The report … shows that only 21 states currently have legislation that requires monitoring and public reporting for surgical site infections. Of those, only eight states actually make the data publicly available, and only a total of 10 procedures – out of 250 possible types of surgeries – get reported.
And even many those states that reported some surgical infection rates as of late 2010 (Colorado, Massachussetts, Missouri, New York, Ohio, Oregon, South Carolina, and Vermont)
In each of those cases and in three others, the nursing staff failed to document the errors properly, state investigators found.
Employees told the investigators that St. Luke’s did not require annual competency training on the pumps. Unnamed employees offered conflicting statements about when and whether all the staff had received retraining in 2010.
For their part, hospital officials say they have bought new patient-controlled pumps, developed a restricted dosage plan and retrained staff.
“When St. Luke’s nursing staff members identified the dosing pump programming issues, the events were promptly reported to all the appropriate individuals and regulatory agencies as outlined in our Network Patient Safety Plan,” said Carol Kuplen, chief nursing officer for St. Luke’s Hospital & Health Network.
“There was complete transparency in these events,” she said in an interview Thursday.
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.
Parkland Memorial Hospital in Dallas, the subject of recent reports that patients were at risk, has sued the Texas attorney general in an attempt to prevent the release of records requested by The Dallas Morning News.
Parkland filed the latest lawsuit — its fifth against the AG related to the newspaper — on Monday. This time the goal is to block release of Parkland police department records dealing with the psychiatric emergency room. The News is not seeking medical records.
Late Friday, a damning federal report declaring that patients were at risk at Parkland Memorial Hospital in Dallas was released. Even later that same day, Dallas Morning News reporters Miles Moffeit, Sue Goetinck Ambrose, Reese Dunklin and Sherry Jacobsen published their first report online (available to subscribers only).
The reporters write that the inspectors’ findings were released in response to a reform plan the hospital submitted just before its Friday deadline, a plan they report “involves hiring new nurses; rewriting some policies; retraining staff; retiring outdated medicines, supplies and equipment; and launching an intensive series of daily or weekly performance audits over at least the next five months.” According to those who have viewed the 600-page release, they have a lot to overcome.
“It appears safety was routinely relegated to a lower priority by other pressures,” said Vanderbilt University professor Ranga Ramanujam, a national expert in health care safety. “The CMS action is extraordinary. I am hard-pressed to think of an example of a similarly high-profile hospital facing the very real possibility of losing their CMS funding as a result of safety violations.”
The paper’s speedy, thorough response to the release shouldn’t be entirely surprising, considering that they’ve been out ahead of the story from the very beginning.
The top-to-bottom July inspection of Parkland was sparked by a News report of the death of a Parkland psychiatric patient in February. The hospital didn’t report the death to the Texas Department of State Health Services or to CMS, both of which then investigated the case. CMS regulators later determined that the rights of the patient, George Cornell, had been violated repeatedly by Parkland.
The hospital has until Sept. 2 to get its correction plan approved by CMS and to pass inspections, otherwise it could lose the Medicare and Medicaid funds on which it so heavily depends.
“I don’t really see any improvement in patient safety,” said Dr. Arthur Palamara, a Hollywood vascular surgeon and advocate for safer practices. “Unfortunately, despite all the protocols that were put in place, the adverse incidents, the wrong-site surgeries still keep happening at the same rate.”
A long list of technological advances and a national emphasis on preventing mistakes “hasn’t made a difference,” said Douglas Dotan, chief executive of CRG Medical, a Houston firm that sets up error-prevention systems…
They found that, while some progress has been made, even the most aggressive hospitals have found it difficult to crack the exceeding complex web of human and mechanical interactions that make errors possible.
Writing for the Las Vegas Sun, reporter Marshall Allen put a fitting cap on an award-winning investigative run at the paper with a story rounding up the state’s first steps toward transparency in medical error reporting. Through the lens of former Beth Israel Deaconess chief, transparency pioneer and blogger Paul Levy, Allen demonstrates just how much transparency in Nevada could benefit both hospitals and their patients. It’s potential that was created, in no small part, through the reporting that Allen and Alex Richards have done.
Over the course of the Sun’s two-year investigation, most Las Vegas hospitals refused to discuss patient safety issues. The Nevada Hospital Association has since 2002 lobbied against mandated public reporting of patient harm. But since the Sun’s investigation, and with legislation pending, the association has said it will begin posting patient injury and infection data on its hospital quality website.
Throughout the piece, Allen paints a sunny picture of a more transparent future, and uses examples from Massachusetts to dissolve any reservations readers might have.
Dr. Tejal Gandhi, Partners’ director of patient safety, said at first there was panic over posting on the hospitals’ websites the infections and injuries suffered by patients. People worried there would be a media frenzy or a rise in malpractice lawsuits, she said.
When the information became public, in 2009, The Boston Globe published one story but there was little other reaction, she said.
The hospitals have seen no increase in malpractice lawsuits. But it has brought a new focus on reducing certain infections and injuries, including the formation of task forces and establishment of standardized safety protocols.