increased risk of iatrogenic complications compromises the patient's safety and robs him / her of the opportunity to avoid the injury. Furthermore, advertising extolling the high quality of care in the face of such known staffing shortages is tantamount to misrepresentation.
In a nutshell, if all hospitals were required to give full disclosure to the public of dangerous conditions such as any units for which their nurses filed an unsafe staffing report, the patient's family members would have the opportunity to take steps to protect their loved ones. Moreover, the requirement for such disclosure would motivate hospital management personnel to correct existing hospital hazards and prevent new ones. This would indeed be an "intervention for prevention".