Tag Archives: hospital errors

Alarm fatigue hurts patient care, overwhelms nurses

Andrew Van Dam

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 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

Andrew Van Dam

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.

scalpel
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

Andrew Van Dam

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.

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

Andrew Van Dam

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.

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.

UK hospitals fail to comply with safety alerts

Andrew Van Dam

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.

Following medical errors and patient safety issues, the United Kingdom’s National Patient Safety Agency issues national safety alerts so that hospitals can change their practices and avoid repeat occurrences. As The Daily Telegraph‘s Rebecca Smith reports, a patient advocacy group has found (28-page PDF) that two-thirds of UK hospitals have failed to meet the implementation deadline on at least one alert.

The group blames haphazard enforcement and monitoring for the lapses.

Action against Medical Accidents warned that despite repeated warnings that the alerts were not being complied with, there was no central policy or guidance on which organisation should be monitoring compliance and what action should be taken.

Smith focused on two particularly serious issues, the inappropriate administration of oxygen and injectable medicines. The report groups instances of noncompliance by hospital and by alert.

Hospital infections on rise in Nev., reporters find

Andrew Van Dam

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.

lasvegassun

Part two of Marshall Allen and Alex Richards’ Las Vegas Sun hospital investigation series “Do No Harm” takes on hospital-acquired infections. Even though no agency in the state tracks such things, the duo managed to find 2,010 instances of drug-resistant bugs in local hospitals between 2008 and 2009. That number included 647 instances of hospital-acquired MRSA.

In the story, the explain how they overcame industry resistance to dig up the data themselves:

No health agency tracks these cases. In fact, hospitals derailed proposed legislation in 2009 that would have required them to publicly report cases of MRSA in their facilities.

However, hospitals are required by law to submit to the state billing records based on each patient visit. The Sun obtained that information from 1999 to 2009 and analyzed the 2.9 million hospital billing records as part of its two-year investigation, “Do No Harm: Hospital Care in Las Vegas.”

Because of how the records are coded, the Sun was able to identify the number of infections by the two bacteria, and for the years 2008-09 further identify the cases in which the records say the patients acquired the bacteria while hospitalized.

While it’s hard to put their numbers in a national context because of widely varying methods of measurement and reporting, the duo can say that such infections jumped 34 percent from 2008 to 2009. Allen and Richards then establish two facts:

  1. Some institutions have developed ways to keep MRSA and friends under control.
  2. None of those institutions are in Las Vegas, where inspections show that hospitals could be doing a lot more.

Efforts to force Nevada hospitals to disclose MRSA cases withered under heavy industry opposition, though the legislature is now considering a watered-down version that would not public the MRSA rates of specific facilities.

It’s worth noting that the paper has published responses from readers who have plenty of their own hospital horror stories. The website includes their input both in text and through excerpts of some of the voicemails Allen has  received since the first part of the series was published. They are heart wrenching but serve as an excellent example of how reporters can involve readers in a project.