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Why Can’t Medicine Seem to Fix Simple Mistakes?

The death of 12-year-old Rory Staunton from septic shock prompted NYU’s Langone Medical Center to revamp its emergency room procedures to address a startling lapse. History shows that the profession is unlikely to learn from this mistake.

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(Brian Stauffer/theispot.com)

NYU's Langone Medical Center announced this week that it was adopting new procedures after the death of a 12-year old boy from septic shock. The hospital's emergency room sent Rory Staunton home in March and then failed to notify his doctor or family of lab results showing he was suffering from a raging infection.

In response to the case, which was closely covered by The New York Times, the hospital promised a bunch of basic fixes: ER doctors should be immediately notified of certain abnormal lab results and, if such results come in after a patient is sent home, the hospital should call the patient and his doctor.

As veteran health reporters, we wish we could tell you that this case will spur changes in emergency rooms across the nation, that never again will a hospital make such an avoidable mistake. But, sadly, decades of experience covering such incidents suggest the medical system may prove resistant to change. Forget about every hospital rewriting its procedures. History suggests it would be a victory if NYU Langone manages to follow its own new rules as we all hope they will.

It's long been known that medical errors are a major problem—a national panel concluded more than a decade ago that nearly 100,000 people die each year as a result of errors in hospitals. Despite the resulting national focus on patient safety, patients continue to be harmed and killed by medical shortcuts, inadequate training and breakdowns in communication.

Unlike the airline industry, which relies on a safety net of checklists, the medical community has been slow to adopt them in all areas and often puts its faith in the outdated idea that doctors are infallible.

Time and again reporters have uncovered unfathomable lapses at medical facilities, often resulting in patient injuries and death. Time and again, hospital officials have put in place solutions that seem ridiculously obvious.

And, inconceivably, the fixes are frequently ignored or ineffective.

That's why we at ProPublica are working on a project to document cases of harm to patients. (If you or a loved one has been harmed while undergoing medical care, will you please share your story with us by filling out our Patient Harm Questionnaire.)

Few medical skills seem as basic as operating on the right body part of a patient. Yet, Rhode Island Hospital, the main teaching hospital of Brown University's medical school, couldn't get its surgeons to identify the right one.

Three times in 2007, surgeons there drilled into the wrong side of patients' heads. After the second incident, the state health department ordered the hospital to hire a consultant and to double-check surgical sites. After the third, the department reprimanded the hospital and fined it $50,000.

But in May 2009, it happened again. During an operation to fix a child's cleft palate, a surgeon at Rhode Island Hospital operated on the wrong side of the patient's mouth. And then, in October of that year, an orthopedic surgeon operated on the wrong finger of a patient.

That's five times in less than three years.

After each incident, the hospital said it was committed to patient care and would make needed changes.

The hospital was reprimanded again, fined an additional $150,000, ordered to install video cameras in its operating rooms, and required to follow accepted procedures for preventing these types of slip-ups.

There hasn't been another wrong-site surgery at the hospital since then, a hospital spokeswoman said. But in 2010, the state health department fined the hospital $300,000 for leaving a broken drill bit inside a patient's skull. That's another frequent medical foul-up, leaving things inside people, experts have been working to eliminate.

At times our own reporting has left us dumbfounded that the easy-to-follow solutions—and the media's hot spotlight—have not kept patients from harm.

In mid-2003, Ornstein and Weber began writing about problems at Martin Luther King Jr./Drew Medical Center, a public hospital near Los Angeles with a troubling history of poor patient care.

One of their first stories detailed how a nurse in the cardiac monitoring unit failed to notice that her patient's heart had slowed and stopped for more than 45 minutes. The nurse wrote on the patient's chart that she was not in distress, even though her heart had already stopped. Two weeks later another patient on a monitor died after her failing condition also went unnoticed.

After the deaths, Los Angeles County health officials vowed that nurses and technicians in monitoring units had been retrained and new procedures had been put in place to prevent such events from ever happening again.

Over the next two years, however, five more patients in King/Drew's monitoring units died in similar circumstances. In some cases, nurses were found not only to have neglected patients as they lay dying, but to have purposely turned down the alarms on the monitors or lied about their actions on patient charts.

A county supervisor said he was confounded by hospital's inability to correct basic problems. “You can yell, scream, jump up and down, but things don't seem to change.” The hospital closed in 2007.

Allen, who previously worked in Las Vegas, reported on the nation's largest healthcare-based hepatitis C outbreak in 2008. Nurses at a colonoscopy clinic there were reusing syringes and single use medicine vials, infecting more than 100 people with the deadly disease.

