All Entries Tagged With: "patient death"
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.
Sentinel events for first half of 2011 available
The November issue of The Joint Commission’s Perspectives gives us an idea of the sentinel events that resulted in death or major permanent loss of function in the beginning half of 2011. This includes 76 incidents of foreign body left after surgery, 67 reports of wrong-patient, wrong-site, or wrong-procedure surgery.
That seems like a lot to me in just six months (especially the wrong-site surgeries).
One other stat that surprised me was 23 criminal events. Perhaps I am just naïve, or maybe there’s just more reporting?
What do you think of these numbers? Do you think it is accurate and unsurprising? Share your thoughts below.
Boston Globe highlights dangers of alarm fatigue
In a two-part series, The Boston Globe has explored the dangers of alarm fatigue, a term used to describe frontline staff becoming desensitized to the incessant beeping of copious amounts of medical machines in hospitals.
Alarms are ignored because they are not high priority, such as those that indicate low batteries; because they are too frequent, such a nuisance alarms that go off when a lead falls off a patient; or too sensitive, sounding off when a patient coughs or turns over. There is also the danger of turning down or shutting off alarms because they keep going off unnecessarily, only to be missed later when there is a true emergency. Alarms can also be programmed incorrectly.
The Globe identified at least 15 deaths in the past six years due to alarm problems, but experts told the Globe that finding a solution to alarm fatigue isn’t easy. Fewer monitors might help, but it’s difficult to convince physicians not to use such readily available technology, even when a patient may not need it. Another option, smart monitors, would monitor multiple patient indicators before going off, lessening the chance of a false alarm.
The problem is certainly at the forefront of patient safety. I recently spoke with experts at the ECRI Institute, which consistently ranks alarm fatigue as a top healthcare technology hazard, about the problem in the latest issue of Patient Safety Monitor Journal. They say the amount of alarms a single nurse must listen for during his or her shift reaches into the hundreds.
What do you think? How can we start to solve alarm fatigue?
A dozen CA hospitals fined over patient safety issues
The California Department of Public Health (CDPH) has fined 12 hospitals for patient safety-related noncompliance, according to a CDPH release. The fines are for putting patients in “immediate jeopardy” of harm.
Out of 14 fines, eight were for failure to follow proper surgical safety protocol that resulted in objects left inside patients. A portion of the funds received from the fines will go toward improvement projects that focus on preventing this particular type of adverse event.
Hospitals that were cited in 2008 were fined $25,000, but a new law requires hospitals cited in 2009 and beyond to be fined $50,000 for the first citation, $75,000 for the second, and $100,000 for the third.
A detailed run down of each adverse event can be found at HealthLeaders Media. Other events include medication administration errors, medication storage errors, and failure to properly treat pressure ulcers. One patient fell out of bed, causing cardiac monitor to become disconnected. She later died.
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.
Some medical students already taking patient safety courses
Students at medical schools across the country are being given the opportunity to take elective courses in patient safety and error prevention. However, there are far less that actually require these types of courses as part of their curriculums, reports the Providence Journal. This is often because there is so much medical knowledge that students need to absorb during their time at medical school that patient safety takes a backseat.
However, the Lucian Leape Institute released a report in March calling out residency programs for not focusing enough on patient safety. Some schools that are requiring courses on patient safety, like Brown University’s Warren Alpert Medical School, where students take a course just before they begin their hospital rounds. The instructor of the course relates physicians to airplane pilots, who rely on good communication, the use of checklists, and can often fall prone to “solo thinking.” One issue medical schools are coming up against is that they cannot find qualified physicians to teach these types of courses, because they were never taught this way of thinking when they themselves were in medical school.
Readers, if you work in a teaching facility, do you think that medical students have a better grasp of how to prevent adverse events when they enter hospitals for their residencies? Have you seen any effects of a patient safety curriculum?
You can read the full article from the Providence Journal here.
AHRQ Study: Patients less likely to receive necessary care on weekends
A new report out from the Agency for Research and Healthcare Quality shows that patients who go to the hospital on the weekend are less likely to receive the necessary care than patients who visit the hospital during the week, according to HealthLeaders Media. In addition, 2.4% of patients admitted to the hospital on the weekend die, compared with 1.8% of patients during the week.
The study analyzed data for 2007 hospital inpatient stays through the AHRQ’s Healthcare Cost and Utilization Project
The AHRQ is saying that while these data were drawn from the study, it’s too early to say definitively that patients receive worse care when they arrive on the weekends. Specifically concerning the death rate–far more patients visit the hospital for an emergency on the weekends, as compared to during the week (70% vs 40%). It’s difficult to compare the care of patients who have planned admissions with those whose admissions are unplanned and emergent.
