MEDICAL ERRORS IN THE HOSPITAL SETTING

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Slide 1 : Medical Errors in the hospital setting By Paul Parks-RN, LNC-Research Expert “integrating medicine and law” © PMLC 2012
Slide 2 : MEDICAL & HOSPITAL ERRORS ARE A MAJOR PUBLIC HEALTH PROBLEM Factors related to patient harm - First is the type of treatment received.  Studies have shown that patients receiving high risk procedures in intensive care are more at risk than those receiving low risk procedures in an outpatient treatment setting. The risk increases with: 1. Complexity of treatment. 2. Length of stay. 3. Use of internal devices which breach normal defense mechanisms. 
Slide 3 : Factors related to patient harm: Risk is also a factor of the Hospital environment due to the organizational set-up of health services. For example, high bed occupancy, increased movement of patients and the tendency of hospitals to admit patients from a wide geographical range can further heighten the risk associated with medical treatment. 
Slide 4 : MEDICATION ERRORS Definition: Any incorrect or wrongful administration of a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct drug or formulation for a particular disease or condition, use of outdated drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects of certain drug combinations. Causes of medication error may include difficulty in reading handwritten orders, confusion about different drugs with similar names, and lack of information about a patient's drug allergies or sensitivities. When the nurse is in doubt, administration of a drug should be delayed until specifically authorized by a physician.
Slide 5 : "Top 10" Medications Involved in Adverse Events A common question that arises is: "What drugs are most often involved in medication errors?“ The Institute of Medicine (IOM) published findings in 1999 on the quality of healthcare in America. That report, "To Err Is Human: Building a Safer Health System," concluded that as many as 7000 Americans die from medication errors each year.
Slide 6 : Drugs Most Commonly Implicated in Adverse Events 1. Insulin (8%) 2. Anticoagulants (6.2%) 3. Amoxicillin (s) (4.3%) 4. Aspirin (2.5%) 5. Trimethoprim-sulfamethoxazole (2.2%) 6. Hydrocodone/acetaminophen (2.2%) [Vicodin/Norco] 7. Ibuprofen (2.1%) 8. Acetaminophen (1.8%) 9. Cephalexin (1.6%); and 10. Penicillin (1.3%).
Slide 7 : FACTORS INVOLVED IN RX ERRORS Unintentional overdoses made up 40% of ED visits. Other mechanisms included side effects and allergic reactions. Some of the drugs on this list are especially common (eg, hydrocodone and amoxicillin), so the sheer volume of prescriptions written is a major factor. Common misuses that lead to adverse drug events are taking incorrect doses, taking doses at the wrong times, forgetting to take doses, or stopping the medication too soon.These are all non-adherence issues. Antibiotics represent inappropriate prescribing: Twenty-three million antibiotic prescriptions are written for colds, bronchitis, and upper respiratory infections each year, despite the fact that antibiotics don't kill viruses.
Slide 8 : Medications Involved in Drug Errors These 10 medications are most commonly misused or mishandled in some way by healthcare professionals. 1) Insulin (4% of all medication errors). 2) Morphine (2.3%); 3) Potassium chloride (2.2%); 4) Albuterol (1.8%); 5) Heparin (1.7%); 6) Vancomycin (1.6%); 7) Cefazolin (1.6%); 8) Acetaminophen (1.6%); 9) Warfarin (1.4%); and 10) Furosemide (1.4%).
Slide 9 : OTHER FACTORS IN RX ERRORS Similar names for some of these drugs often cause confusion, such as: Avinza and Evista; Morphine and hydromorphone; Oxycontin and MS Contin; Hydrocodone and oxycodone; andOxycodone and codeine. Morphine oral solutions cause many problems because of the multiple concentrations that are available, all stored close to each other.
