Owning Up to Errors May Actually Benefit Hospitals

The Wall Street Journal (“WSJ”) reports on a medical error case arising at Baptist Children’s Hospital in Miami.  An 18-month old child suffered a severe brain injury when her breathing tube became dislodged while she was under sedation for an MRI.  The hospital quickly owned up to the mistake, settled the case with the family and immediately instituted new measures to prevent future similar mistakes.  Then, the hospital engaged the child’s parents in educational efforts with the medical staff to underscore he importance of patient safety.  They even went so far as producing a 15 minute video to internally educate the staff about the events leading to the child’s injury.  The mother of the child now serves as a community liaison on the hospital’s quality and patient safety committee.  The family did not sue the hospital.

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Federal Analysts Believe Rate of Medical Errors Increasing a Decade After Prominent Study

In November 1999, the Institute of Medicine (“IOM”) issued a comprehensive report, authored by 22 top medical experts, titled “To Err is Human” in which it  concluded that approximately 98,000 people die each year from preventable medical errors.  Recently, a national investigation led by Hearst Newspapers, including the San Francisco Chronicle, found that the federal government, most states and the hospital industry have failed to take the recommended steps in that report to lower these figures and provide safer hospitals. 

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Medication Errors Still Abound in U.S. Hospitals

Many recent articles and studies have been written about the ever increasing number of medication errors that injure patients each year. Recently,  U.S. Pharmacopeia, (“USP”), a private group that sets standards for the industry, released its MEDMARX report.  The MEDMARX report analyzed records from 1998-2005 for adults, geriatric and pediatric patients. MEDMARX was founded in 1998 and since then has received 1.2 million reports of medication errors from more than 870 healthcare facilities across the U.S. It utilizes an anonymous, Internet-accessible program to report, track and analyze medication errors.

The MEDMARX report  found that patients who undergo surgery face the greatest risk of becoming a victim of a medication error. According to the MEDMARX report, more than 11,000 medical errors in the perioperative setting revealed that approximately 5% of the reported medication errors resulted in harm, which included four deaths. Significantly, this percentage of harm is more than three times higher than the percentage of harm among all MEDMARX records. More significantly, children suffered the highest risk with nearly 12% of those medication errors resulting in harm. Most of the reported errors involved the use of antibiotics and pain killer medications. The most commonly reported medication mistakes involved giving the wrong amount of medication, giving the medication at the wrong time, omitting a dose of medication, or administration of the medication incorrectly. 

As part of its program, USP even offers tips for consumers to help avoid medication errors in the surgical setting. Among these tips, USP advises patients to inform the surgical staff of known food or drug allergies (no matter how insignificant); bring a list of prescription and over the counter medications that you are taking on the day of your procedure; mark your surgical site with your healthcare provider; make sure your chart goes with you to the operative suite. 

USP also provides recommendations to the healthcare providers to help reduce the incidence of medication errors. Some of these recommendations in the operating room include:

  • Requesting that institutions and professional associations call upon manufacturers to produce drug products in ready-to-use packaging with sterile, duplicate labels to avoid errors with labeling. As soon as commercially available, hospitals should obtain as many products as possible in sterile, ready-to-use packaging;
  • Forming a multidisciplinary team to periodically examine preference cards (physician requirements for a particular procedure) to ensure appropriate use of abbreviations or acronyms, ensure clarity of medications intended for the procedure, and affirm instruments and equipment needed for the case; there should also be evidence of the last date the card was reviewed;
  • Providing practitioners with access to accurate patient information, standardized dose charts, and/or assistive technologies with proper medication calculations and formulations so no patient will be at risk of receiving the wrong dose;
  • Expanding the “time-out” standard to allow sufficient review of the preference card and confirmation of the medication directions, patient allergies, and preprocedural antibiotics; and
  • Ensuring that practitioners adhere to the safe medication practice of “repeating back and visually identifying the product” during hand-off between the circulating nurse, scrub personnel, and surgeons.

           

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Studies Show That Hospitals Can Do More To Avoid Infections

The Washington Post has recently reported on three new studies relating to infections acquired in hospitals.  In its article Studies: Hospitals Could Do More to Avoid Infections, the Post states that the studies show new evidence that hospitals could prevent many of the growing number of infections that afflict patients nationwide each year.  The studies were published in the American Journal of Medical Quality.  Its editor, David B. Nash commented on the findings: 

"These three groups independeltly found that despite hospitals'claim that in the sickest patients it's inevitable that someone is going to get a hospital-acquired infection, that's just not the case"

Nash, who is also the Chairman of the Department of Health Policy at Thomas Jefferson University in Philadelphia, states:

"[H]ealth professionals should do more to promote hand-washing among medical staff, take greater care in donning gowns ans other infection-preventing clothing during medical procedures, reduce traffic in and out of operating rooms ,isolate patients when necessary and use antibiotics more selectively."

The three studies reported in the American Journal Of Medical Quality were from Allegheny General Hospital in Pittsburgh, Cardinal Health, Inc, in Massachusetts, and Professor Christopher Hollenbeak, surgical department, Penn State College of Medicine respectively.  Dr. Hollenbeak's study examined Pennsylvania's data for more than 180,000 surgical patients and found that hospital practices such as hand-washing, the duration of surgeries and traffic through the operating room played a greater role in hospital based infections.  The Allegheny Hospital and Cardinal Health  studies respectively demonstrated that there are financial advantages of reducing infections and the severity of the effects of the infection could not be attributed to how sick the patient was at admission.

