Fire in the O.R.

5/17/2010

THE more Ohio health-care consumers know about how well or poorly hospitals perform, the better informed their decisions will be when they seek medical services. And the more transparent hospitals are about patient treatment and care, the more likely they may be to address shortcomings that affect their performance.

The Ohio Department of Health posts data on its Web site that compare various quality measures hospitals have agreed to share. Missing is reporting on surgical fires, which are not uncommon in operating rooms across the country.

Some of the materials used during surgery - from alcohol-based solutions to oxygen - can be highly flammable, especially in proximity to electrical equipment. Some studies suggest as many as 650 surgical fires occur in health-care facilities each year.

Several states, including Pennsylvania, New York, and California, require hospitals to report whenever a fire breaks out in an operating room and burns a patient. Not Ohio, though.

Six surgical fires at Cleveland Clinic during a 12-month period that ended in March came to light only in late April, when health officials conducted an inspection for the Centers for Medicare and Medicaid Services. Inspectors made recommendations to prevent a recurrence, which the clinic said were implemented within hours.

But that was a year after the first fire. How much sooner could changes have been made if the facility had to notify the state of the error? With reporting comes accountability, a patient advocate observed, along with greater prevention of mistakes and improvement in patient safety.

A state health official said that because Ohio doesn't license its hospitals, there is no procedure for reporting surgical errors. But why can't the Hospital Measures Advisory Council, which came up with the quality measures listed on the Health Department Web site, push for data on surgical fires as a critical public service?