Hospital Errors — The Third Leading Cause of Death in the U.S.
By Bob Aronson
When your life has been saved in hospitals several times as mine has, it is difficult to write a blog that is critical of those institutions but, it is just as difficult to ignore the facts. As a writer who has made a commitment to provide accurate and timely information to his readers it would be irresponsible to do so.
This blog is about and for pre and post-transplant patients, their families, donors, donor families, caregivers and friends. Those of us who are awaiting transplants or who have had them spend an inordinate amount of time in hospitals and clinics. Our compromised immune systems make us far more susceptible to a myriad of diseases and problems than the average patient and that means we have to be more alert and aware of our surroundings. It is for that reason that I am posting this information.
I did not make up the numbers you are about to read. They are available for everyone to see and to analyze through the links I have provided. Your comments are not only welcome, they are encouraged.
Never Events, Hospital Acquired Conditions and Sentinel Events
Heart disease and cancer are the number one and two causes of death in the United States. Number three is medical errors. The very people who are supposed to be experts in saving lives are also responsible for thousands of deaths.
Medical errors in hospitals are killing us faster than chronic lower respiratory diseases, stroke (cerebrovascular diseases), accidents of all kinds, Alzheimer’s disease and diabetes combined. The very people we trust our lives to – are not only contributing to our deaths they don’t seem to be learning from their mistakes because the problem appears to be getting worse. While many hospitals claim they are making progress the national numbers don’t show it. The evidence to the contrary is overwhelming. And — one cannot help but believe that the problem is even worse than is stated in this posting because there is no system in the U.S. for reporting and tracking medical errors and their results. Voluntary reporting is spotty and incomplete so we are left with educated guestimates and they are frightening.
In 1999, the Institute of Medicine published the “To Err Is Human” report. It generated huge front page headlines everywhere by estimating that nearly 100,000 people die every year as a result of hospital errors. At first there was widespread denial in the medical community but no longer. The medical profession accepts that number. The problem is that the number is wrong.
In 2010 another number was announced. The Office of the U.S. Inspector General for Health and Human Services said that poor hospital care contributed to the deaths of 180,000 patients in Medicare alone in any given year… Note — they said Medicare alone! But — that number is wrong, too. The story is about to get much worse.
A study published in September of 2013 in the Journal of Patient Safety says the numbers may be much higher. They say that between 210,000 and 440,000 patients die in hospitals each year as the result of preventable errors. Please note that the numbers quoted in the preceding reports only refer to deaths. None of the numbers I have seen say anything about the number of injuries caused by medical errors.
The new estimates were the result of work by John T. James, who works as a toxicologist at NASA’s Houston, Texas space center. James also runs a group called Patient Safety America. http://patientsafetyamerica.com/ James dedicated the site to his 19-year old son, John Alexander James, who he says, “Died as a result of uninformed, careless, and unethical care by cardiologists at a hospital in central Texas in the late summer of 2002.”
ProPublica an investigative journalism group asked three prominent patient safety researchers to review James’ study and all said his methods and findings were credible. http://www.propublica.org/ The American Hospital Association, though, rejects the number preferring to believe the number of 98,000 deaths from the 1999 report.
What’s the right number? Nobody knows for sure but we do know it is not getting smaller. As stated earlier there is no standardized national reporting system on medical errors, who is affected and who makes them.
So we’re left with approximations, which are imperfect in part because of inaccuracies in medical records and the fact that a good many of the errors that take place are never reported. Hospitals and physicians have traditionally fought establishing a formal reporting system for fear of prosecution. Instead they advocate a voluntary reporting system which begs the question, “Who is going to voluntarily admit to committing an error that resulted in a patient’s injury or death.” I have to believe the number would be quite small. Admissions of that nature could have extremely negative effects on careers and may even open the door to civil suits or criminal prosecution. Perhaps I can be persuaded to think otherwise but I’ve seen nothing so far to indicate any voluntary system can work.
While the lay public calls them medical mistakes or errors the medical community has chosen to use different terminology. They refer to their errors as “Never Events” or Hospital Acquired Conditions (HACs) Never events are never supposed to happen – but they do and the onus is clearly on hospitals to do something about them. The Government found that one way to force hospitals to deal with these problems is to refuse payment so for several years now Medicaid and Medicare do not pay for any Hospital Acquired Condition.
