All Entries in the "Lawsuit" Category
Top 10 most read blogs posts from 2011
The new year is upon us. I thought before we dive into what’s to come for patient safety and quality in 2012, we might want to look back at 2011 and see what grabbed the attention of the patient safety world.I calculated the top ten by how many times each post was viewed. They are:
10. Joint Commission and FDA to focus on alarm fatigue
The Joint Commission (TJC) told The Boston Globe that it would work with the Food and Drug Administration (FDA) to make alarm fatigue—a worrisome problem in most hospitals—a priority.
9. Disruptive behavior, negligence, endangered patients, and millions of dollars
In August, settlements for old patient safety incidents in Boston and recent investigations in Dallas found more recent patient safety infarctions.
8. Rewarding near-miss reporting
This post discusses the importance–and challenge–of getting staff to report near misses, highlighting an example in one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards.
7. Joint Commission issues Sentinel Event Alert about workplace violence
The Joint Commission issued an alert on workplace violence in July 2010, but workplace violence was a hot enough topic to remain at the top in 2011.
My personal story of a patient and family whose anger and frustration grew as they faced an elusive plan of care and a care team who seemed uncommunicative.
5. New York Times article exposes radiation therapy errors
Another post that was published in 2010, but the issue of radiation errors and over-radiation remained hot in 2011. This post highlights one of the first articles in a series The New York Times ran from 2010 and into 2011 on radiation concerns.
4. Medication error prompts lawsuit for Massachusetts General Hospital
A medication error that resulted in a death and a lawsuit was met with a communicative response from hospital representatives, who said systematic improvements implemented since the error now help staff to avoid making similar errors.
3. Boston hospital admits three spinal surgery errors in two months
Published at the very end of 2010, this is yet another post on a hospital admitting to errors—this time surgical site errors—that did not need to happen. Beth Israel Deaconess Medical Center in Boston is in the spotlight after its surgeons made errors in three separate spinal operations in two months.
This post explaining how a resident failed to carry out an order on her mobile device after she was interrupted by a personal text messaged grabbed the attention of Patient Safety Blog readers. With this anecdote as proof, social media concerns have leaped from HIPAA violations to immediate threats to patient safety.
1. Can a video really help curb infections?
Perhaps videos are just more fun to watch. This post embedded the winning video of the APIC Infection Prevention Film Festival, which lays blame on frontline providers who fail to do everything they can to “do no harm—” in this case, failing to wash their hands.
What do you think? Any of your favorites missing? Let me know.
Joint Commission proposes new goal to prevent harm, waste
Last week, The Joint Commission announced it was proposing a new National Patient Safety Goal. The goal would address overuse of treatments, procedures, and tests.
The idea is that if evidence shows no benefit, you are exposing a patient to only potential harm by giving an unnecessary test or treatment.
The proposed goal would have hospitals implement a program to address the issue by selecting a treatment or test to focus on. Pick something, evaluate it, monitor it, and implement new methods to decrease any overuse that’s found.
I find this proposed goal an interesting one. The other goals impose measures to decrease the risk of harm, but the risk here seems more minimal or evidence-based. I don’t mean to say there aren’t risks, I’ve discussed the risks of too much radiation over time, but there is no denying this goal would also reduce waste and cost, and those effects will be much easier to measure. Was this designed to back up physicians who don’t order a test for everything for fear of malpractice suits? Would this help if a physician was charged with negligence for not ordering a test that was not necessary but, as it turns out, would have discovered something?
What do you think of the proposed goal? Post your comments below.
And by the way, the The Joint Commission is taking comments until January 24!
Apologies and action for famous actors only?
Hospital chief Sandra Coletta is making waves throughout the healthcare community after being frank with her audience of hundreds at the 10th annual dinner of Medically Induced Trauma Support Services (MITSS), a widely respected group that aims to support patients, families, and staffs after things go medically wrong.
She spoke about the death of James Woods’ brother in the emergency department at Kent Hospital in Warwick, RI, after orders were not carried out in a timely manner.
“Quite honestly, I did nothing other than what my mother taught me,” Coletta said of apologizing.
James Woods and the hospital settled the suit, in the process created a foundation, the Michael J. Woods Institute, in honor of his brother. The institute aims to recreate healthcare from a human factors perspective.