The public, regulators and medical providers were outraged: How could anyone think it was OK to reuse syringes? But when inspectors checked other facilities, they found the same problems. According to the Centers for Disease Control and Prevention, 125,000 patients have been notified since 1999 of potential exposure to blood-borne diseases due to unsafe injection practices.

The ongoing breaches of medical standards led to the CDC's One & Only public health campaign, which reminds providers to use only one needle and syringe per patient. And yet, just last week, the Colorado Department of Public Health and Environment said thousands of patients may have been put at risk of HIV and hepatitis because "needles and syringes were used repeatedly, often for days at a time," at the offices of Stephen Stein, a Colorado dentist. Last year, Stein agreed to stop practicing, at least temporarily.

That's what's so difficult to understand about medical mistakes. It seems inconceivable that nurses and doctors would reuse a syringe on multiple patients or that they would turn down alarms on cardiac monitors after patients at their hospital had died as a result.

Rory Staunton (Photo courtesy of <a href='http://rorystaunton.com/'>http://rorystaunton.com/</a>)NYU's Langone Medical Center has had its own share of problems over the years. Between 2002 and 2008, it was hit with a string of fines and penalties from the New York State Department of Health for errors that led to patient deaths. In 2007, for example, it was fined $6,000 after delays in diagnosing an infant's herniated bowel and deteriorating condition in the emergency room led to the patient's death.

NYU's history of fines shows that like Rhode Island Hospital, it operated on patients' wrong body parts, and like King/Drew, it did not properly watch over a patient in need of continuous monitoring.

In the cases we've covered and read about, problems don't usually happen because medical staffs are malicious. Instead, they stem from the culture of an institution—a much harder fix that requires a strong and sustained will.

Administrators need to empower front line staff, no matter their rank, to speak out when they see safety lapses before they cause harm — which is difficult in a system that reveres doctors above others.

Addressing the types of failures that led to Rory Staunton's death depends on redirecting resources at a time when they are scarce and accountability amid the chaos of busy hospitals. And it depends on convincing people that something as simple as adding one new task to an already long list could save lives.

ER doctors should be immediately notified of certain abnormal lab results and, if such results come in after a patient is sent home, the hospital should call the patient and his doctor.

This is almost never done. Tests, even at one’s doctor, can take weeks to get. I once left the ER with stomach pains, was told to take a strong laxative, threw it up, went back to the ER in the early AM, said I was worse, they took another x-ray, said I was not worse, I said yes, I am and they said do you think you have a blockage—I said yes, something, it hurts! They came back in my cubicle and said they were looking at the wrong x-ray and I did have a blockage. I spent a week in the hosp on a nasogastric tube (no picnic) and it resolved, which was good because they said my insurance was so bad no surgeon would have treated me. I later got the records (you can and should do it—call Records office) and it said POSSIBLE BLOCKAGE on the first day. I have many of these stories for me, my sister and my 95-yr-old mother.

Also on that limb thing—they make you write on the health side—NOT THIS ONE., Why not write CUT HERE on the bad one? Sick World is a dopey place.

And knowing that so many mistakes are being made we have politicians who think the best way to improve things is to have tort reform so that the injured can’t sue for damages. Because God knows that that’s the real problem with health care costs.

I worked on an adolescent psych ward.  I repeatedly asked why the nursing staff was allowing patients to serially share electric razors.  They told me they were soaking the rotary blades in alcohol between patients.  I had witnessed one patient handing the razor after use on to another patient. I could not get any response except “Mind your own business. We know what we are doing.”  I finally wrote to infection control.  They contacted the unit and told them to quit allowing patients to share the rotary razor that the psych unit owned and told them to make up a policy and procedure and back—date it.  That’s how the problem was handled except for one additional fact.  I received an irate phone call from the Unit Nursing Supervisor telling me that there had always been a no-share policy on razors and to just look in the P&P book (where they had just added one.)  I knew what was in the P&P book previously because I was the only person on the unit who ever read the book.

This title is disingenuous: it suggests that “simple mistakes” are 100% preventable. This is simply not possible in any system where humans are involved. Doctors are humans, humans are fallible, therefore doctors are fallible.

INCOMPETENCE , its everywhere——you have an incompetent indivual
and put them in nursing, you end up with an incompetent nurse, or doctor, or administrator, or government employee, or—————-

Darla Reynolds-Sparks

July 20, 2012, 12:10 p.m.