When I was a communications consultant I specialized in health care so I spent a great deal of time working in and around hospitals and clinics. The great majority of them take the issue of patient safety very seriously and have implemented a multitude of actions to address the problem. They all have preventive programs and systems on what to do when there is an error. Most hospitals conduct a “Root Cause Analysis” every time there is a significant error so they can be sure the same error doesn’t happen again. They are working on the problem but patients owe it to themselves to always be alert and to question everything. Hospitals need to know that we are watching very carefully and that we will report what we see and experience.
Here is a list of HACs or Never Events as prepared by the National Quality Forum (NQF).
|Table. Never Events or Hospital Acquired Conditions
|Surgery or other invasive procedure performed on the wrong body part|
|Surgery or other invasive procedure performed on the wrong patient|
|Wrong surgical or other invasive procedure performed on a patient|
|Unintended retention of a foreign object in a patient after surgery or other procedure|
|Intraoperative or immediately postoperative/post procedure death in an American Society of Anesthesiologists Class I patient|
|Product or device events|
|Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting|
|Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended|
|Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting|
|Patient protection events|
|Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person|
|Patient death or serious disability associated with patient elopement (disappearance)|
|Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility|
|Care management events|
|Patient death or serious injury 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 injury associated with unsafe administration of blood products|
|Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting|
|Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy|
|Artificial insemination with the wrong donor sperm or wrong egg|
|Patient death or serious injury associated with a fall while being cared for in a health care setting|
|Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care facility|
|Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen|
|Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results|
|Patient or staff death or serious disability associated with an electric shock in the course of a patient care process in a health care setting|
|Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances|
|Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting|
|Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a health care setting|
|Death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area|
|Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider|
|Abduction of a patient/resident of any age|
|Sexual abuse/assault on a patient within or on the grounds of a health care setting|
|Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care setting|
Real Life Examples of Medical Mistakes
- Wrong Heart and Lung Transplant. One of the most tragic medical blunders ever took place at Duke University medical center in 2003, when surgeons transplanted a heart lung combination with the wrong blood type into 17-year-old Jesica Santillan. Her body began to shut down almost immediately. The hospital somehow secured a second and proper matched heart lung combination for Jessica but it was too late and she died. Dr. James Jaggers accepted responsibility for the tragic mistake, and Duke along with most other hospitals now have systems that require double checking the blood and tissue matches for transplants.
- Souvenir of surgery. In the year 2000 49 year old Donald Church had an abdominal tumor removed at the U of Washington Medical center in Seattle. While he left the hospital without the tumor, he had something that he didn’t have on admission — a 13-inch-long retractor had been left in Church’s abdomen by mistake. To make matters worse it was a repeat performance for the hospital, four other such occurrences had been documented there between 1997 and 2000. Fortunately, surgeons were able to remove the instrument but also agreed to pay Church nearly $100,000.
- Healthy kidney removed. Park Nicollet Methodist Hospital in Minnesota’s twin cities was the site of the next never event. A man was admitted to have one of his kidneys removed due to a cancerous tumor. Surgeons did just that but upon a post-surgical examination of the removed kidney they found no malignancy. That’s when they discovered they had removed the wrong one. We can’t report further because the family involved requested anonymity but Park Nicollet publicly admitted the error.
What Patients Can Do
The cable network developed this list of what they call “10 Shocking Medical Mistakes and Ways to Not Become a Victim.
1. Mistake: Treating the wrong patient
• Cause: Hospital staff fails to verify a patient’s identity.
• Consequences: Patients with similar names are confused.
• Prevention: Before every procedure in the hospital, make sure the staff checks your entire name, date of birth and barcode on your wrist band.
2. Mistake: Surgical souvenirs
• Cause: Surgical staff miscounts (or fails to count) equipment used inside a patient during an operation.
• Consequences: Tools get left inside the body.
• Prevention: If you have unexpected pain, fever or swelling after surgery, ask if you might have a surgical instrument inside you.
3. Mistake: Lost patients
• Cause: Patients with dementia are sometimes prone to wandering.
• Consequences: Patients may become trapped while wandering and die from hypothermia or dehydration.
• Prevention: If your loved one sometimes wanders, consider a GPS tracking bracelet.
4. Mistake: Fake doctors
• Cause: Con artists pretend to be doctors.
• Consequences: Medical treatments backfire. Instead of getting better, patients get sicker.
• Prevention: Confirm online that your physician is licensed.
5. Mistake: The ER waiting game
• Cause: Emergency rooms get backed up when overcrowded hospitals don’t have enough beds.
• Consequences: Patients get sicker while waiting for care.
• Prevention: Doctors listen to other doctors, so on your way to the hospital call your physician and ask them to call the emergency room.
