Patient Safety: What types of dumb medical mistakes can you expect as a hospital patient?

The Institute of Medicine estimates that each year in the United States our healthcare system wastes up to 98,000 lives, 2.4 million extra hospital days and $9.3 billion in excess charges due to “serious reportable events”; put plainly, errors/mistakes that were easily preventable.  

“Tens of thousands of lives are forever changed each year as a result of healthcare errors.  There is a critical need to enhance health system capacity, so that all patients will receive care that is safe and effective.”    - NQF President and CEO Janet Corrigan  

Who pays for SRE’s?

Who pays for these mistakes? You and I do. The taxpayer does either through taxes to provide governmental medical assistance programs to the poor and aged, through higher rates for private health insurance premiums or generally in higher health care costs.

What are these serious but avoidable mistakes?

There is a list of SRE’s, as they are referred to in the medical industry. I’ll include that list below. Most of the SRE’s are easily avoided or corrected.  Others are not; such as the criminal behavior SREs.

Are civil lawsuits for damages the only way to seek changes to avoid SREs?

I’d like to say no, but I’m not so sure the general public appreciates how difficult proactive change can be in the health care system.  Traditionally civil lawsuits were the vehicle to right the wrongs. Civil lawsuits come after the SRE either maimed or kills the patient and in that sense it’s simply putting a band aid on the wound that already exists; the lawsuit comes after the insult and doesn’t stop that incident, but suits do have a deterrence effect for the future.  In recent years jurors have become stingier and stingier in awards; a trend that has all but eliminated any deterrence. Defendants feel empowered by jurors that ignore wrongdoing and take the law into their own hands.  Conservative judges who pander to the mentality of jurors awarding little or nothing only extend the empowering of those who do wrong and rationalize their own wrongdoing.  Corporations have no conscience, no heart and no soul.  Everyone in corporations have a job to do and can easily rationalize away systematic wrongdoing simply by saying, “It wasn’t my job.” Or “I was just doing my job.” Jurors who reflect the “it won’t change anything” or “accidents happen” mentality simply ignore reality. Yes what goes around does come around. And no just because you’re now injured doesn’t mean you get treated any different by pandering and uncaring juries. You too get the same attitude from those conservative judges and juries.

Where does your state stand on SRE’s? Is your state included or not included? If not included then why not?

Only 25 states have joined the efforts to make the medical facilities in their states safer by avoiding those practices that make up the SRE list.  Iowa, where I live is not one of them. Tomorrow I’ll list those states and you can ponder the difficult question of why your state government would choose to not be a part of changing your healthcare system to avoid SREs.  One has to wonder if lobbyists associated with hospital and health care systems are doing more harm to this country than any civil lawsuit ever did.

What is the bottom line? How can you be affected?

Take a good look at the following list of SRE’s and consider if you are the patient how each may impact your life.  When you read this list you are walking through history of health care in which, in the past these mistakes, like many of the patients have been buried, covered up or only whispered about in the hallway, rather than published, discussed and changes implemented to avoid them in the future. Don’t fool yourself into believing they still don’t occur; because they do. The general public seems weary of the law and use of civil lawsuits to implement change; and that’s fine with me, so long as you the public become active in seeking change yourselves. Go back to sitting in front of the television or not wanting to be bothered and you may very well find yourself, your spouse or even your children one of the disabled or dead. It’s your choice, as a juror, choose to honor the civil lawsuit process or get active. There is no free lunch.

Serious Reportable Events

• Surgical Events
• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a patient
• Unintended retention of a foreign object in a patient after surgery or other procedure
• Intraoperative or immediately postoperative death in an ASA Class I patient

Product of Device Events

• Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
• Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

• Infant discharged to the wrong person
• Patient death or serious disability associated with patient leaving the facility without permission
• Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility

Care Management Events

• Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
• Patient death or serious disability associated with a hemolytic  reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products
• Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
• Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns
• Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
• Patient death or serious disability due to spinal manipulative therapy
• Artificial insemination with the wrong donor sperm or wrong egg

Environmental Events

• Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
• Patient death or serious disability associated with a fall while being cared for in a healthcare facility
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the grounds of a healthcare facility
• Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

Patient Safety: Why does Iowa wish to keep SREs the hosptials dirty little secrets?