Yes, incompetence is everywhere but when doctors and hospitals are incompetent,it can kill you.  Patients need to have a complete medical degree to help themselves stay alive after checking into one of those places.  It still would not help much due to the absolute arrogance of anyone in the medical field.  They really think their patients have no brain cells.  My advice…educate yourself,once they give you a diagnosis.before submitting to any medical person.  If they do not wish to listen and answer questions, fire them and get new ones.  Do NOT submit to anyone in a medical facility until they have addressed all your concerns. It doesn’t matter how busy or how full the waiting rooms are….They belong to you when you are asking a question.

richard rosenthal

July 20, 2012, 12:19 p.m.

Want to greatly reduce error and infection deaths &injuries;?Simple. Disaccredit the major offenders for medicare and medicaid reimbirsements. These payments comprise 70% of health care facility income. Hit them in their wallets.& they’ll do what needs doing. CMS (Cernter for Medicare Services) has this authority So to a great extent does the Joint Commission which, under deeming authority from CMS accredits 80% of the nations healthcare facilities for medicare & medicaid payments. But the Joint Commission operates in an inherently corrupt situation. The very hospitals they accredit pay them for their accreditation inspections. It’s Moody’s and Lehman Brothers all over again. . The raters paid by the ratees.And the press barely notices this & Congress yawns at it.

The hospitals know how to control infections and errors.They’ve known sinceSemelweis & Oliver Wendell Holmes told them how in the 1840"s. They won’t clean up their act until the consequences for not doing so are truly serious.  .

I live in NE TN and we have an extremely high rate of MRSA infections. Although hospitals in our area say they are taking steps to stop this staph, people are still dying from it. Less than a year ago, a friend of mine died from a massive MRSA that had been in his blood for a month. When I asked if he had had any type of surgery, I found out he’d had a very minor procedure in his primary care doctor’s office approximately one month before he died. I’ve even seen recent videos of nurses and doctors not washing their hands between patient examinations. I suppose they just won’t learn.

Poor nursing care isn’t the only reason for medical mistakes, obviously. But it is a major reason. Because of the severe current and potential nursing shortages, nurses are receiving very cursory training from many two year schools. Some enroll students that can barely read. The phasing out of diploma nurses who were trained in hospitals under the supervison of experienced nurses is part of the problem The lack of baccalaueate trained nurses is another. Many so-called nursing assistants and medical assistants are entry level positions and these persons have had only a few weeks of training yet are given tasks that only well trained nurses should carry out. Medicine is now highly complex with basic needs for computer skills and training in pharmceuticals and complex machinery. The minimal training most nurses receive just isn’t adequate to the jobs they are expected to perform.

I seem to remember that there was a study released 5-10 years ago, that showed that half the deaths that took place in hospitals were preventable, and that 10-12 simple changes could do it. Things like labeling the body part that was to be operated on, requiring a check-in of all surgical instruments before closing up a patient, cutting hours on a shift, forcing every member of the staff to work at least some nights and weekends,

As I remember, hospitals fought those standards, complaining they were insulting. But when people used them, it worked.  That stuff should be in place everywhere—and it should be regularly revisited.

There were other projected improvements. One was an electronic health record that would automatically check all medical orders against that record, so you couldn’t give a patient the wrong blood or a medication they were allergic to (or that was contraindicated by their symptoms or current medications).

The problem is that a medical degree has always come with the right to play god and to answer to no one, and the industry fights that.

Panos Ipeirotis

July 20, 2012, 12:55 p.m.

I think that a reference to the book by Atul Gawande “The Checklist Manifesto: How to Get Things Right” would be appropriate in the article. The book advocates for the use of checklists in hospitals (and shows the dramatic improvements that come as a result of using a checklist). Wonderful book.

This is the same mechanism/environment that allows for 326k iatrogenic deaths per year. Amazing that so many people could be against things like homeopathy and acupuncture etc when of course there is no measurable death rate whatsoever in the field of all combined alternative modalities.
Read Shannon Brownlee’s work. She has amassed a tremendous amount of peer reviewed material substantiating the above number.

Jon, your statement is, itself, a bit disingenuous, I think.  Humans are fallible, but they’re far more fallible when they refuse simple help.

In contrast to the number of stupid medical blunders, when’s the last time you heard about a plane’s wing falling off because someone forgot to fasten a bolt?  Everybody who works with a plane, generally, works from a checklist.  Same deal with most “miraculous” landings; the pilots dealt with the emergency by following the list.

By making sure you’ve gone through a step and given it a modicum of thought, you eliminate the error (of skipping that step) every time unless you’re pathological about it.  Doctors are, by and large, pathological about this (see Anita’s story), believing that checklists are beneath them.  And so, people are prescribed drugs that have bad interactions with other medication, the wrong leg gets amputated, blades and needles go unsterilized, or nobody bothers to mention a flatlining patient.  Yeah, oops, fallible humans, but a checklist can make an uneducated child a better caretaker than that and ignoring that demonstrably costs lives.