6. Mistake: Air bubbles in blood
• Cause: The hole in a patient’s chest isn’t sealed airtight after a chest tube is removed.
• Consequences: Air bubbles get sucked into the wound and cut off blood supply to the patient’s lungs, heart, kidneys and brain. Left uncorrected the patient dies.
• Prevention: If you have a central line tube in you, ask how you should be positioned when the line comes out.
7. Mistake: Operating on the wrong body part
• Cause: A patient’s chart is incorrect, or a surgeon misreads it, or surgical draping obscures marks that denote the correct side of the operation.
• Consequences: The surgeon cuts into the wrong side of a patient’s body.
• Prevention: Just before surgery, make sure you reaffirm with the nurse and the surgeon the correct body part and side of your operation.
8. Mistake: Infection infestation
• Cause: Doctors and nurses don’t wash their hands.
• Consequences: Patients can die from infections spread by hospital workers.
• Prevention: It may be uncomfortable to ask, but make sure doctors and nurses wash their hands before they touch you, even if they’re wearing gloves.
9. Mistake: Lookalike tubes
• Cause: A chest tube and a feeding tube can look a lot alike.
• Consequences: Medicine meant for the stomach goes into the chest.
• Prevention: When you have tubes in you, ask the staff to trace every tube back to the point of origin so the right medicine goes to the right place.
10. Mistake: Waking up during surgery
• Cause: An under-dose of anesthesia.
• Consequences: The brain stays awake while the muscles stay frozen. Most patients aren’t in any pain but some feel every poke, prod and cut.
• Prevention: When you schedule surgery, ask your surgeon if you need to be put asleep or if a local anesthetic might work just as well.
There are other steps you can take to protect yourself besides those offered by CNN. For example:
Demand a hand-wash. While hospitals try to be germ free it is hard when almost everyone who enters the building is sick. It is a well-known fact that the best thing people can do to protect themselves from disease is frequent hand washing. The potential for contamination is everywhere so you are well within your rights to ask personnel to wash their hands before touching you. And…by the way, wash your hands frequently too.
Make sure your room is clean. Usually hospital rooms are thoroughly washed between patients but not as thoroughly if you are going to be there for a while. If you are concerned with the state of your room ask for certain areas or all of it to be disinfected. Transplant recipients in particular must be sure they are in as germ free an environment as possible. Certainly if hospitalized they should always wear a face mask to protect themselves. And, do your best to stay out of crowded areas like elevators. If you must enter a crowded room, wear a face mask. All hospitals have them you just have to ask for one…
To be even more specific though, Patient Safety America suggestions these you do the following to stay safe http://patientsafetyamerica.com/truth-about-healthcare/
1. The single most important way you can help to prevent errors is to be an active member of your health care team.
That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Here are some specific tips, based on the latest scientific evidence about what works best.
2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs.
At least once a year, bring all of your medicines and supplements with you to your doctor. “Brown bagging” your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date, which can help you get better quality care.
3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
This can help you avoid getting a medicine that can harm you.
4. When your doctor writes you a prescription, make sure you can read it.
If you can’t read your doctor’s handwriting, your pharmacist might not be able to either.
5. Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you receive them.
- What is the medicine for?
- How am I supposed to take it, and for how long?
- What side effects are likely? What do I do if they occur?
- Is this medicine safe to take with other medicines or dietary supplements I am taking?
- What food, drink, or activities should I avoid while taking this medicine?
6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?
A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose.
7. If you have any questions about the directions on your medicine labels, ask.
Medicine labels can be hard to understand. For example, ask if “four doses daily” means taking a dose every 6 hours around the clock or just during regular waking hours.
8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you’re not sure how to use it.
Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being told how to use the devices helps even more.
9. Ask for written information about the side effects your medicine could cause.
If you know what might happen, you will be better prepared if it does—or, if something unexpected happens instead. That way, you can report the problem right away and get help before it gets worse. A study found that written information about medicines can help patients recognize problem side effects and then give that information to their doctor or pharmacist.
10. If you have a choice, choose a hospital at which many patients have the procedure or surgery you need.
Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.
11. If you are in a hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands.
Hand washing is an important way to prevent the spread of infections in hospitals. Yet, it is not done regularly or thoroughly enough. A recent study found that when patients checked whether health care workers washed their hands, the workers washed their hands more often and used more soap.
12. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home.
This includes learning about your medicines and finding out when you can get back to your regular activities. Research shows that at discharge time, doctors think their patients understand more than they really do about what they should or should not do when they return home.
