Medical Errors

Los Angeles Business Journal

A middle-aged woman enters a hospital for a hysterectomy, and a surgical sponge is left in her abdomen.

A neurologist orders an emergency MRI of a patient’s lower back, but it’s not done for eight hours and the man is left a paraplegic.

A man suffering intense abdominal pain is suspected of having a leaking abdominal blood vessel but no one orders surgery and the man dies after it bursts.

When patients seek treatment at hospitals they hope their medical problems will be solved. But instead medical mistakes, such as these in Los Angeles area hospitals, can cause serious injuries and even be deadly.

A landmark report by the Institute of Medicine found that up to 98,000 people die each year in the nation’s hospitals from medical mistakes. On average, that’s nearly 20 for each of the nation’s 4,900 hospitals–making it the eighth leading cause of death nationally.

Are they anomalies? Don’t bet on it.

No such statistics are available statewide or locally because no
organization or government agency aggregates such data. But hospitals and patient advocates agree that such incidents are much more common than they would like.

Although some hospitals are safer than others, a growing body of evidence suggests that even in sophisticated urban areas like Los Angeles, hospitals are places where avoidable deaths and injuries happen.

Surgeons operate on the wrong body part. Seriously ill people are left for hours in understaffed emergency rooms. Patients are given the wrong medication doses. Thousands die annually from hospital-acquired infections.

The culprits?

Critics cite financially stressed hospitals that have cut staffing, even cleaning crews. But there’s also a shortage of nurses and ever-more complex medical procedures, medications and technology-all topped by a tendency of caregivers to cover up mistakes and a lack of standards.

The Institute of Medicine’s 1999 report was called “To Err is Human,” and declared that mistakes are inevitable. It said improvements should focus on detecting them and developing systems to prevent them. Many have heeded that call.

“Most of the reviews since then have concluded the problem is both deeper and broader than we estimated,” said Dr. Molly Coye, who sat on the committee that produced the report.

California hospitals are under a state mandate to cut medication errors. And a plethora of national organizations are focusing on establishing safety standards. But many of these efforts are still in their infant stages and are years away from fruition.

‘Surgical misadventure’

Joyce Foster’s story seems too incredible to believe, but experts have already coined a name for her type of experience: a “surgical misadventure.”

The 48-year-old had a hysterectomy performed at San Dimas Hospital in October 2001, and less than two months later began experiencing abdominal pain that grew intense, landing her back in the hospital on Christmas Eve.

When a diagnostic screening indicated she had some kind of mass in her abdomen, the initial diagnosis was possible cancer. The same surgeon who performed her initial surgery went in again. This time, he found a 3-inch wide, 2-foot long surgical sponge left behind, according to Foster’s lawsuit against the doctor and hospital.

“Coming from cancer, when that is what they found I was relieved. But after, my thankfulness the anger set in,” said Foster.

A spokesman with Tenet Healthcare Corp., which owns the hospital, refused to comment on the case, citing the litigation.

How could something like that happen? A member of the surgical team is supposed to count sponges three times: before surgery, in the middle and at the end. But sometimes that person, often the nurse, may miscount.

Surgical mistakes can be far worse. In its database going back to 1995, the Joint Commission on Accreditation of Healthcare Organizations, the accrediting body of the nation’s hospitals, lists 197 operations on the wrong body site. And since reporting to the database is voluntary, the commission estimates it may catch only a half of one percent of all errors committed.

Surgical mistakes are such a problem that the commission has made eliminating surgeries on the wrong site and the wrong patient, as well as incorrect procedures performed on patients, a top safety issue.

“We are saying, ‘You guys need to learn where you are vulnerable and build safety into systems,”‘ said Dr. Dennis O’Leary, president of the Joint Commission.

Test delayed

Joe Deocampo was left a paraplegic after eight hours passed between the time his hospital neurologist ordered a “stat”–or emergency–MRI and the time he was given one by the radiology department, according to his attorney, David Drexler.

Deocampo, who had come to Providence Saint Joseph Medical Center in Burbank for treatment of a mild heart attack, was given a blood thinner that caused pain in his back and bleeding in his spine. “The doctor was brand new to the hospital. He really assumed he would write down ‘stat’ and the test would get done,” Drexler said.

By the time the bleeding was found, damage had been done. Deocampo reached a settlement with the hospital and won a judgment against the doctor totaling $ 5 million in a legal case that just finished up last month.

Drexler said the incident prompted Saint Joseph to alter how it operates its radiology department. A hospital spokesman declined to discuss details of the case, but said any improvements in its operations were not necessarily related to the case.

Critics of the hospital industry acknowledge there are so-called systems problems, but cite a more fundamental one: budget cuts that have left them understaffed of nurses and other critical personnel.

