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
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