Yesterday I promised the list of states that had joined the efforts to avoid SRE’s.  As I said Iowa is not one of those states with mandatory reporting or SRE’s.

Where does your state stand on SRE’s? Is your state included or not included? If not included then why not?

Only 25 states have joined the efforts to make the medical facilities in their states safer by avoiding those practices that make up the SRE list.  Iowa, where I live is not one of them. Today you and I can ponder the difficult question of why our state governments would choose to not be a part of changing your healthcare system to avoid SREs.  One has to wonder if lobbyists associated with hospital and health care systems are doing more harm to this country than any civil lawsuit ever did.

Quality and Patient Safety

State adverse event reporting rules and statutes*

Note: States listed here are linked to NASHP's Patient Safety Toolbox and to individual
state profiles of each state's adverse event reporting system

California
Title 22 Division 5 Chapter 1 Article 70737

Colorado              
Colorado Revised Statutes, sec. 25-1-124
The Code of Colorado Regulations, ch. 2, sec. 3.2
State Board of Health, General Licensure Standards

Connecticut        
General Statutes Section19a-127n

Florida                   
Fla. Stat. ch. 395.0197 (2003):  Internal risk management program

Georgia
Georgia Rules 290-9-7-.07

Illinois
Public Act 094-0242

Indiana
Executive order 05-10 
Indiana Department of Health; 410 IAC 15-2.4-2.2

Kansas                 
Kan. Stat. Ann. § 65-4923 (2002)
Kansas Administrative Code, 25-52-1

Maine                   
Me. Rev. Stat. Ann. tit. 22, § 8753 (2003)

Maryland
COMAR 10.07.06

Massachusetts 
105 Code of Massachusetts Regulations 130.331

Minnesota
Minnesota adverse events legislation

New Jersey        
New Jersey Regulations NJAC 8:43G-5.6
www.nj.gov/health/quality/pslaw_chap9.pdf

Nevada
Nevada Revised Statute (NRS) 439.800-890 
Nevada Administrative Code (NAC) 439.900-920
Assembly Bill 59 (AB59)

New York            
New York Public Health Law, sec. 2805(L)
New York Code of Rules and Regulations, Title 10, Section 405.8

Ohio
Ohio Department of Health's reporting requirements for 9 specific services
Revised Code Section 3702.11
Ohio Administrative Code Chapter 3701-84
The rules are available at www.odh.state.oh.us

Oregon
Oregon law to improve patient safety by reducing the risk of adverse events:
Section 9, Chapter 686, Oregon laws 2003

Pennsylvania    
Pa. Stat. Ann. tit. 40, § 1303.308 (2003)
Pa. Stat. Ann. tit. 40, § 1303.313
Medical Care Availability and Reduction of Error Act

Rhode Island     
Rhode Island Statutes, section 23-17-40
Rules and Regulations for Licensing of Hospitals, R23-17-HOSP, please refer to sections 1.41, 1.42 and 34.0

South Carolina  
South Carolina Code of Regulations, Regulation No. 61-16, Sec. 206

South Dakota     
Administrative Rules of South Dakota 44:04:01:07

Tennessee         
Tennessee Rules Chapter 1200-8-1. SB2316

Texas
Tex. Health and Safety Code Sec. 241.201 - 241.210 (2003)
Patient Safety Program and Medical Error Reporting - Final Rules (Amending 25 Texas Administrative Code, Chapter 133)

Utah                    
Utah Division of Administrative Rules, R380-200
Health Care Facility Patient Safety Program Rule R380-210

Washington      
Washington Administrative Code, section 246-320-145

*All rules and statutes refer to mandatory reporting except for Oregon, which established a voluntary reporting system.