Nancy Foster, vice president for quality and patient safety at the American Hospital Association agreed that more hospital infections are preventable:

"[t]he new wave of research is showing that our previous expectations around what was preventable underestimated what we could actually achieve."

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One Fifth of Federally Funded U.S. Heart, Liver and Lung Transplant Centers Substandard

According to a recent investigation undertaken by the Los Angeles Times, Medicare and Medicaid have allowed 48 (out of a total 236) heart, liver and lung transplant centers to continue operating despite often glaring and repeated lapses. The heart, liver and lung programs considered in the Times investigation had 71 more patients die than expected within a year of transplant. Of the 236 total programs considered, 36 heart transplant programs failed to meet survival or volume standards and accounted for 43 more deaths than expected. Nine lung programs failed to meet the standard number for surgeries and/or survival, accounting for 21 more unexpected deaths.

According to Dr. Mark Barr, a cardiothoracic transplant surgeon interviewed by the Times:

The bottom line message is that there are too many programs in the United States that need to be shut down.

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AARP Reports That Fatal Medical Mistakes Kill 98,000 People Each Year

In its April 2006 issue, the AARP reports that at least 98,000 Americans die and millions more are injured as a result of medical errors. As an example, a new study by the Duke Clinical Research Institute found that inappropriate drugs are prescribed to one in five people over the age of 65.

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New England Journal of Medicine Reports That Patients Get Proper Health Care Only About 50% of the Time

According to a new study published in the New England Journal of Medicine, patients receive the appropriate recommended care from health care providers only 54.9 percent of the time.

The study utilized telephone surveys in 12 metropolitan areas to identify willing participants who would provide a health history and listing of their health care providers. Those who agreed signed written consent forms so that their medical records could be reviewed.

The initial sample included 20,028 adults. Medical records were then reviewed for acute and chronic conditions that represented the leading causes of death and illness. Physicians then reviewed national guidelines and medical literature and applied that to the review of each patient's chart.


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Blacks With Cancer Receive Lower Quality Health Care

In January, 2005, The Journal of Clinical Oncology released a study that showed several alarming statistics regarding the disparity in health care between blacks and whites diagnosed with cancer.

The study demonstrated survival rates between black patients and white patients for five specific types of cancers including breast, colon esophageal, lung and prostate. It also showed survival rates between blacks and whites for the general category of "all cancers."

According to the study, white patients had a survival rate of 64% for all cancers compared with 53% for black patients. This disparity in survival rates was similar for breast cancer, 88% whites, 74% blacks, colon cancer, 63% whites, 53% blacks, esophageal cancer, 15% whites, 9% blacks, lung cancer, 15% whites, 12% blacks, prostate cancer 98% whites, 93% blacks.

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Minorities Receive Lower Quality Healthcare

In 1999, Congress requested that the Institute of Medicine (IOM), conduct a study to assess disparities in the kinds and quality of healthcare received by racial and ethnic minorities and non minorities.

The stated purpose of this study was to assess the extent of racial and ethnic differences in health care that are not otherwise attributable to ability to pay or insurance coverage and to evaluate potential sources of racial and ethnic disparaties including the role of bias, discrimination and stereotyping. The IOM reported its findings in the 2002 report titled "Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare."

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To Err Is Human

The Institute of Medicine (IOM), reports that as many as 98,000 Americans die each year and another 1,000,000 are injured as a result of preventable medical errors that cost the nation an estimated $29 billion. In its comprehensive book titled "To Err Is Human," the IOM recounts two studies which reported on adverse events.

The Harvard Medical Practice Study reported on more than 30,000 randomly selected discharges from 51 randomly selected hospitals in New York in 1984. In 1992, a study of adverse events in Colorado and Utah reviewed a random sample of 15,000 discharges from a representative sample of hospitals in these two states.


In its study, the IOM reports that some estimate that the 98,000 annual number likely underestimates the occurrence of preventable errors because (i) it only considered hospital errors and not errors in other medical settings (ii) it only considered certain more serious injury cases and (iii) the study imposed a very high threshold to determine whether an error occurred.

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In Hospital Deaths From Medical Errors Reach 195,000 Per Year

In 1999, the Institute of Medicine (IOM) issued a report titled "To Err is Human," in which it reported that as many as 98,000 Americans die each year and another 1,000,000 are injured as a result of preventable medical errors.

On July 27, 2004, HealthGrades, Inc., the leading independent healthcare quality company which provides ratings information and advisory services to healthcare providers and insurance companies, issued its own study in which it reported that on average, 195,000 people die each year from potentially preventable, in-hospital medical errors. This data was compiled for each of the years 2000, 2001, and 2002. The report studied 37 million Medicare patient records during this period.

HealthGrades vice president of medical affairs, Dr. Samantha Collier, stated:

"The HealthGrades study shows that the IOM report may have underestimated the number of deaths due to medical errors, and, moreover, that there is little evidence that patient safety has improved in the last five years."

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