The patient’s breaths had become labored. He struggled to pull air from his mouth to his lungs. It got so bad late one Saturday night that he decided to say something about it the next time his nurse made rounds at Jackson South Community Hospital.
The complaint traveled from the nurse to a doctor, who looked at the patient’s records and quickly saw the problem: a feeding tube had been placed into the side of his lung. An anesthesiology trainee had inserted the tube without proper supervision, a federal health inspection later determined, and over the coming weeks, the patient developed pneumonia and sepsis related to the medical error. He was in the hospital two months longer than initially planned.
Teaching hospitals like Jackson South, located in metro Miami, are where physician trainees get practice treating patients. They prepare the next generation of doctors, and they have a reputation as places of cutting-edge patient care, given their ties to academic institutions.
But at some of these hospitals, residents may be learning bad habits. A STAT analysis of federal inspection data finds that there’s a wide gap in the quality of training at teaching hospitals, as shown by how frequently these hospitals are cited for deficiencies by the Centers for Medicare and Medicaid Services. While the majority of the roughly 1,200 teaching hospitals received no citations each year from 2014 to 2017, others racked up dozens of safety violations in that time period — putting patients at risk, and compromising the training that students receive.
“In the places where young doctors-in-training practice, what they learn can affect how the person will practice for decades to come,” said Rosemary Gibson, a patient safety advocate and the author of the book “Wall of Silence.” “They’re developing habits … and it’s essential for trainees to learn in clinical settings where patient safety is baked into the system.”
At Jackson South, even before the hospital received a citation from CMS, administrators were analyzing how the feeding tube mistake happened and how to prevent similar errors in the future. They realized that the issue had to do with the initial reading of the X-ray, which is used to make sure doctors don’t misplace feeding tubes. The hospital put in place a pilot program to verify that feeding tubes are properly placed.
“We take every deficiency seriously and thoroughly investigate each safety violation,” a Jackson spokesperson said in a statement. “We implement plans to correct them.”
Teaching hospitals are making some positive changes, and according to STAT’s analysis, that’s led the average number of violations per teaching hospital to drop to its lowest point in three years, following a major spike in 2015 and 2016. But experts worry that the remaining mishaps mean that America’s future doctors aren’t always being prepared to practice medicine safely.
“If residents train in a program where patients aren’t receiving safe care, [they’re] likely at increased risk of burning out or leaving clinical medicine entirely, or providing not as good of care if they stay in clinical medicine,” said Dr. Sumant Ranji, chief of the division of hospital medicine at the Zuckerberg San Francisco General Hospital.
Hospitals that participate in Medicaid or Medicare must follow federal safety regulations, and the agency sends inspectors to verify that they are doing so every three to four years, or when a complaint triggers the need for an investigation. Those regulations cover everything from the storage of drugs and supplies to the protection of patient rights.
Inspections by CMS represent a fraction of all the inspections that hospitals undergo. Independent accreditors and state agencies perform the majority of routine hospital surveys, but rarely make detailed findings public. So STAT’s analysis was based only on the CMS reports.
“When [CMS] inspections are done and violations are found, especially the more severe violations, they’re important,” said Dr. Ashish Jha, professor of health policy at the Harvard T.H. Chan School of Public Health. “Sometimes they’ll find minor violations. But the things that are really a threat to patients being alive, it’s hard to discount those.”
STAT’s review — aided by the Association of Health Care Journalists’ HospitalInspections.org database — looked at medical facilities that fit the CMS definition of a teaching hospital: those that received Medicare direct graduate medical education or indirect medical education payments from the agency between 2014 and 2017. Collectively, more than 5,500 safety violations occurred at teaching hospitals over that four-year span. In each of those years, more than a quarter of the roughly 1,200 teaching hospitals had at least one safety violation documented.
The highest number of citations went to West Valley Medical Center in Idaho (45 violations), Regional Health Rapid City Hospital in South Dakota (44), Howard University Hospital in Washington, D.C. (37), and Jackson Memorial Hospital (36), which is part of the same health care system as Jackson South. Among the others cited were some of the nation’s most prestigious medical centers — including ones affiliated with Columbia, Harvard, and Case Western Reserve universities — as well as rural hospitals that dot the western half of the United States.
Many teaching hospitals STAT contacted for interviews declined to provide information about their violations. The spokespeople who responded generally said administrators had taken appropriate action to address deficiencies cited by CMS.
Some violations, like the Jackson South one, directly concerned medical trainees, while others implicated the leaders responsible for overseeing their education. Jha said CMS inspection reports, known as 2567 forms, provide valuable insight into hospital safety — particularly regarding the quality of training and oversight for medical trainees.
In the neonatal intensive care unit of Cooper University Hospital in Camden, N.J., pediatric residents shadow staff physicians as they care for newborns in precarious health. Before entering, staff and visitors are required to wash, rinse, and lather their hands for at least 15 seconds and decontaminate personal items such as cellphones, according to hospital policy.
But over a three-hour period last April, an inspector observed nearly a dozen doctors and nurses break those rules. Additionally, the inspector could find no evidence that, after an infant in the ward contracted a superbug, the staff took these precautions to limit the spread of infection.
“Unfortunately, these types of infections are not uncommon in NICUs around the country due to the highly fragile nature of this patient population,” Cooper University Health Care spokeswoman Wendy Marano told STAT. “Cooper promptly reported the infections to the New Jersey Department of Health. … We have not experienced any recurrence of MRSA cross-contamination in the NICU.”