13. If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done.
Doing surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. The American Academy of Orthopedic Surgeons urges its members to sign their initials directly on the site to be operated on before the surgery.
Other Steps You Can Take
14. Speak up if you have questions or concerns.
You have a right to question anyone who is involved with your care.
15. Make sure that someone, such as your personal doctor, is in charge of your care.
This is especially important if you have many health problems or are in a hospital.
16. Make sure that all health professionals involved in your care have important health information about you.
Do not assume that everyone knows everything they need to.
17. Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can’t).
Even if you think you don’t need help now, you might need it later.
18. Know that “more” is not always better.
It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it.
19. If you have a test, don’t assume that no news is good news.
Ask about the results.
20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.
You may ask yourself upon reading all of this what the U.S. Food and Drug Administration (FDA) is doing to make hospitals safer. Well, they can’t be in every hospital all the time to watch everything and…that’s not their role. The FDA is probably not doing enough to protect us, there’s no way you can satisfy everyone but they are doing a few things that could make a huge difference. One of which is to eliminate drug name confusion.
To minimize confusion between drug names that look or sound alike, the FDA reviews about 300 drug names a year before they are marketed. “About one-third of the names that drug companies propose are rejected,” says Phillips. The agency tests drug names with the help of about 120 FDA health professionals who volunteer to simulate real-life drug order situations. “FDA also created a computerized program that assists in detecting similar names and that will help take a more scientific approach to comparing names,” Phillips says.
After drugs are approved, the FDA tracks reports of errors due to drug name confusion and spreads the word to health professionals, along with recommendations for avoiding future problems. For example, the FDA has reported errors involving the inadvertent administration of methadone, a drug used to treat opiate dependence, rather than the intended Metadate ER (methylphenidate) for the treatment of attention-deficit/hyperactivity disorder (ADHD). One report involved the death of an 8-year-old boy after a possible medication error at the dispensing pharmacy. The child, who was being treated for ADHD, was found dead at home. Methadone substitution was the suspected cause of death. Some FDA recommendations regarding drug name confusion have encouraged pharmacists to separate similar drug products on pharmacy shelves and have encouraged physicians to indicate both brand and generic drug names on prescription orders, as well as what the drug is intended to treat.
The last time the FDA changed a drug name after it was approved was in 2004 when the cholesterol-lowering medicine Altocor was being confused with the cholesterol-lowering medicine Advicor. Now Altocor is called Altoprev, and the agency hasn’t received reports of errors since the name change. Other examples of drug name confusion reported to the FDA include:
- Serzone (nefazodone) for depression and Seroquel (quetiapine) for schizophrenia
- Lamictal (lamotrigine) for epilepsy, Lamisil (terbinafine) for nail infections, Ludiomil (maprotiline) for depression, and Lomotil (diphenoxylate) for diarrhea
- Taxotere (docetaxel) and Taxol (paclitaxel), both for chemotherapy
- Zantac (ranitidine) for heartburn, Zyrtec (cetirizine) for allergies, and Zyprexa (olanzapine) for mental conditions
- Celebrex (celecoxib) for arthritis and Celexa (citalopram) for depression.
For more information on the FDA and what they are doing click on this link http://www.fda.gov/
The bottom line on medical errors is activist patients. Don’t sit by quietly when you perceive something to be wrong with your care or the care of someone near and dear to you. Speak up, tell someone about your concerns. Every city and state has some sort of health department so if you see something wrong speak up and tell the appropriate authority starting with the hospital.
Most importantly, though, be aggressive and knowledgeable about your own health care. Don’t be afraid to ask for second opinions, to question physicians, nurses and other practitioners. Force your health care provider to speak to you in plain English and if you don’t understand ask for clarification. Hospital personnel work for you so they have a responsibility to respond to your concerns in as thorough and clear a manner as possible. The only way hospitals will really change for the better is for citizens, patients like you and me to speak up and let them know we know.
Now retired and living in Jacksonville, Florida with his wife Robin he spends his time advocating for patients with end stage diseases and for organ recipients. He is also active in helping his wife with her art business at art festivals and on her Rockin Robin Prints site on Etsy.
Bob is a former journalist, Governor’s Communication Director and international communications consultant.
Posted on January 9, 2014, in Health care and tagged doctors, FDA, Hospital errors, infections, medical errors, medical mistakes, never events, patients, ProPublica, sentinal events, surgery. Bookmark the permalink. Leave a comment.