Slide 10 : Drug Labeling Nomenclature For example, it would be easy to confuse "mL" with "mg"; using 5 mL of morphine 20 mg/mL (100 mg) instead of the prescribed 5 mg (0.25 mL) would lead to overdosing the patient. Alternatively, an intended dose of 1 mL of morphine 20 mg/mL (20 mg) might be given as 1 mL of 10 mg/5 mL (2 mg), thus underdosing the patient. Avinza (morphine ER caps) 30 mg was misinterpreted and dispensed as "qid" (4 times daily) instead of "qd" (once daily), causing a near-fatal overdose.
Slide 11 : EXAMPLES OF POOR COMMINCATION A prudent nurse would have questioned this order prior to administration. If not, this patient could have easily died, make no mistake these errors occur every day.
Slide 12 : Doctor’s Handwriting Could Kill Perhaps the most infamous example of the dangers of illegible handwriting to date occurred when misfiled prescription resulted in the recent death of a Texas man. The prescription was for Isordil, a drug to treat [angina] chest pain was filled by the pharmacist as Plendil, a calcium channel blocker. A Texas jury awarded the patient’s family $450,000.The physician was required to pay half of this award, and the pharmacist the other $250,000.
Slide 13 : POTENTIAL LEGAL PROBLEMS It is well known in the world of medical documentation that if it is not written in the chart, it did not happen. But what if it cannot be read? What type of defense is, “I know the jury cannot tell for certain, but that does say ‘informed consent was given’”? The court stated in Norton v Argonaut Insurance Company (144 So2d 249) that physicians have a duty to make their intentions “clear and unmistakable” and that the physicians must “make certain” of the lines of communication between them and anyone who may execute their orders.
Slide 14 : OVERVIEW OF HOSPITAL RISK FACTORS Type of treatment received. The Hospital set-up of their health services. Variable compliance with hygienic procedures. Poorly designed facilities that lead to a heightened risk of iatrogenic harm from badly considered room layout and departmental setup, for example hospital acquired infections or HAI’s. Environmental in terms of low levels of cleanliness in clinical areas. Conditions outside the auspices of hospitals can lead to patient harm such as inappropriate use of antibiotics in medicine and agriculture.
Slide 15 : AGRICULTURE AND FACTORY FARMS Animals raised in confinement create an ideal setting for bacteria and disease to spread rapidly. Antibiotics were developed around the time of World War II and were soon adapted into the farming system. In the U.S., almost 50% of all antibiotics are administered to farm animals. These drugs form a toxic residue in animal tissue. It is much of this same tissue that is sold to consumers as food products. Each year, we see an increase in the number of salmonella poisoning cases from contaminated eggs, meat and milk. These strains of salmonella are difficult to treat because they are antibiotic resistant. Antibiotics are not the only chemicals administered to factory farm animals; many animals are fed growth-promoting hormones, appetite stimulants and pesticides, fertilizers, herbicides and aflatoxins that collect in the animals' tissues and milk.
Slide 16 : All Drugged Up
Slide 17 : OTHER HOSPITAL FACTORS IN PATIENT HARM Patient harm occurs when local standards of care fall short of those of desired evidence-based practice.  Therefore, patient safety is an issue for those involved in the management and organization of the health care delivery.  Certain aspects of the delivery of health care can hamper efforts to maintain standards and reduce patient harm:  These include:
Slide 18 : SUB-OPTIMAL STANDARDS OF CARE IN HOSPITAL SETTINGS Lack of explicit controls that allows a culture of blame to proliferate. Insufficient investment in systems redesign leading to potentially unsafe systems by virtue of them being outdated and or poorly maintained. lack of the appropriate equipment and supplies, insufficient time and inadequate supervision , this happens even in the BEST teaching facilities…names mean nothing!!!
Slide 19 : SUB-OPTIMAL STANDARDS OF CARE IN HOSPITAL SETTINGS Inability to afford information technology due to high costs and privacy concerns. Lack of the appropriate technical expertise through the absence of a continuous training environment. Poor interpersonal communication with no effective interaction between patients and staff, as well as between health professionals, leading to communication failures.