Similar action was taken after Dennis Quaid’s twins were put in peril because of a medication administration mistake. (According to an April 2010 USA Today story, Quaid said Cedars-Sinai hospital in LA “stepped up to the plate and spent millions of dollars on bedside bar codes.” He and his wife also created the Quaid Foundation, which has merged with the Texas Medical Institute of Technology.) Do you think these cases are addressed more swiftly, and more apologetically, because of their high-profile nature? Or do you think the tides are turning?
Of course, Sorrel King, without being famous (at least then), spurred plenty of action on her own. But are hospitals finally reacting with action and apologies, even without fame and publicity?
Share your thoughts on the blog.
Disruptive behavior, negligence, endangered patients, and millions of dollars
August had been filled with a number of different patient safety rulings and findings that show poor patient safety can be costly in many different ways.
Let’s start with Boston, where two old cases have been settled.
First, parents of a newborn who died at Beth Israel Deaconess Medical Center in Boston seven years ago were awarded $7 million by the Suffolk County Superior Court after a physician and nurse practitioner were found negligent in their care. The parents claimed they did not react quickly enough to the infant’s deteriorating condition. The premature infant developed necrotizing entercolitis, something caregivers should have been watching for as it is common in infants delivered prematurely.
The parents alleged they came to visit their daughter and found her discolored and unresponsive, and said staff took more than an hour to respond.
In another recent decision, the U.S. Court of Appeals upheld a lower court verdict against Brigham and Women’s Hospital involving alleged disruptive behavior exhibited by Arthur Day, MD, the former head of neurosurgery. Sagun Tuli, MD, claims the hospital retaliated against her for complaining about her work environment.
The court ruled that Tuli was defamed and that her career was affected.
Now, on to Dallas.
It was recently reported that in March, 2010, Parkland Medical Memorial Hospital in Dallas, TX, informed 73 female patients that instruments that were not properly sterilized had been used on them, putting them and any sexual partners at risk of infections.
Following that incident, the Centers for Medicare & Medicaid Services (CMS) investigated the hospital in July, 2011. The investigation led to the finding that the hospital created an “immediate and serious threat to patient health and safety.” The report found that ED patients in severe pain were given maps of the hospital to find the appropriate place for treatment and children sent home without screenings.
Meanwhile, in a separate investigation, Parkland Memorial Hospital, along with the University of Texas Southwestern Medical Center, agreed to pay $1.4 million after a four-year Medicare billing fraud investigation revealed that resident surgeons were not properly supervised and also failed to comply with informed consent requirements.
Another Dallas hospital, Methodist Dallas Medical Center, was also recently cited for 10 violations by CMS, some which include failing to screen and stabilize emergency department (ED) patients and understaffing the ED.
Do these more recent findings indicate that CMS is getting tougher? Would similar findings be found elsewhere, if investigated? Is this the sign of the times of healthcare reform? What do you think? Share thoughts below.
Physician and nurse practitioner duo blamed for six drug fatalities
A physician and nurse practitioner in Needham, MA, have been indicted for the deaths of six drug-addicts who were prescribed painkillers by the pair including methadone, oxycodone, and fentanyl. The indictment alleges the pair prescribed the drugs to make a profit, according to charges heard on March 3 in a Boston federal court.
Joseph Zolot, a nonsurgical orthopedic specialist, and Lisa Pliner, a nurse practitioner, could spend 20 years to life in prison if convicted, reports The Boston Globe. Since the investigation began, Zolot has given up his medical license and Pliner gave up her nurse practitioner license but remains a licensed nurse.
According to the indictment, Zolot and Pliner allegedly knew the six patients were drug addicts, but prescribed anyway for money and insurance payments. The patients overdosed on their drugs, causing death.
Patient awarded $2.2 million after injuries from laparoscopic surgery
A female patient was awarded $2.2 million by Richard Wolf Medical Instruments after she suffered a stray electrosurgical burn to her bowel during laparoscopic surgery in 2007. A jury awarded the settlement after deciding the burn was due to defective laparoscopic instrument.