You can read more about some of the findings by checking out the full article here.
Does this report line up with what you see at your facility? There are many factors here, which is why the AHRQ doesn’t really draw any full conclusions as to why patients may be receiving less timely care on the weekends, but it does make one raise an eyebrow.
Another case of hospitals behaving badly
St. Francis Hospital and Medical Center in Hartford CT is the latest facility to make headlines for violating state regulations concerning patient care. The hospital was placed on probation by the Connecticut Department of Health, according to the Hartford Courant. One of the more recent instances involved a heart surgery patient who sustained a brain injury during a May18 surgery. The patient later died on June 18, and on July 2, the hospital stopped offering non emergent cardiac surgeries.
The major problem in this case stemmed from a pump failure with the pump used for cardiopulmonary bypass, according to the Courant. The hospital did not address the pump failure adequately. Specifically, the hospital didn’t report the pump failure to the Food and Drug Administration or the manufacturer or communicate the failure to hospital leaders and other members of the medical staff. Additionally some of those providers involved in the surgery did not participate in a cause analysis, and what I think constitutes the worst offense, the hospital put the pump that failed back into use just three or four days after the incident.
The hospital has issued a statement saying that it has made administrative changes, updated OR procedures, and revised equipment and maintenance protocols. You can find the full article here.
I wrote this post last week about a Rhode Island hospital that was fined by the state’s Department of Health. I know that these two cases are gaining media attention, so that’s not to say that other facilities in their area are not committing similar errors. But in reading the descriptions of how the situations were handled, it seems to me that neither facility really placed much emphasis on learning from their mistakes, which I think is what is most startling.
Joint Commission releases latest sentinel event data
Coming off of yesterday’s post about The Joint Commission’s newest Speak Up campaign, which is geared toward preventing medical errors with pediatric patients, today’s post is about the latest sentinel event data released by The Joint Commission. As of June 30, 2009, wrong-site surgery is still the most commonly reported sentinel event, making up 13.4% of all reported events. In the first two quarters of 2009, 53 wrong-site surgeries were reported to The Joint Commission. In 2008, 116 wrong-site surgeries were reported during the entire year, to give you some background.
Close behind wrong-site surgery is suicide for reported sentinel events, making up 12% of all reported events. The top five most frequently reported sentinel events through the first two quarters of 2009 are:
- wrong-site surgery
- suicide
- operative/ post operative complication
- medication error
- delay in treatment
To read the full list, click here. To find The Joint Commission’s Web page about sentinel events, click here.
Sidney Zion, advocate for limiting doctors’ hours, dies
Writer Sidney Zion, whose daughter’s death at New York Hospital led him to successfully advocate for reforms in residents’ hours, passed away on Sunday at the age of 75. He had been suffering from bladder cancer, the New York Times reports.
Zion was a well-known New York journalist and author who raised concerns about the long hours and workloads of interns and residents after the death of his 18-year-old daughter Libby. A freshman at Bennington College, she had been admitted to New York Hospital on March 4, 1984, with fever, chills, and agitation. She had a history of despression and cocaine use, but her condition was not diagnosed and two interns gave her a painkiller and sedative after consulting by phone with a senior clinician. Libby died eight hours after admission.
Zion and his wife Elsa sued the hospital and four doctors, alleging gross negligence in their daughter’s death. The Zions also campaigned for improved supervision and limited hours for hospital interns and residents, who at the time would work 100-120 hours per week and 36-hour shifts. The high-profile case led to many newspaper and magazine articles, TV coverage, and a book.
A grand jury in 1987 rejected Zion’s claim of medical “murder” charges, but said hospital errors may have contributed to Libby’s death. As a result, the hospital admitted some errors was fined $13,000 by New York State. Two years later, the state limited interns and residents to 80-hour weeks and 24-hour shifts, and said senior clinicians must be in hospitals at all times. In 2003, the Accreditation Council for Graduate Medical Education adopted similar standards nationally.
In 1995, a jury came back with a mixed verdict in the Libby Zion case, saying the hospital wasn’t to blame for her death but that an intern and two doctors had contributed to it by giving her a drug that could be fatal for patients on antidepressive medication. A damages award of $750,000 was cut in half because the jury found that Libby Zion was equally to blame for not disclosing that she had taken cocaine and prescription drugs. The trial judge threw out that latter finding, but kept the award at $375,000, according to the Times.