“Hospitals have become increasingly dangerous, because they are operating on shorter shoestrings with fewer personnel,” said consumer health advocate Jaime Court of the Foundation for Taxpayer and Consumer Rights. “It’s like a conveyor belt and when you speed it up people are going to get hurt.”

The California Healthcare Association, the state’s trade group, acknowledges that hospitals cut their staffs starting a decade ago in an effort to stem losses caused by decreased reimbursements, but since then have tried hard to beef up.

“Hospitals have come to a true understanding that clinical staffing is critical for health care systems,” said Jan Emerson, the association vice president of external affairs.

Overworked nurses

Studies have shown that medication errors by harried nurses are a leading cause of medical mistakes, and an investigation by the Chicago Tribune two years ago found at least 1,720 hospital patients have died and 9,584 were injured by nurse errors nationwide since 1995.

One Los Angeles nurse said that patient safety conditions at her hospital are the worst she has seen them in her 31 years on the job. “The nurses are so overworked we cannot get to the patients in time,” said the nurse, who asked she and her hospital not be identified.

The nurse works in the critical care unit of a community hospital and said medication errors are a particular problem, exacerbated by the decision to pull an on-site pharmacist from her floor.

One nurse at the hospital gave a patient who had just come out of surgery a fatal overdose of pain medication because she did not know how to work the machine that pumped the medication directly into the spinal area. “There was a total lack of education and, of course, who was to blame? The nurse,” she said.

The hospital industry readily admits it has problems.

“We are humans and humans make errors,” said Emerson. “But since the (Institute’s) report has come out it has truly been a wake-up call and hospitals are doing all kinds of different things to solve these problems.”

California hospitals have been pushed, in particular, by legislation that required all hospitals to file plans on how to reduce their medication errors and implement those plans by 2005.

State Sen. Jackie Speier, D-San Francisco, author of the legislation, calls hospitals “marginally safe” institutions that will have to rely on new technologies to reduce safety problems. “I am interested in hospitals working safer. I am not interested in the blame game,” Speier said.

One of the ways hospitals can meet state requirements is by implementing computerized prescribing systems that help eliminate errors in. reading, filling and transmitting medications to patients. Cedars-Sinai Medical Center is spending $ 20 million on such a system.

“In a world where there are more drugs than ever, more sophisticated drugs and more potent drug interactions that becomes a set-up for problems if you don’t manage the process,” said Dr. Neil Romanoff, the hospital’s vice president for medical affairs.

When the system is up and running in February, it will be impossible for doctors to write a paper prescription.

Dr. Lee Hilborne, UCLA Medical Center patient safety director, said large institutions have problems moving around patient records, especially if a person is seeing a variety of caregivers. This can lead to doctors making decisions about medication, tests and treatment without the full story.

“Often in a complex place like UCLA they are not available. When you don’t have records you don’t have access to history,” he said.

As a result the hospital is moving toward a fully electronic record that can be accessed from anywhere, though it’s a solution not all hospitals can afford.

Not admitting mistakes

Another big effort involves reducing hospital infections. The Centers for Disease Control estimated some 2 million patients came down with hospital-acquired infections in 1997 and roughly 90,000 died as a result.

“Hospitals are not good places to go,” said Dr. John Whitelaw, president of the California Medical Association. “They are dangerous places. There are germs in hospitals.”

The first defense against the spread of infections is having direct
caregivers wash their hands before seeing new patients. But studies have shown doctors and nurses are often too busy to follow protocol. As a result, hospitals are installing dispensers of an antiseptic hand-cleaning gel that does not have to be washed off.

But those who study hospitals say perhaps among the most fundamental problems hospitals face in improving safety is measuring their problems.

If someone dies unexpectedly, or there is a mistake that results in a serious injury, administrators will learn about it. But at that point the damage has been done. Hospital personnel must learn about the smaller ones first to prevent the bigger ones.

“If I am a nurse and I made a medication error, and I don’t think I harmed a patient I am not going to report it,” said Marsha Nelson, vice president of the California Institute for Health Systems Performance, a nonprofit group working to improve hospital quality and safety.

Joint Commission head O’Leary is a former practicing physician and even he admits as much. “When I was a practicing doctor, I made mistakes, and I didn’t tell a lot of people about them, but they scared the hell out of me. You have a sense of your vulnerability and your isolation,” he said.

Studies have shown medical professionals won’t report their mistakes because they are afraid of being punished, and that the information will not be used for any useful purpose. They also fear getting sued.

Hospitals are trying to change that by creating a “culture of safety” in which caregivers are assured that they will not be punished for minor errors. UCLA Medical Center is an example. “We are moving toward a blame-free environment,” Hilborne said.

But the push for reform has not been easy.

A bill made its way through the California legislature last session that would have allowed for the creation of a statewide database for hospitals to share. The measure ran into opposition by trial lawyers who did not want the legal. protections hospitals now enjoy doing internal peer review of medical mistakes extended outside hospital walls.

It died in committee.