Tag Archives: pennsylvania

Programming errors led to overdoses with pain-medicine pumps

Building off a state health department report showing that, as The Morning Call‘s Tim Darragh wrote, “Nurses at St. Luke’s Hospital three times in 2010 and 2011 improperly programmed patient-controlled pumps to deliver pain medication, causing patients to overdose themselves,” Darragh dug deep into each incident, uncovering patient details and adding perspective to the errors, which were severe enough that the feds decided the hospital’s patients were in “immediate jeopardy” until steps were taken.

pumpPhoto by Felix42 via Flickr.

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.


Jeffrey Shuren, director of the FDA’s Center for Devices and Radiological Health, appeared at a newsmaker briefing at Health Journalism 2010 to announce an FDA initiative to reduce risks associated with infusion pumps. Log in to the AHCJ website to see his presentation and listen to his announcement.

New IRS rules reveal hospital conflict disclosures

The new IRS disclosure rules for nonprofit hospitals seemed to promise some interesting revelations, and now that they’re public, the Pittsburgh Tribune-Review‘s Walter Roche has taken full advantage of the new disclosures. Roche checked out fiscal 2009 filings from the nonprofit hospitals in his area and found a big handful of conflicts ($10 million at one firm alone), all of which the nonprofits say are entirely above board.

Jennifer Chandler of the National Association of Nonprofits said it is not unusual or improper for nonprofits to have business dealings with board members as long as IRS disclosure requirements are followed.

“It has to be managed correctly,” she said.

The meat of Roche’s story is made up of a laundry list of disclosed conflicts, which include commercial dealings with board members and relatives.

Med school prof: Dartmouth Atlas is ‘malarkey’

In a story done in collaboration with The Philadelphia Inquirer, Kaiser Health News’ Jordan Rau’s report on a leading physician’s provocative attack on the Dartmouth Atlas gets off to a lively start:

As he raced through the U.S. Capitol this fall, Dr. Richard “Buz” Cooper, a 73-year-old University of Pennsylvania medical school professor, didn’t mince words. He denounced as “malarkey” a reigning premise of the health care debate – that one-third of the nation’s $2.5 trillion in annual health spending is unnecessary – and said that the idea came from “a bunch of clowns.”

Digging beyond these inflammatory comments, Rau finds that Cooper’s argument revolves around one idea: That the research “doesn’t take into account the high cost of helping the impoverished, who often spend more time in hospitals because they don’t have people to care for them at home and often return to the hospital when they can’t afford needed medications.”

Meanwhile, the Atlas folks’ response has been as blunt as Cooper’s attacks. They say the Penn researcher is wrong and doesn’t adequately understand Dartmouth’s statistical controls.

“It’s impossible to carry on a debate with somebody who does not understand statistics, and seems uninterested in learning,” Jonathan Skinner, a senior author of the Atlas, says of Cooper.

Most experts seem to be lining up on the Dartmouth side of the dispute, and Rau digs past the “clowns” and “malarkey” and helps readers understand the validity of Cooper’s criticism and the Atlas.


To learn more about the Dartmouth Atlas and how to use it to determine how medical resources are distributed and used in the United States, read AHCJ’s Covering Hospitals, a slim guide that focuses on how journalists can best use Dartmouth Atlas and Hospital Compare.

WSJ looks at effects of Penn. outcomes database

The Wall Street Journal‘s Thomas Burton has taken a look at the effects of one state’s commitment to publishing hospital data. Since 1989 Pennsylvania has compiled and published data on hospital outcomes and, to a lesser extent, costs. Collecting the data isn’t cheap, estimates of the cost to the state’s 172 acute-care hospitals range from $7 million to $10 million, but Burton’s story makes it clear that the investment has paid off. Burton reinforces that impression with statistics (“An August 2008 study in the American Journal of Medical Quality reported that Pennsylvania in-hospital odds of death were 21% to 41% lower than those in other states.”) and convincing examples (by basing their health plans on outcomes data, companies were able to save millions). His profile of a now-defunct Hershey company plan is particularly interesting.

“High-quality care costs less — always,” says David B. Nash, a medical-quality expert and dean at Thomas Jefferson University’s School of Population Health in Philadelphia. “If the federal government could behave like a savvy shopper, that would change the health-cost game overnight. But the government is a bill payer, not a savvy shopper.”

Burton also reports that some stakeholders, given the success of Pennsylvania’s example, are pushing for hospital outcomes research to be part of the $1 billion stimulus investment into comparative effectiveness.

The White House is looking at publishing information possibly including medical outcomes as part of overhaul efforts, officials say. Quality data could also be used in existing programs. “There is a clear understanding from the Obama administration that both Medicare and Medicaid need to move in the direction of what’s happening in Pennsylvania,” says Jonathan Blum, director of the government’s Center for Medicare Management.