Tag Archives: adverse events

Dentist under investigation after sedated child dies

About Mary Otto

Mary Otto, a Washington, D.C.-based freelancer, is AHCJ's topic leader on oral health and the author of "Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America." She can be reached at mary@healthjournalism.org.

A Hawaiian pre-schooler died after lapsing into a coma in a dentist’s chair. Now state authorities are investigating her dentist, according to a report by Susan Essoyan of the Honolulu Star-Advertiser. (The articles are behind a paywall but AHCJ has been given permission to republish them here.)

“The state Department of Commerce and Consumer Affairs has begun an investigation of Kailua dentist Dr. Lilly Geyer after a 3-year-old girl fell into a coma while she was in the dentist’s chair and later died,” Essoyan reported on Jan. 8.

“Finley Puleo Boyle, the only child of Ashley and Evan Boyle of Kai­lua, never awoke after losing consciousness and suffering massive brain damage following heavy sedation at the dentist’s office Dec. 3, her mother said.”

The little girl died Jan. 3 at a local hospice. Continue reading

OIG: While adverse events are common, records of them aren’t

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

To draw attention to its ongoing monitoring of the incidence of adverse events in US hospitals and the accurate reporting thereof, the HHS Office of Inspector General is highlighting a roundup of reports on the subject.

If you get a chance to read it, you’ll probably see why I decided to distill it to a bulleted list of somewhat remarkable numbers.

Here goes:

  • In a one-month period, 27 percent of Medicare recipients experienced “care-related harm.”
  • In that month, these events cost Medicare an estimated $324 million.
  • Half of them were adverse events, half were “temporary” events such as allergic reactions.
  • 44 percent of the adverse events were deemed “preventable.”
  • “Hospital staff did not report 86 percent of events to incident reporting systems.”
  • That is partly because only 12 percent of incidents of care-related harm met requirements for being reported in the state in which they occurred.
  • “Many of the events not reported as required involved serious harm, including six patient deaths.”

For those looking to dig deeper and better understand the adverse events and how they’re reported, the OIG refers to a number of relevant reports. Journalists will be particularly interested in reports explaining how reporting requirements have failed, as it helps explain the limitations of currently available data sets.

Spotlight on health care quality, measures

About Pia Christensen

Pia Christensen (@AHCJ_Pia) is the managing editor/online services for AHCJ. She manages the content and development of healthjournalism.org, coordinates AHCJ's social media efforts and edits and manages production of association guides, programs and newsletters.

The April issue of Health Affairs focuses on the quality of health care in the United States. Some highlights of the issue, which was sponsored by the Robert Wood Johnson Foundation:

  • analysis and commentary on improving performance measures
  • research that found the methods currently used to gauge patient safety actually missed 90 percent of the adverse events
  • the cost of errors and adverse events
  • research on measuring quality
  • lessons to be learned from other countries
  • how pay-for-performance has affected quality
  • several case studies of how quality has improved in specific institutions

Those of you who attended Health Journalism 2010 might be particularly interested in an update from Peter J. Pronovost, M.D., who was the keynote speaker at last year’s conference. In this issue of Health Affairs, Pronovost writes about the advances in reducing central line-associated bloodstream infections – which he discussed at last year’s talk.

Remember, AHCJ members receive free access to Health Affairs. If you haven’t already signed up for access, be sure you take advantage of that benefit.

After 8 years, Quebec’s adverse event reporting law remains unenforceable

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

The Montreal Gazette‘s Charlie Fidelman has assembled a round-up of what has, and hasn’t, happened in the eight years since Quebec passed a law requiring hospitals to tell patients about all adverse events as soon as staff became aware of them.

According to Fidelman, “the provincial Health Department has yet to set up its registry of adverse events,” which it was supposed to track in order to improve patient safety. It’s expected to finally get started next year.

Until then, hospitals are supposed to track their own events and report them each year, yet “no hospital contacted by The Gazette includes adverse events in its annual reports.” This may have something to do with the fact that the requirement came with no clear enforcement mechanism.

Initiatives not improving patient safety; poor implementation to blame

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

A large-scale study that followed mistakes in health care delivery at 10 North Carolina hospitals from 2002 to 2007 found that, despite state efforts, there was no improvement in patient safety over the time period. According to The New York Times‘ Denise Grady, the problem lay primarily not in design, but in execution. Even when safeguards were in place, they were not followed.

The study, published in the New England Journal of Medicine, reviewed thousands of patient records and looked for any of 54 red flags that something had gone wrong.

Dr. [Christopher] Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.

The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

Problems cited in the study include a lack of electronic medical records, doctors and nurses regularly working long hours and poor compliance with even simple interventions such as hand washing. Proposed solutions include computerized drug ordering systems and a mandatory nationwide monitoring system.

Identical tubing demonstrates FDA’s inaction

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

In The New York Times, Gardiner Harris  outlines the problem of medical tubing that looks very similar leading to medical errors – then deftly works his way up the chain in an attempt to find the source of device regulator’s failure to solve a problem that seems entirely solvable.

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Many medical device tubing looks the same, which leads to horrific mix-ups like the delivery of food straight into the bloodstream. In 2007, The Wisconsin State Journal‘s David Wahlberg earned first place in the medium newspapers category of AHCJ’s Awards for Excellence in Health Care Journalism for his Medical Misconnections series, which detailed the same problems. He even wrote an AHCJ article teaching journalists how to investigate patient safety problems.

euPhoto by bennylin0724 via Flickr

Since then, not much has changed. Which is not all that surprising, when you consider that not much had changed in the decades before Wahlberg’s story either. Harris’ mission is to dig past the finger-pointing and figure out why. In the end, it all seems to point to some remarkable systemic flaws in the FDA’s device approval system, as well as an unwillingness on the industry to change without the threat of brute regulatory force. In addition to compelling analysis, Harris punctuates each argument with a few spicy quotes.

You’ll have to read Harris’ story to truly understand the perversity of the FDA system and how its lent such inertia to the status quo, but here’s a sample:

Dr. Robert Smith, an F.D.A. device reviewer who left the agency on July 31 and was among nine agency employees who in 2009 decried the agency’s device approval process as illegal and dangerous, said that the tubing problem, which has gone on for decades, was another example of how the agency failed to protect the public. “F.D.A. could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,” Dr. Smith said.

And, from Nancy Pratt, a senior vice president at Sharp HealthCare in San Diego who believes that “Nurses should not have to work in an environment where it is even possible to make that kind of [tubing] mistake.”

“The regulators have been waiting for the manufacturers to come up with a solution,” Ms. Pratt said, “and the manufacturers won’t spend the money to design and produce something different until the regulators force them to. And now the international standards organization is taking forever to get the whole world onto the same page.”