Slide 20 : FACTS & STATISTICS ON PATIENT HARM Under-reporting of Iatrogenic events is a FACT. Many go unreported, some are covered up in order to keep the hospitals reputation favorable in the community. As a matter of fact, as few as 5% and only up to 20% of Iatrogenic acts are ever reported. This implies that if medical errors were completely and accurately reported, we would have a much higher annual Iatrogenic death rate of the reported 200,000+ a year.
Slide 21 : STATISTICS: MEDICAL ERRORS In one decade 10 years, the deaths caused by conventional medicine are approximately 8 million. This is more than all the casualties from all the wars America has ever fought in. The total number of medical errors and deaths every 10 years equals SIX jumbo jets crashing every day? Medical errors are one of the Nation's leading causes of death and injury. A recent report by the Institute of Medicine estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of medical errors. This means that more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS.
Slide 22 : STATISTICS: MEDICAL ERRORS If medical errors were completely and accurately reported, we would have a much higher annual death rate than 783,936 . As far back as 1994, the figure was 180,000 medical mistakes annually. This is equivalent to three jumbo-jet crashes every two days. As of today the reports show that six jumbo jets are falling out of the sky each and every day!
Slide 23 : THE IMPACT OF MEDICAL ERRORS The latest Institute of Medicine IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 in long-term care settings, and roughly 530,000 among Medicare recipients in outpatient clinics .
Slide 24 : ERROR EXAMPLES Misdiagnosis of an illness, failure to diagnose or delay of a diagnosis. This type of error could be a direct mistake of a doctor or caused when the doctor is acting on incorrect information supplied by some other person. Giving the wrong drug or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route). Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts. Wrong-site surgery, such as amputating the wrong limb. Retained surgical instruments. In particular, gossypiboma, resulting from a surgical sponge being left behind inside the patient after surgery
Slide 25 : ERROR OCCURANCE EXAMPLES Patients' implementation of drugs and treatments. Using race as a diagnosis, not a factor. Transplanting organs of the wrong blood type. Incorrect record-keeping. Common excuses made are: "Why disclose the error? The patient was going to die anyway.“ "Telling the family about the error will only make them feel worse.“ "It was the patient's fault. If he wasn't so (obese, sick, etc.), this error wouldn't have caused so much harm.“ "Well, we did our best. These things happen.“ "If we're not totally and absolutely certain the error caused the harm, we don't have to tell."
Slide 26 : One in Three Patients Harmed During Hospital Stays A study, in April's Health Affairs, reflects two reports issued in November 2010 that showed rates of adverse events hovering near 25% among hospitalized Medicare patients nationwide . A survey released in [2010] March 31, revealed patients are scared of medical mishaps. Nearly 60% of adults polled by the Consumer Reports National Research Center believe medical errors are common in hospitals, and nearly half said serious harm is common. Nearly 80% of patients said they feared contracting an infection in a hospital, 71% were worried about medication errors and 65% were scared of surgical mistakes…..and with good reason. Consider the following real life stories.
Slide 27 : The Sixth Biggest Killer in America Researchers at the Harvard School of Medicine have found that even today, about 18 percent of patients in hospitals are injured during the course of their care and that many of those injuries are life-threatening, or even fatal. The Office of the Inspector General of the U.S. Department of Health and Human Services found that one in seven Medicare patients are injured during hospital stays and that adverse events during the course of care contribute to the deaths of 180,000 patients every year. Since the IOM first shined a light on the dismal state of patient safety in American hospitals, an IOM seminal study of preventable medical errors estimated the cost of dying to be $29 billion annually!! If the Centers for Disease Control were to include preventable medical errors as a category, these conclusions would make it the sixth leading cause of death in America. This is totally unacceptable and must be changed.
