Serious medical errors, little public information
Girl, 16, dies during restraint at an already-troubled hospital
Caution urged with facedown restraints
Doctor lost hospital privileges but kept clean record
Editorial: Transparency is the best medicine to improve health care quality
Praise for story on medical secrecy
Hurray for the St. Louis Post-Dispatch: For puncturing the secrecy around doctors’ mistakes, CJR’s Campaign Desk
Tip sheets:
A road map for covering your local hospital’s quality: This tip sheet, from ProPublica's Charles Ornstein and Tracy Weber, features a number of sources for quality data and a state-by-state list of websites for statistics on health care quality.
How well does your state oversee nurses?: Also from Ornstein and Weber, has suggestions gleaned from their award-winning investigatin into California's Board of Registered Nursing.
By Jeremy Kohler
Who protects the patients?
That’s what we want to know at the St. Louis Post-Dispatch – and it’s the title of an occasional series on health care. My colleague, AHCJ member Blythe Bernhard, and I plan a series of stories about the paucity of information available to patients to help them choose hospitals and doctors.
Multiple sources told us a surgeon took out the wrong kidney from a patient in 2007 at DePaul Health Center. We thought patients in need of a surgeon might want to know that.
We found that although several agencies investigated, there was very little on the public record. That was frustrating.
The Joint Commission, an organization that accredits hospitals, told us it would confirm any wrong-site surgery that it knows about. The commission then confirmed a "wrong-site" surgery occurred at DePaul in 2007. It wasn’t a lot of information but it was enough to know we were on the right track. Kenneth Powers, the commission’s media relations manager, was friendly and responsive to our requests, even if thin on detail. His e-mail address is kpowers@jointcommission.org.
When 'never events' occur, the public has virtually no way to find out about them, at least in Missouri and many other states without reporting laws.
One of our tips said the case was settled before going to court. No court file existed. We requested the state database of malpractice claims; the agency removed identifiers before providing it. We found just two cases involving wrong-site surgeries in St. Louis in 2007. One involved urology. The surgeon and his practice paid the patient about $1.7 million without a lawsuit being filed.
We downloaded the National Practitioner Data Bank "public use data file" and found that payment. The 18MB file is in SPSS format, which I converted to a Microsoft Access database. The public file omits doctors’ names and fudges other identifying information. But we did learn that the surgeon was in his 50s and got his medical degree in the 1980s. The patient was a man in his 50s who was significantly and permanently injured.
We requested the Statement of Deficiencies and Plan of Corrections forms (CMS 2567) from the Missouri Department of Health and Senior Services, which investigates errors at hospitals for the U.S. Centers for Medicare and Medicaid Services. Those cost $72 to copy and it took the state a month to get them to us.
One report referred to a serious error in December 2007 that seemed connected to a review of urologic surgery at DePaul. Several surgeons were performing "minimally invasive" procedures without record of proper credentials. One of them involved a patient who came in for a nephrectomy – removal of a diseased kidney. The surgeon hadn't completed a medical history of the 55-year-old patient in advance, and hand wrote one the day of surgery – Dec. 13, 2007.
Missouri DHSS officials did confirm that the scrutiny of DePaul's urology department started with a wrong-kidney surgery. They just wouldn't confirm it was the one on Dec. 13.
If the state's investigation started with a wrong-kidney surgery, why did it branch off into other issues? Why didn't the state dig into the cause of the wrong-kidney surgery, or even make mention of it? A CMS official told us the surgery was found to be the sole fault of the doctor, and they are only tasked with investigating system-wide problems. They turned the case over to the Missouri Board of Professional Registration for the Healing Arts, which disciplines doctors, in early 2008.
We checked disciplinary actions against Missouri doctors. Those are published in newsletters that are archived. None involves taking the wrong kidney out of someone. The healing-arts board will not discuss, well, pretty much anything about a licensee.
Those CMS-2567 reports turned us on to an even bigger story involving DePaul. We found that a 16-year-old foster child was suffocated in October 2009 while being held down by two psychiatric technicians. No one started CPR on the girl until 12 minutes after she was found not moving.
If we didn't look for evidence of the kidney case, we probably never would have known about the death.
We requested every record we could think of on that case – including those from the police, medical examiner, child-welfare officials – and found the case had been ruled a homicide.
The death came less than two years after state and federal regulators warned that patients at DePaul weren't safe. In January 2008, a patient with doctor's orders for constant supervision died alone after five days in seclusion. That led to a state inquiry that uncovered instances of improperly secluding and restraining patients and failing to report deaths to authorities.
A health inspector was already investigating the kidney operation when those problems came to light.
You might have guessed it, but no one alerted the public about any of the cases. That became the overarching theme of our package: When "never events" occur, the public has virtually no way to find out about them, at least in Missouri and many other states without reporting laws.
Jeremy Kohler is an investigative reporter for the St. Louis Post-Dispatch.
