Tag Archives: surgical errors

Disclosure of hospital infections still in its infancy

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.

On Forbes.com, Gergana Koleva evaluated the woeful state of national hospital-associated infection reporting, with the help of recently published research. As Koleva writes, such infections account for more than 8,000 deaths each year in the United States and add an estimated $10 billion in annual cost, and hospitals routinely collect valuable data on such things for internal use, yet no clear reporting standards exist on a national level.

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)

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Fla. hospitals make little progress on error reduction

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.

South Florida Sun Sentinel reporters Sally Kestin and Bob LaMendola report that, despite the myriad initiatives and protocols launched in the dozen years since a landmark report thrust medical errors into the headlines, little progress has been made in actually reducing the toll taken by medical errors.

“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.

These findings, which have become a depressingly predictable event, are built in part on research published in the April, 2011 issue of Health Affairs, a publication to which AHCJ members are granted free access.

AHCJ resources on patient safety

“Never events” still happen sometimes

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.

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.

Reporters encounter hospital’s lack of transparency

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.

Blythe Bernhard and Jeremy Kohler of the St. Louis Post-Dispatch investigated a string of serious mistakes at a local hospital and found the story of a 16-year-old girl who suffocated in a bean-bag chair after being sedated. It’s a remarkable and chilling story on its own and, as AHCJ Immediate Past President Trudy Lieberman points out, it’s made even more valuable for health journalists thanks to Kohler’s willingness to explain his investigative process.

Acting on multiple tips referring to a botched 2007 kidney removal, Kohler began the laborious process of triangulating the error. You should really take a minute to read his entire explanation, but if you really don’t have time, just take note that his path was something like this: Tips from sources -> Joint Commission -> Missouri Division of Insurance -> National Practitioner Data Bank -> Missouri Department of Health and Senior Services -> Missouri Board of Professional Registration for the Healing Arts -> The actual hospital.

And even then, he was unable to get clear confirmation that surgeons had removed the wrong kidney from a patient. Instead, the hospital cited privacy regulations.

Last week, officials with SSM Health Care, the St. Louis-based corporation that operates DePaul and several other hospitals, said they could not speak about specific patient cases because of federal privacy laws. “The desire to defend ourselves and paint an accurate and full picture does not outweigh our patients’ right to privacy,” they said in a statement.

Even a subject like this, which clearly involves what Kohler calls “information that patients in need of a surgeon would be interested in knowing,” the obstacles between readers and the truth about a “never event” appear insurmountable.

Hearst project looks at toll of medical mistakes

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 team of reporters from Hearst news organizations across the country contributed to “Dead by Mistake,” a broad investigation into deaths caused by “preventable medical injuries,” of which the reporters estimate there are almost “200,000 per year in the United States.” A decade after a federal report challenged the medical community to halve the accidental death rate, the toll taken by medical mistakes has instead increased even further, the Hearst reporters found. Furthermore, reporters found that “the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago.”

According to the report, the American Medical Association and American Hospital Association are partly to blame, as they have opposed any mandatory reporting of medical accident. Even in the 20 states that have implemented mandatory reporting rules, research indicates that only a small fraction of accidents are actually reported. Despite this “chaotic, dysfunctional patchwork,” the Obama administration is not supporting national mandatory reporting.

Cathleen Crowley and Eric Nalder’s centerpiece, which focuses on hospital reporting of mistakes, is an informative read for anyone interested in the availability of hospital safety data on national and local levels, both now and in the future.

The package as a whole includes local stories for Hearst markets including California, Texas, Washington, Connecticut and New York as well as a number of in-depth anecdotes and stories with a national scope.

Editor Phil Bronstein explains how the project was reported, including compiling and analyzing nine databases and conducting hundreds of interviews. The cross-platform project involved journalists from print, television reporters and the Web. BayNewser has a Q&A with Bronstein about how the project was done.

Philly VA botched 92 of 116 cancer treatments

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.

Walt Bogdanich of The New York Times uncovered an astounding series of regulatory and oversight errors that allowed a “rogue” cancer unit operate with impunity at the Veterans Affairs Medical Center in Philadelphia.

Bogdanich reports that its doctors, primarily Dr. Gary Kao, had botched 92 of 116 cancer treatments in more than six years. The unit treated prostate cancer with radioactive implants, a process known as brachytherapy. Doctors in the unit avoided regulation in part by revising surgical plans to cover for mistakes.

The first clear signs of trouble cropped up in early 2003, the unit was suspended in 2008. Here’s a brief catalog of missed opportunities to reign in Johns Hopkins-trained Kao and associates:

  • The unit did not have any peer review process in place.
  • The V.A.’s radiation safety program didn’t intervene.
  • Neither did the Joint Commission, the group that accredited the hospital.
  • Doctors in the radiation implant program weren’t properly supervised.
  • Or “trained in what constitutes a substandard implant and the need to report it.”
  • Errors went unreported for months, or even years, while patients had no idea they were even made.

The whole house of cards only came tumbling down when a mistaken purchase of lower-radiation implants triggered an investigation of previous cases. Investigators didn’t find any lower-radiation implants, but they did find errors. Lots of them.

No patients are believed to have died from this mistake-riddled treatment; the unit was suspended in mid-2008 and similar programs (whose problems don’t seem to have been as severe) were shuttered in Jackson, Miss., and Cincinnati. Seven of the affected patients were flown to a more experienced V.A. unit for additional treatment.


In a related story, The Philadelphia Inquirer reports that the problems came to light “not because the NRC finished its inquiry” but rather when a Nuclear Regulatory Commission advisory committee asked the agency for an update because “committee members had been hearing disturbing things about the Philadelphia VA’s program.”