Slide 28 : NEVER EVENTS: NEVER SAY NEVER A “Never” event is an inexcusable outcome in a health care setting. The initial list of 28 events was compiled by the National Quality Forum of the United States. They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." Even errors that the government and private health insurers have classified as “never events,” events that should never happen in a hospital, are occurring at alarming rates. Recently the Joint Commission Center on Transforming Healthcare reported that as many as 40 wrong site, wrong side and wrong patient procedures happen every week in the U.S. Similarly, researchers in Colorado recently found that surgical “never” events, such as operating on the wrong patient or wrong site or performing the wrong procedure, are occurring all too frequently.
Slide 29 : “NEVER EVENTS” THAT ARE NOT SUPPOSED TO HAPPEN: Surgery on the wrong body part Surgery on the wrong patient Wrong surgical procedure performed on a patient Object left in patient after surgery Death of a patient, who had been generally healthy, during or immediately after surgery for a localized problem Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics Patient death or serious disability associated with the misuse or malfunction of a device Patient death or serious disability associated with intravascular air embolism Infant discharged to the wrong person Patient death or serious disability associated with patient disappearing for more than four hours
Slide 30 : 27 “NEVER EVENTS” Patient suicide or attempted suicide resulting in serious disability Patient death or serious disability associated with a medication error Patient death or serious disability associated with transfusion of blood or blood products of the wrong type Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy Patient death or serious disability associated with the onset of hypoglycemia, a drop in blood sugar Death or serious disability associated with failure to identify and treat hyperbilirubinemia, a blood abnormality, in newborns
Slide 31 : “NEVER EVENTS” Severe pressure ulcers acquired in the hospital- see photo Patient death or serious disability due to spinal manipulative therapy Patient death or serious disability associated with an electric shock Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances Patient death or serious disability associated with a burn incurred in the hospital
Slide 32 : “NEVER EVENTS” Patient death associated with a fall suffered in the hospital Patient death or serious disability associated with the use of restraints or bedrails Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider Abduction of a patient Sexual assault on a patient Death or significant injury of a patient or staff member resulting from a physical assault in the hospital
Slide 33 : STORIES OF HARM & DEATH FROM MEDICAL ERRORS Brother bleeds to death from central line medical error: On June 2011, Mr. C’s brother died as a result of a mistake made by 2 anesthesiologists at a hospital. While central lines were being placed into his internal jugular vein to prepare for a liver transplant, the catheter/needle was advanced too far, perforating both the jugular and right subclavian artery. The brother bled to death. Although these doctors admit to making a terrible mistake, they are not being held accountable in any way. The hospital offered to pay his Mother $18,000.00, but only in exchange for her not to pursue complaints on the hospital or any of the physician’s involved.
Slide 34 : Surgical Error During Biopsy Left Patient Permanently Blind A simple forceps biopsy was performed (in my chest of a massive 13cm tumor) to diagnose, and/or grade and stage Non-Hodgkin's lymphoma. A surgical accident occurred during this biopsy; the Superior Vena Cava (large vein which returns blood to the heart from the head, neck and both upper limbs) was erroneously cut and erroneously sewn closed, resulting in Superior Vena Cava arrest. Surgery was emergently ended. During recovery, while on a ventilator (a breathing machine; aka life support), I awoke and was already totally blind.
Slide 35 : Misdiagnosed With Aggressive Cancer Patient was misdiagnosed. She was told she had an aggressive, deadly cancer, and six months to live unless I got the necessary chemo to buy myself an extra year. Despite resistance from her oncologist, she was able to prove she had no cancer at all. Almost five years later she had never had treatment. It took three months from the original biopsy that instigated the error until word from the NIH came that She was correct and had no malignancy. She had to fight the system of doctors who did not want to admit their error. She had no medical training or healthcare background. Today she advocates for others through a number of writing, speaking, broadcasting activities.