In the spring of 2017, inspectors cited Montefiore Medical Center in the Bronx after two patients committed suicide in an eight-day period. One of those patients was a 76-year-old man who had collapsed in grief after attending a friend’s funeral. Upon admission to Montefiore, doctors didn’t record a plan for psychiatric treatment, even though hospital policy called for suicide screenings in cases of potential emotional or behavioral disorder. Three days later, the man hanged himself in a shower at the hospital.
“Yes, he would have been someone who we would have liked to have seen before he died,” one doctor told an inspector.
A spokesperson told STAT that Montefiore is “singularly focused on providing the best education and training for the doctors of tomorrow.”
“If you find the problem on an inspection, it’s worrisome. If you fail to find problems, it’s not a get-out-of-jail-free card.”
Dr. Ashish Ja, Harvard T.H. Chan School of Public Health
Medical trainees were at the center of some of the violations listed in reports STAT reviewed. A team of NewYork-Presbyterian Hospital residents didn’t notify an attending physician for hours about a patient’s rapid heart rate and drop in blood pressure, and the patient died the following morning. And a resident started a fire in a Nebraska Medicine operating room by accidentally bringing a cautery too close to a flammable liquid medical adhesive. In that case, hospital spokesperson Taylor Wilson told STAT, no patients were harmed. But the incident spurred “new, stronger safety measures” that included training of all surgical staff and trainees, Wilson said.
Experts caution that inspection reports don’t tell the whole story. Dr. Tejal Gandhi, chief clinical and safety officer for the Institute for Healthcare Improvement, said each of the leading ways to assess quality and safety “alone won’t give you an overall view” of hospital performance. Matt Austin, a professor of anesthesiology and critical care medicine at Johns Hopkins University’s medical school, said they reflect an “important, but not a complete, picture of patient safety” in hospitals.
“If you find the problem on an inspection, it’s worrisome,” Jha said. “If you fail to find problems, it’s not a get-out-of-jail-free card.”
For many decades, preventable medical errors in hospitals were chalked up as an inevitable cost of training new doctors, according to Peter Rivard, associate professor of health care administration at Suffolk University in Boston. If something went awry, health administrators reprimanded trainees or their supervisors instead of focusing on the underlying systems that allowed for a mistake to occur in the first place.
Then in 1999, the Institute of Medicine released the landmark “To Err Is Human” report, which concluded that as many as 98,000 Americans were killed in the process of receiving medical care. Hospitals scrambled for answers: They began tracking errors more closely, hiring airline pilots as safety consultants, and expanding patient safety as a subject of medical education. But by the mid-2000s, only 54 percent of residents surveyed knew how to report errors at their facilities.
Ranji, at San Francisco General, said a “pernicious old-school culture” still pervades much of medical education and espouses minimal oversight of trainees, in addition to the belief that learning happens through making mistakes.
In part due to their frequent turnover, medical trainees told STAT that they don’t always feel empowered like permanent staffers to suggest improvements to hospital safety.
Trainees who are involved in medical errors can experience “profound psychological consequences,” Ranji said.
“The patients I remember best were the adverse ones,” he added. “Those experiences made me more cynical, and sucked the joy out of patient care for me. If something bad happened to patients, [the mindset was to] sweep under the rug, and keep your chin up. But they were profound emotional experiences.”
Recognizing that teaching hospitals present specific challenges for patient safety, the leading medical education accreditation group has stepped up its oversight policies.
Since 2012, the Accreditation Council for Graduate Medical Education — which accredits more than half of the nation’s teaching hospitals — has sent staff to these hospitals to conduct an evaluation that includes interviewing administrators, observing doctors, and walking the halls with residents.
“We’re really focused on changing behavior. It’s important that someone raises their hands, wherever they are on the hierarchy, and can say, ‘I see a problem.’”
Dr. Vineet Arora, University of Chicago Medical Center
Dr. Kevin Weiss, senior vice president of institution accreditation for the ACGME, said these mandatory site visits are intended to “increase awareness of residents in formal patient safety activities” like reporting medical errors or participating in debriefs of those errors after the fact, something that makes trainees more mindful of practicing medicine safely.
And teaching hospitals are taking matters into their own hands.
At the University of Chicago Medical Center, every resident must undergo patient safety training. As part of it, they must spot medical errors in a simulated environment dubbed the “horror room.” They’re also strongly encouraged to report adverse patient events or “near misses,” and are expected, in collaboration with superiors, to reverse engineer incidents where patients were harmed under their watch.
“We’re really focused on changing behavior,” said Dr. Vineet Arora, director of graduate medical education clinical learning. “It’s important that someone raises their hands, wherever they are on the hierarchy, and can say, ‘I see a problem.’ That’s a mindset change.”
Participation in this curriculum, Arora noted, was associated with “three times more event reports by those programs.” University of Chicago Medical Center hasn’t received a safety violation in over two years.
Meanwhile, researchers at Boston Children’s Hospital created “I-PASS,” a mnemonic device that’s bundled with training and lectures in order to help improve patient handoffs. A resident whose shift is ending relays information to his or her successor by running through five pieces of information: illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver.
It’s worked so well in pediatric units — one study found its use was associated with a 23 percent drop in medical errors — that Massachusetts General Hospital decided to adopt it throughout the institution. Dr. Elizabeth Mort, senior vice president of quality and safety at Mass. General, said the program led to a “fivefold increase” in safety reporting from trainees.
“An understanding of patient safety is something we’re not born with,” said Dr. Anai Kothari, a fourth-year surgery resident at Loyola University. “But it can be learned and applied — and can make a difference when we do it well.”
This story has been updated to correct a slight undercount of the number of violations contained in the above chart, “25 teaching hospitals with the most violations, 2014 – 2017.”