Preventable hospital errors show increased reporting in Minnesota

St. Cloud, MN – New serious preventable hospital errors reporting shows past mistakes buried, rather than reported.

As a hospital patient are you safe? Are you safer this year than last year? Until everyone gets on board with reporting preventable errors the answers to those two questions can’t be taken seriously.  Of the 18 preventable events, which are you likely to encounter on your way to better health? It’s refreshing to see hospitals begin to tackle in an open way, these issues. They can dislike the legal tort system all they wish but until they begin to openly manage preventable errors the public will not tolerate institutional ignorance.

Minnesota’s new reporting requirements for serious preventable hospital errors resulted in an almost three-fold increase in the number of reported errors from the previous year.

The number of adverse events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals increased from 125 to 312 in 2008. In the absence of the new reporting requirements, the number of reported adverse events would have been 141.

In addition to the seven falls and four ulcers included in this year’s report, St. Cloud Hospital had seven “adverse health events” — one more than last year’s, which predated reporting requirements approved during the 2007 legislative session.

None of the 18 adverse health events reported this year by St. Cloud Hospital resulted in death, according to the statewide report released today by the Minnesota Department of Health.

If you’re from Minnesota you may wish to read this or other articles about this subject and order the 2008 or the 2007 report.  You should put this report in perspective, more reports doesn’t mean more mistakes; assuming in previous years they were underreported.

“Preventable adverse events include such things as pressure ulcers, retained objects after surgery, wrong-site surgeries, wrong procedures, death or serious disability from a medication error, and death from a fall. The most frequent events noted in this year’s report were stage three or four pressure ulcers (43), wrong site surgery (24), and a foreign object left in a patient after surgery (25).”

A full copy of the adverse health events report and additional information can be found on MDH’s Adverse Health Events Web page, at www.health.state.mn.us/patientsafety. More information about hospitals can be found at http://www.mnhospitals.org.

John Stieger
MDH Communications
(651) 201-4998

As a patient you can search by facility and cross-reference with preventable errors. Be safe, be smart and be proactive in protecting yourself.

Patient Safety

As part of its mission to protect, maintain, and improve the health of all Minnesotans, the Department of Health is a leader in promoting patient safety and the prevention of adverse health events. MDH is a partner in the Minnesota Alliance for Patient Safety, a broad-based partnership established by MDH, the Minnesota Hospital Association, and the Minnesota Medical Association and since joined by over 50 stakeholder groups.

MDH also administers the Adverse Health Care Events Reporting System. This reporting system, established in 2003, requires all Minnesota hospitals, ambulatory surgical centers, and community behavioral health hospitals to report whenever one of 28 "never events" occurs. Reportable events include surgery on the wrong patient or body part, objects retained in a patient’s body after surgery, death associated with a fall, and death or serious disability from a medication error.

By supporting learning and accountability, this system is helping to improve patient safety across the state, and serves as a model for other states interested in developing mandatory public reporting systems.

Search facilities' adverse events reporting
Searchable database that displays reports about individual hospitals.

Information for consumers, patients and families
Factsheets and links specifically for consumers and patients.

Adverse events reporting system
List of 28 reportable events, links to statute, background sheets and articles.

Wrong-site surgery
Minnesota research and recommendations related to prevention of wrong site surgery, retained objects, and other surgical events.

Patient safety publications
Current and previous reports on patient safety.

Patient safety links
Links to other sites with safety and quality information.

Patient safety training
Past and upcoming training.

For more information about this page, please contact the MDH Division of Health Policy at 651-201-3564.

In Des Moines, Iowa contact Steve Lombardi. In St. Cloud, Minnesota contact Attorney Mike Bryant and in Hawaii, Wayne Parsons.

Wrong=Site Surgery: Medical issues clearer and benefiting patients and doctors

Medical Malpractice - Iowa Supreme Court allows patients to give the doctor the benefit of the doubt before definitive diagnosis is made.

