By Robert Pear
New York Times

WASHINGTON - Federal investigators have documented almost 3,000 medical mistakes and mishaps in less than two years at veterans hospitals around the country, and more than 700 patients have died in those cases, the Department of Veterans Affairs says in a new report.

The accidents and deaths occurred from June 1997 to December 1998, in the first 19 months of a new policy that requires employees to report medical errors and "adverse events." Since then, the department has been getting such reports at a rate of more than 200 a month.

The problems include medication errors - like prescribing or dispensing the wrong drugs - the failure of medical devices, abuse of patients, errors in blood transfusions, surgery on the wrong body part or the wrong patient, improper insertion of catheters or feeding tubes, and a variety of "therapeutic misadventures" that caused serious injuries or deaths.

The comprehensive self-examination by the VA believed to be the first of its kind by any health care system in the nation, shows what could be expected if all hospitals had to report their errors as recommended recently by the National Academy of Sciences. The number of reported errors would be high, but health care executives would get useful information about problems that need to be fixed, officials said.

3,000 errors logged at VA hospitals

Starting in June 1997, the VA ordered its hospitals to report their mistakes to the agency's regional offices, which in turn send the information to Washington, where it is logged into an official file known as the patient safety register. Hospitals must try to identify the causes of each incident to reduce the likelihood of repetition.

The new emphasis on patient safety was prompted by several factors: sporadic complaints of substandard care at veterans hospitals, pressure from Congress and the zeal of a senior official, Dr. Kenneth W. Kizer, who was under secretary of veterans affairs from October 1994 to June of this year.

For decades, the veterans health care system had a reputation as hidebound and bureaucratic. But under Kizer, it emerged as a national leader in efforts to improve patient safety.

Spells out 'adverse events'

The report's author, Dr. James E. McManus, a surgeon from New York City who is the VA's medical Inspector, said: "The adverse events reported by the VA were so serious that 24 percent of the patients died. One in four died." The study found 2,927 errors in the first 19 months of mandatory reporting, and 710 deaths.

The number of deaths in 1999 has not been determined. While each hospital analyzes its own cases, the department has not yet analyzed this year's figures for the nation as a whole.

As medical inspector, McManus is a sort of watchdog and ombudsman, continually evaluating the quality of care provided to veterans. The department runs the nation's largest health care delivery system, with 172 hospitals, 132 nursing homes and more than 650 outpatient clinics.

McManus and other health care experts said they believed that the prevalence of errors at veterans hospitals was similar to that at other hospitals. "I don't think it's any different from the private sector." McManus said.

Dr. Donald M. Berwick, a member of the study panel convened by the National Academy of Sciences, said "The first sign of a serious endeavor to deal with errors is that the number of reported errors should go way up."

The Joint Commission on Accreditation of Healthcare Organizations, which inspects 80 percent of hospitals in the United States, encourages private hospitals to report "unexpected occurrences" involving death or serious injury to patients, but it does not require such reports.

Since January 1995, the commission says, 714 such events have been voluntarily reported. The Department of Veterans Affairs had tallied a much larger number of mishaps in just 19 months of reporting.

Medical errors prove deadly

The institute of Medicine, an arm of the National Academy of Sciences, said last month that medical errors killed 44,000 to 98,000 people a year in hospitals alone. More people die from medical mistakes each year than from highway accidents, breast cancer or AIDS, it said. The institute said Congress should require hospitals to file reports with state governments, disclosing any medical errors that cause death or serious harm.

Of the 2,927 "adverse events" analyzed by the VA, 171 were medication errors, in which patients received the wrong medication. Patients died in 22 of these cases. McManus said he believed such drug errors were "greatly underreported."

The veterans agency defines "adverse events" as untoward incidents, illnesses or injuries caused by medical treatments or directly associated with care provided by the department.

Of the other adverse events described in the VA report, about 540 patients were injured in falls at veterans hospitals and nursing homes. In addition, the department said 277 patients committed suicide at veterans hospitals or soon after being discharged, and 476 patients tried to kill themselves but survived.