Richard Wolf Medical Instruments was found liable for Andrea Huber’s injuries because of a poorly designed laparoscopic coagulator, reports Outpatient Surgery. After Huber’s surgery, she experienced abdominal pain and was later diagnosed with peritonitis, an inflammation of the tissue that lines the abdomen wall. She had to have further surgery to remove part of her bowel, and then had to have her fallopian tubes removed because of surgical complications, according to the article.
The attorneys for Richard Wolf argued that the injury to the bowel did not occur from an electrical burn, but happened while the trocar was being inserted. The jury disagreed, finding that the injury was caused by stray electricity from the shaft,.
Drill bit left in patient’s scalp prompts investigation
We get splinters inside of us and even fine particles of metal, but it’s not every day that a drill bit gets stuck inside.
During diagnostic imaging on August 6, Rhode Island Hospital staff realized a neurosurgery patient still had a surgical drill bit inside her scalp two days after surgery.
The physician and operating room staff were suspended after the event, and the Rhode Island Department of Health has opened up an investigation, reports WRPI.
This isn’t the first incident that has been investigated within Rhode Island Hospital. In October, 2009, a doctor performed surgery on the wrong finger of a patient, reports WRPI. After that incident—the fifth in two years—video cameras were installed in operating rooms.
New California law prompts healthcare facilities to report radiation overdoses
California hospitals have less than a year to adhere to a new law requiring the state Department of Public Health to be notified any time a patient is given a radiation dose in an imaging scan exceeding 20% of what was intended, reports HealthLeaders Media.
The new bill signed by Arnold Schwarzenegger won’t go into effect until July 1, 2012.
Recent overdoses of radiation in the state have prompted the new bill. Cedars-Sinai Medical Center in Los Angeles admitted to accidently giving 206 stroke victims eight times the dose of a normal radiation procedure, according to an article in The New York Times.
A two-year-old boy in a California hospital was administered an overdose of radiation which allegedly burned parts of his face, according to CW13.
The new law requires hospitals and clinics to record every radiation dose done on CT systems. The recorded doses then must be verified by a medical physicist. Healthcare facilities have five days to inform the Department of Health if anything goes wrong.
Read the rest of this article on California’s new law at HealthLeaders Media.
What do you think of the new law passed by California? Share your comments with us!
Physicians recall their shocking stories of what went wrong
The last thing a patient wants to hear is that their doctor made a mistake. An article published in Reader’s Digest gives doctors the spotlight in telling their horrific, sometimes fatal, mistakes made in the hospital.
I thought our readers would find this interesting. Read the stories of real life doctors whose career and lives were put on the line.
Well known patient safety advocates Peter Pronovost, MD, PhD and Robert M. Wachter, MD, among others, tell their stories of simple mistakes with dire consequences. Wachter recalls a mistake he made as a second-year medical student by simply failing to read a textbook chapter. The article is just another reminder that healthcare is slowly but surely becoming more transparent.
Have you ever made a mistake in a healthcare setting? Was it made transparent? Did you or the hospital learn from the mistake? We’d love for you to share below.
Can the safety risks associated with organ donation be reduced?
One topic I don’t find myself researching and writing a lot about is the patient safety issues surrounding organ donation. The Wall Street Journal has a revealing story today that has put the issue on my agenda, however. THe story is about the dangers organ recipients face due to a precarious balance that those organizations collecting and distributing organs face. On the one hand, there is a long waiting list for most organs, and in fact 9,000 people die annually waiting for an organ. Therefore, time is of the essence, and there often is not the adequate amount of time to rigorously test organs for disease, parasites, cancer, and infection, and many organs that are not extremely healthy make it onto the list of those eligible to be received. However, there’s a growing number of people who suffer extreme severe reactions to organs that have been transplanted into them because the organs do in fact carry some sort of infection.
The United Network for Organ Sharing, which operates the U.S.’ organ transplants, has been tracking rates of reported infection since 2004 and found that only 1% of patients who receive an organ report also acquire a disease because of an infected organ. However, the group says that most likely patients underreport any such transmission.
The group’s latest project is the development of an organ donor ID system. The idea is to prevent the spread of disease via organ/tissue transplant. One such donor infected with Hepatitis C donated 91 different tissues and organs to 40 patients. Of those, eight patients became infected and two died from the disease.
To read more on this topic from the Wall Street Journal, click here.