Slide 36 : Holding Doctors & Nurses Accountable for Medical Errors Consistent with what patients say they would expect after a medical error, studies of patients who file suit find litigants are motivated to find out what happened and to prevent future injury, motivations that implicate apologies. Surveyed medical malpractice claimants about the reasons they filed suit, over 90% of respondents indicated they wanted to prevent the same thing from happening to someone else, to receive an explanation for what had happened, or for the doctors to realize what they had done. Of the respondents who thought something could have been done to prevent the lawsuit, approximately 40% reported that if they had received an explanation and apology, they would not have felt the need to file suit. This should clue doctors, nurses and hospitals to be more transparent about admitting errors, sadly as of yet they do not.
Slide 37 : Medical Mistakes Kill & Injure Thousands Cost-cutting exacts toll on patients, hospital staffs: Overwhelmed and inadequately trained nurses kill and injure thousands of patients every year as hospitals sacrifice safety for an improved bottom line, a Tribune investigation has found. Since 1995, at least 1,720 hospital patients have been accidentally killed and 9,584 others injured from the actions or inaction of registered nurses across the country, who have seen their daily routine radically altered by cuts in staff and other belt-tightening in U.S. hospitals.
Slide 38 : Medical Paradigm in the Following Statistics These estimates of death due to error are lower than those in a recent IOM report.  If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.  Even at the lower estimate of 225,000 deaths per year, this constitutes the third leading cause of death in the U.S. NOT sixth.
Slide 39 : DEATHS FROM MEDICAL ERRORS
Slide 40 : GOING TO THE HOSPITAL: WHAT YOU NEED TO KNOW
Slide 41 : Transparency: When Patients File Complaints Against Health Care Workers Now Under Consideration In The Senate. Patients who file complaints against doctors and other health care providers would be able to find out more information about the status of their complaints and how they are handled under a bill now being debated by state lawmakers. HB 1493 would improve the process for holding doctors and other health care workers accountable for unprofessional conduct and unsafe care, according to Consumers Union, the nonprofit publisher of Consumer Reports. The bill was approved by a 68 to 29 vote in the House last week and has been sent to the Senate for consideration.
Slide 42 : State Bill Would Create More Transparency Under the proposed bill, patients who file complaints will have the opportunity to submit an impact statement detailing how they were affected by the doctor’s or health care worker’s conduct. The bill requires the agency handling the complaint to respond promptly to any inquiries regarding the status of the case. The person who filed the complaint and the person who is the subject of the complaint may request a complete copy of the file on the matter with some exceptions of confidential information.
Slide 43 : More Transparency Once a complaint has been reviewed, the disciplining body must inform the person who filed it of the results of its evaluation. If the complaint is settled before an impact statement has been filed, the patient must be given the chance to submit one and make a request for reconsideration. The doctor or health care worker will be allowed to respond to the amended complaint. Once the matter has been fully considered, the agency must issue a written report that provides an explanation for its decision.
Slide 44 : CONCLUSIONS Despite the shocking number of medical errors, few injured patients ever file a medical negligence lawsuit, and fewer still file frivolous claims. Research shows almost all medical negligence claims are meritorious. Claims where there was no error are rarely paid and researchers have concluded the reverse – errors which are never compensated – is a far bigger problem. The reality is, an epidemic of medical malpractice, not of malpractice lawsuits. The rising cost of health care intensifies the need to focus on preventable medical errors and their huge associated costs. The savings from preventing medical errors run into billions of dollars. The savings from restricting patients’ access to justice, however, are negligible.
Slide 45 : Civil Justice Keeps Us Safer In conclusion every profession has its bad apples and doctors, nurses and hospitals are no exception. With that said, only six percent of doctors are responsible for nearly 60 percent of all medical negligence, and the civil justice system is the only effective means for holding them accountable period. No apologies for a wrongful death or putting a “cap” on a loved ones life.
