Tag Archives: hospital errors

Allen looks at present, future of Nev. transparency

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.

Allen, who recently took a job with ProPublica, completed part of this series while on an AHCJ Media Fellowship on Health Performance, supported by the Commonwealth Fund. The series, which was reported with Richards, won a 2010 Award for Excellence in Health Care Journalism, the investigative reporting category in the 2010 Scripps Howard Awards, best in show for the print category of the National Headliner Awards and the 2011 Goldsmith Prize for Investigative Reporting.

Alarm fatigue hurts patient care, overwhelms nurses

In the wake of several high-profile incidents, The Boston Globe‘s Liz Kowalczyk has assembled a thorough investigation of alarm fatigue in hospitals. Alarm fatigue, for the record, is the idea that the huge arsenal of patient monitors in any given hospital floor are going off so often that nurses become slower in their responses to the alarms. For example, in one 15-bed unit at Johns Hopkins, staff found that, on average, one critical alarm went off every 90 seconds throughout the day.

With the help of ECRI, Kowalczyk has managed to attach some numbers to the issue.

The Globe enlisted the ECRI Institute, a nonprofit health care research and consulting organization based in Pennsylvania, to help it analyze the Food and Drug Administration’s database of adverse events involving medical devices. The institute listed monitor alarms as the number-one health technology hazard for 2009. Its review found 216 deaths nationwide from 2005 to the middle of 2010 in which problems with monitor alarms occurred.

But ECRI, based on its work with hospitals, believes that the health care industry underreports these cases and that the number of deaths is far higher. It found 13 more cases in its own database, which it compiles from incident investigations on behalf of hospital clients and from its own voluntary reporting system.

Kowalczyk also looks at potential solutions to the problem and how some institutions are trying to make changes to eliminate alarm fatigue, including cutting back on unnecessary monitors and having monitor warnings appear on nurses’ pagers or cell phones.

To back up the numbers, Kowalcyzk got some telling quotes from frustrated nurses.

“Yes, this is real, and, yes, it’s getting worse,’’ said Carol Conley, chief nursing officer for Southcoast Health System, which includes Tobey Hospital. “We want to keep our patients safe and take advantage of all the technology. The unintended consequence is that we have a very over-stimulated environment.’’

“Everyone who walks in the door gets a monitor,’’ said Lisa Sawtelle, a nurse at Boston Medical Center. “We have 17 [types of] alarms that can go off at any time. They all have different pitches and different sounds. You hear alarms all the time. It becomes . . . background.’’

Kowalcyzk’s investigation points out that, while alarms do tend to go off when there’s a real problem, it appears that they do so at the expense of also going off when there isn’t.

Monitors can be so sensitive that alarms go off when patients sit up, turn over, or cough. Some studies have found more than 85 percent of alarms are false, meaning that the patient is not in any danger. Over time this can make nurses less and less likely to respond urgently to the sound.

For more specifics on device design issues, see the final subheading, titled “Looking for solutions.”

For a one year, the Joint Commission made routine alarm testing and training part of their accreditation requirements, but dropped the stipulation in 2004 when it felt the problem had been solved.

Other parts of the series:

“Never events” still happen sometimes

Photo by Garrett P. via Flickr

MedPage Today’s Crystal Phend drew two key lessons from a recent paper on the persistence of “never events,” particularly wrong-patient and wrong-site surgeries, in Colorado.

The first, drawn from an invited critique (subscription required), is that research often underestimates the frequency of never events because, like this study, they rely on self reporting and overly narrow definitions of the events in question. After all, it’s not wise to assume that folks are going to voluntarily link their name to a wrong-patient surgery.

The second is that attempts to prevent never events, such as the Joint Commission-required pre-surgery routine, don’t cast a wide enough net.

Nonsurgical specialists were just as likely to cause significant injury from wrong-site errors as those in the procedural specialties, who have gotten more of the focus (31.2% versus 30.8%, P=0.67).

That’s because, in their analysis, the researchers put the responsibility for wrong procedures at the step where things went wrong, Stahel told MedPage Today. And sometimes that’s before the cutting stage.

“In certain cases we realize that the harm is already done before the patient sets foot in the hospital,” he told MedPage Today.

“Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to achieve a zero-tolerance philosophy for these preventable incidents,” Stahel’s group wrote.

Canadians fight for disclosure of medical treatment

It took eight years, a whistleblower and intervention from a state commissioner to uncover a fatal medical error in a Newfoundland hospital, one committed by a doctor with an (undisclosed) record of such actions. As Canadian broadcaster CTV reports, Canada’s free access to health care doesn’t translate to free access to information.

Here’s my summary of the story’s key events, as I understand them:

  1. A woman in Newfoundland dies soon after her ER doctor misdiagnosed a blood clot in her lung and gave her treatment that a colleague said would have been equivalent to a “lethal injection.”
  2. The victim’s family doesn’t know that anything was out of the ordinary until six years later, when the colleague contacted the family directly to explain what he believed to be a mistake.
  3. The family approaches the hospital for information, and gets a few treatment records, but is denied access to records from an internal investigation of the incident.
  4. Using the province’s FOI laws, the family again pushes for the investigation information. Their request is denied.
  5. Finally, “the family appealed to the province’s Information Commissioner, who ordered Eastern Health to hand over the records.”
  6. A year later, the records were disclosed – but key EKG information was not. Thus, the family’s fight for disclosure continues unabated.

Innovative approaches to malpractice, errors

American Medical News reporter Kevin O’Reilly writes about a presentation by David Mayer, M.D., University of Illinois at Chicago Institute for Patient Safety Excellence co-director, at an AHCJ Chicago chapter event. The event shed light on some ways to tackle malpractice and errors in a way that will benefit both physicians and their patients.

David Mayer, M.D.

David Mayer, M.D.

Mayer talked about turning doctors away from the “deny and defend” approach to malpractice and toward an open disclosure of medical errors. He seeks to reduce malpractice suits through a “seven pillars” approach. Here’s a quick summary of how things work:

  1. Patient safety incident reporting: Push for fast reporting of possible incidents
  2. Investigation: Figure out if something really went wrong.
  3. Communication and disclosure: Keep patient and family informed during the entire process. Even if it involves very bad news.
  4. Apology and remediation: Don’t just apologize, tell them how you’re going to fix the damage and/or offer compensation.
  5. System improvement: Change the system to prevent it from happening again, invite the patient and family to participate.
  6. Data tracking and performance evaluation: Keep a massive database of all safety incidents and use it with impunity, even for public outreach.
  7. Education and training: Carefully monitored continuing education that is informed and directed by error monitoring and in-house incidents.

Meyer’s pillars are going to be implemented in nine Chicago-area hospitals, thanks to a $3 million grant from the HHS Agency for Healthcare Research and Quality. The grant is one of seven “demonstration grants” the AHRQ awarded as part of its program to evaluate “Patient Safety and Medical Liability” projects. The agency also awarded 13 smaller planning grants.