Iowa Supreme Court Decision – Med. Malp. – Breast Cancer Detection Case Allowed to Proceed

Pamela Rock developed a lump on her breast. She went to the doctor who later diagnosed breast cancer. She alleges malpractice in the detection process and what was told to her about her condition. Allegations are just that and will need to be proven. The District Court and the Iowa Court of Appeals found she filed her case too late; two days late. The Iowa Supreme Court in a decision that backs away from the Court’s latest pronouncements for tort deform held her case could proceed.

“Previously, we held the statute of limitations begins to run as soon as the plaintiff knew or should have known of the physical or mental harm for which damages are sought. Schlote v. Dawson, 676 N.W.2d 187, 194 (Iowa 2004); Langner, 533 N.W.2d at 517. In Rathje v. Mercy Hospital, 745 N.W.2d 443 (Iowa 2008), we acknowledged our past cases may not have correctly captured the intent of the legislature. Rathje, 745 N.W.2d at 447.”

This is good news for patients and doctors. Patients are given the benefit of the doubt in trusting their doctors and to allow them to do the job they’ve been trained to do. It’s good news for doctors because patients aren’t being forced to second-guess every medical decision and test and to seek second opinions.

“Pamela Rock noticed a lump in her left breast in May 2002. She called Dr. Warhank at the Family Medical Center in Blue Grass to have it examined. Rock was referred to the Center for Breast Health for a bilateral mammogram, which was performed on May 28. Rock had a follow-up appointment with Dr. Warhank on June 3. Dr. Warhank palpated Rock’s left breast and located the lump. Dr. Warhank told Rock the mammogram was normal and not to worry about the lump. Sometime on June 3 or 4, Rock received a call requesting she come in for additional views of her right breast. Rock went to the Center for Breast Health on June 4 and had additional views of the right breast taken. A technician told Rock an ultrasound was not necessary because what was seen in the earlier mammogram was no longer present. Rock reminded the technician she had a lump in her left breast and not her right breast. The technician assured Rock nothing was seen on the earlier mammogram of her left breast so she should not worry about the lump anymore. Dr. Hartung reviewed the radiology report of the right breast and advised Rock in a letter dated June 5 that the additional views of the right breast showed no sign of cancer. In September 2002, Rock was still concerned about the lump in her left breast. She made an appointment with Dr. Kelly at the Family Medical Center. Dr. Kelly told Rock the lump was “probably benign.” Nevertheless, Dr. Kelly recommended a surgical consult and referred Rock to Dr. Congreve. Dr. Congreve performed a fine-needle aspiration on September 25. Two days later, Dr. Congreve called Rock and told her the test was not normal and she needed to have a biopsy of her left breast. On October 8, 2002, Dr. Congreve performed the biopsy and diagnosed Rock with breast cancer.”

Rock filed suit on October 5, 2004. The Iowa Supreme Court held: “Rock could not have known, and should not have known, of her injury and its factual cause until the day she was diagnosed with cancer at the earliest.”

This common sense reasoning respects the various roles of doctor and patient. It allows and encourages the patient to respect the doctor’s every decision before a definitive diagnosis is determined. It also respects the doctor’s decision making process without forcing the patient to second-guess the decision making process and trying to force the medical decision-making process.

PAMELA G. ROCK and

KEITH A. ROCK,

Appellants,

vs.

ROSE WARHANK, BLUE GRASS FAMILY

MEDICAL CENTER a/k/a FAMILY MEDICAL

CENTER OF BLUE GRASS, ROBERT

HARTUNG, CENTER FOR BREAST HEALTH,

and GENESIS MEDICAL CENTER,

No. 05-1753, November 21, 2008.

I’d like to thank Dave Mittleman from Michigan for pointing out the significance of this decision.  Dave has been fighting federal preemption in the Michigan Court system.