Slide 46 : Civil Justice Other disciplinary mechanisms are completely inadequate. As most “bad apples” just move to a different State. They know how to play the game leaving the patient and family clueless , thus seeking legal council is the most prudent action. For example, State medical boards, for instance, are supposed to discipline doctors who consistently violate standards of care. Yet two-thirds of doctors who make 10 or more medical negligence payments are never disciplined at all, this is why we need the legal system as the medical boards hardly slap the hand.
Slide 47 : SAFETY WITH ACCOUNTABILITY Hospitals are on the front lines of patient safety, yet nearly half of all U.S. hospitals have never reported a disciplinary action to the National Practitioner Databank since its creation in 1990. Alternative compensation systems, such as health courts, propose eliminating or greatly sidelining disciplinary systems altogether. The civil justice system holds doctors, nurses, hospitals and insurance companies accountable. It is this accountability that drives the development of patient safety systems that help prevent negligence before it occurs. Hospitals, health systems and even entire medical fields have reformed dangerous practices because of the civil justice system. Without the accountability the civil justice system enforces, patient safety will suffer and health care costs will go up for everyone.
Slide 48 : Caveats
Slide 49 : Mistakes in and out of the OR Source: "Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era," Archives of Surgery, October (archsurg.ama-assn.org/cgi/content/abstract/145/10/978
Slide 50 : Preventable Deaths
Slide 51 : Things That Should Never Happen!
Slide 52 : Doctors Remove Wrong Testicle Patient had complained of pain and shrinkage of his left testicle -- concerns of Cancer prompted doctors to schedule surgery for June 14 to remove it. However, medical records suggest a series of missteps, from an error on the consent form to a failure on the part of medical personnel to mark the proper surgical site before the procedure. The error, spurred a $200,000 lawsuit. The medical Center had no comment on the progress of the case or on subsequent safety measures that were implemented at the hospital.
Slide 53 : Surgeons Leave 13-Inch Retractor in Patient Patient had an abdominal tumor, but when he left, the tumor was gone, but a metal retractor had taken its place. Doctors admitted to leaving the 13-inch-long retractor in the abdomen by mistake. This was not the first incident at the medical center; four other such occurrences had been documented. The hospital accepted full responsibility for the error and agreed to pay $97,000.
Slide 54 : Mix-Up Leads to Unneeded Double Breast Removal A 35-year-old single mother from N.Y. filed a lawsuit against a medical pathology laboratory after a mix-up at the lab prompted her to have both her breasts removed. She received a report indicating she had breast cancer, and she said she was told she should have both of her breasts removed. Savvy, she sought a second opinion, but the next doctor relied on the same set of records as the first and reiterated her cancer diagnosis. Continued -?
Slide 55 : Double Breast Removal A state report blamed the mix-up on a technician who admitted cutting corners while labeling tissue specimens. Both this technician, as well as the doctor who signed off on her diagnosis, no longer work for the company. This is of little consolation to a women who NEVER had breast cancer to begin with. Her lawsuit is pending.
Slide 56 : Conclusion Trust in medical safety has eroded, the idea from the I.O.M. report that launched this field was that there was a jumbo jet’s worth of people dying every day. The only way fix this problem is to become much more open and transparent. That transparency should drive providers to improve and educate each other. With that said, doctors, nurses and all healthcare providers MUST admit first that they do not deliver quality care that is of the safety ALL patients deserve. Then they can get past the rampant “God Complex” and professional arrogance.
Slide 57 : Medical Errors are No Joke Nearly 3 percent of patients in the nation's hospitals risk experiencing hospital errors, a new study finds. And the numbers could be on the rise. The report further suggests that those patients who experience an error in treatment or care at a hospital have a one in four chance of dying from the mistake. What it found was that 1.16 million preventable "patient safety incidents" occurred over the three years studied, which means that 2.86 percent of all the patients studied experienced a health problem brought about by their hospital stay. Due to these incidences, 247,662 patients died from potentially preventable problems.
Slide 58 : THE END www.parksmedicallegal.com http://legalrnblog.com – Over 2,500+ clinical guidelines and counting © 2012 PMLC

 


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