Medical Errors

No sooner had we posted our previous item about how we experienced the emergence of a hospital "culture of safety" when we picked up the Health Section of today's Washington Post, and read about a 12-year-old boy who nearly had surgery on the wrong ear. His mom, Tracy Grant, a Washington Post editor, told the medical team over and over and over again in the days, hours, and minutes before the operation that they were about to slice into the wrong ear, that the paperwork was wrong. They treated her like she was the problem. The story has a happy ending—they operated on the right ear. Or rather, the correct, left, ear.

Grant learned through subsequent research that for 15 percent of the population, telling left from right is not automatic. John R. Clarke, a professor of surgery at Drexel University and the clinical director of the Pennsylvania Patient Safety Reporting System, has found that surgical mistakes involving the wrong side of the patient occur three times a day in the United States. That doesn't count the near misses—when someone, in this case a mom, spoke up.

A prominent Boston hospital made a big mistake (operating on the wrong side of the patient—who luckily should be fine) and then told the whole world—including the Boston Globe—about it in an email and a blog post from the hospital CEO in which he describes the circumstances and the hospital's response.

We like Beth Israel Deaconess CEO Paul Levy's "Running a Hospital" blog, and we link to it now and then. Beth Israel has a reputation for being a leader in both quality improvement and transparency, and Levy often writes about how even people on the lower rungs of the hospital hierarchy are encouraged to pipe up when they see something potentially unsafe or just inefficient. What really bothered us about this case was the hospital does have a "time out" policy—before the surgery, the team is suppose to call out, "Right patient, right procedure, right side." No one did, and no one spoke up. It bothered Levy too. As he said, the "culture of safety" hasn't permeated everywhere it needs to go.

Bar codes on medication have been hailed as a remedy for drug errors in hospitals. Medication errors are not a small problem; the Institute of Medicine in 2006 estimated that at least 400,000 preventable medication mistakes occurred annually in U.S. hospitals, leading to about 9,000 deaths and $3.5 billion in extra cost. About one-third of U.S. hospitals now use bar codes to track medications and match up patients and their medicine. Most other hospitals are expected to introduce bar coding in the next few years.

But an interesting story by Josh Goldstein in today's Philadelphia Inquirer, however, reports that what works for your local grocery store doesn't always work so well on the hospital floor. A system that seems great on paper can be flawed in practice if, say, the computer can't be taken into an isolation room (meaning it's down the hall where the nurse can't hear the beep-beep alert of an error) or nurses who find ways of working around the bar code system, for instance, when they have to retrieve insulin for four different patients from a refrigerator on a different floor, scan in the code, and then carry all the medicine on one single tray back to four patients all awaiting different doses.

California now requires that hospitals inform state officials of substantial injuries to patients. The first batch of reports are in: 1,002 cases of "serious medical harm" in the 10 months starting last July, according to the LA Times. By "serious" the state means things like taking out the wrong person's appendix, patients dying after being given the wrong drug, a nine-day-old baby not getting enough oxygen when a ventilator hose is hooked up according to a diagram that was drawn backwards.

The point of error reporting isn't hand wringing or finger pointing. It's coming up with solutions to improve patient safety. The California Department of Public Health can now fine hospitals over safety errors. And increasingly, Medicare, some big health insurers and now a few states are deciding that they want to make patient safety good business—or at least they want to make safety errors bad business. They won't pay for the care needed to fix the mistakes. You break it, you pay.

You know those signs in gift shops, "You break, You pay?" Medicare has adopted that philosophy in refusing to pay hospitals for "never events"—things that just shouldn't happen to patients. Now the agency has proposed adding to its list.

Last year Medicare announced it would not pay for certain medical errors and conditions acquired in hospitals. Starting October 1, several private insurers followed suit. Now Medicare wants to add nine more avoidable conditions and complications, if acquired in the hospital. The goal, which we like, is to put some financial teeth in efforts to improve care of patients, including infection control. Hospitals should not be dangerous to our health.

According to the AP, the new list includes deep vein thrombosis, or a blood clot within the vascular system, which occurred in 140,010 cases for the fiscal year ending September 30, ventilator-associated pneumonia, which occurred in 30,867 cases, bloodstream infections with the staph aureus bacteria, 27,737 cases, and Legionnaire's disease, which occurred in 351 cases.

One pill, two pills? Red pills, blue pills? Each year  more than 1.5 million people are injured by preventable medication errors, and, according to a new study in Pediatrics reported by the Associated Press, about one out of every 15 hospitalized children is harmed by a medication error--getting the wrong drug, the wrong dosage, or the wrong reaction.

We wrote about medication errors recently after actor Dennis Quaid related his baby twins'  ordeal to the  Association of Health Care Journalism conference last month. Quaid is using his celebrity to draw attention to practical ways of reducing medical errors. His newborns nearly died last November after receiving the wrong dosage of the blood thinner Heparin.

Reducing medical errors is an important goal in itself—the Institute of Medicine estimates that as many as 98,000 Americans die each year because of preventable mistakes. But that goal will be most effectively achieved as part of a comprehensive reform which would combine and amplify the incentives for developing health information systems, changing payment incentives and sharing best-practices among all clinicians.

"Oops I did it again," may have made millions as a pop song, but for 11 preventable medical errors, it will no longer get you paid by the Indianapolis-based insurer, WellPoint, according to an article in today's Indianapolis Star.

WellPoint joins a growing number of public and private payers in efforts aimed at promoting quality, reducing errors, and controlling costs in our medical system. WellPoint's new policy adopts the steps taken by the Centers for Medicare and Medicaid Services last fall to no longer pay for preventable medical errors, injuries and infections that occur in hospitals.

Like CMS, WellPoint will make sure that neither it nor its patients pay for three so-called "never events"—surgical mistakes that should never happen under any circumstances. They are:

• Surgery on the wrong body part
• Surgery on the wrong patient
• The wrong surgery performed on a patient.

Additionally the insurer will limit payments for the following events, all of which are highly preventable when evidenced-based guidelines are adhered to:

Imagine if your newborn twins, already hospitalized with an infection likely acquired at another hospital, were given two potentially fatal overdoses of a blood thinner. Imagine if your pediatrician (now your former pediatrician) did not call to tell you. Imagine if the night nurse told you everything was fine when you phoned to check on the babies. Imagine if you learned the truth when you arrived at the hospital at 6 a.m. to see your kids and were met by Risk Management.

That's what happened to Dennis Quaid last winter. His babies survived. His story has been told. But Quaid hasn't forgotten the 41-hour ordeal, when his tiny children nearly bled to death, their blood "squirting on the walls." He has joined the ranks of "cause celebrities," knowing that his fame can bring national attention to medical errors that usually occur in isolation. He has set up a new foundation to address patient safety, particularly regarding medication errors.

Remember that scary Institute of Medicine report a few years back about the 98,000 fatal medical errors in hospitals each year? And the conclusion that it wasn't the fault of a few "bad apple" or incompetent doctors and nurses, but layers of unnecessary hazards built into the system? The problems range from confusing packaging to the "hurry up and rush" culture of hospitals. Today's Wall Street Journal has an interesting article on how hospitals are rethinking how they use the riskiest drugs--the eight medications which studies have shown account for nearly one-third of the drug errors that harm patients.