To Nick’s point, that’s what checklists are all about.  By following directions, you can’t be any worse than the directions.  You may never get a gourmet meal at McDonalds, but no matter how inept or inexperienced the cook, the odds of getting a bad meal are extremely low.  By accepting the directions, the wage-slaves are managed into competence.

Let’s be honest, anybody in a service industry, especially one where lives are at stake, who values their independence over getting things right?  Maybe—just maybe—they’d be better off in another line of work.

Richard, a problem with punishment is that a lot of people fail at these tasks because of stress.  “Hitting them in the wallet” is going to make them more error-prone, not less.

A better solution would be to remove them from the job to recover their nerves.  That, and checklists to rely on during stressful times, will solve the problems more effectively.

Of course, to do that, you need a larger staff to cycle in, and then you butt up against the AMA’s artificial scarcity…

BabyBoomerWriter

July 20, 2012, 1:30 p.m.

Time to start drug testing at hospitals? No one should be exempt. This is an excellent, but terrifying article. Thank you.

Thank you for providing the long held evidence for why Rory died unnecessarily….it wasnt a new problem. Its been an issue going on for decades.

It is just so sad. My heart breaks and cries everytime I hear of another family who has to know this kind of grief.
When your child died preventably - in the hadns of those whom you have entrusted with their care, there is no recovery for the parents either.
And people just dont seem to want to believe it

Having been a clinical laboratory director some 30 years ago at the dawn of the electronic medical record I believe the implementation of these systems will help the case of the ER patient sent home with a potentially fatal infection. It takes at minimum 24 hours for the lab to grow the bacterium on media. Three decades ago we would call the doctors office for all staph aureus or similar serious infective bacteria and the supervisor of the lab had to initial the 3 x 5” report form that she/he had reviewed and the call had been made. Today, we can access the docs office/ER digitally and have the report to him/her very quickly. The ball is then in the docs court. If he fails to implement the standard antibacterial therapy and the patient suffers, his name is given to the supervisory medical officer of the hospital/clinic and he will be called on the carpet. Serious injuries/illnesses are ordinarily brought before the Infections Control Committee and frequently the legal department will attend these sessions. Healthcare institutions/doctors/labs need be held accountable. One way is shut them down, permanently.

So we have checklists. And we have fines and no-pay penalties. And still culture doesn’t change. Accountability slips away.

Could Weber, Orstein and Allen please suggest how their new ProPublica error collection will alter the status quo??

Writing about appalling care isn’t going to fix it. Checklists are “implemented” but solid commitment isn’t behind them.

I’d like to hear what WILL create change. Telling tragic stories to each other doesn’t make change happen. It may trigger guilt, cynicism and change fatigue. But it doesn’t change behavior and peer norms.

What’s the fix, folks?

How are you going to attach a healthcare worker’s conscience to the patient experience? How is something new going to be stronger than habit?

Thanks for sharing your constructive plan. It’s so overdue.

“Unlike the airline industry, which relies on a safety net of checklists, the medical community has been slow to adopt them in all areas and often puts its faith in the outdated idea that doctors are infallible.”

Can you give us numbers to compare mistake/accident rates (per capita or something similar to account for the millions of people treated, most of them successfully each day in US hospitals) between medicine and other industries (e.g., airline industry, aerospace industry, other relevant comparisons)? The comparison between medicine and the airline industry is often made but numbers seem hard to come by. 

Additionally, while it is easy to find blatant mistakes in medicine and tempting to generalize those mistakes to the entire field, your examples of an admittedly damning report from 1999 and a few bad mistakes over the last few years doesn’t necessarily mean that improvements have not been made in the thousands of hospitals across the country that successfully treat millions of patients every day. Do you have data to suggest that the situation has not improved since 1999? Are the horrible examples you cite generalizable to more than a small number of badly managed hospitals?

It’s all about the profit motive: maximizing the number of patients served in the least amount of time, rushing people through diagnosis, not holding people under observation, treating emergencies only (which increases the potential calamity of a misdiagnosis). This creates a culture of rush, of quick fixes, of contempt for patients who want information or take too much time or resources because they do not submit to easy diagnosis. Mistakes are built into the system that is more about quick fixes than long term care, and the results are tragic.

I say this as someone whose appendicitis was misdiagnosed twice, who was sent home from an ER before and after my system went septic. I almost died. I’ve had an internal infection and complications ever since, now 14 years later. The ER that misdiagnosed me held me on a stretcher in a hallway for hours with 6 other patients also on stretchers because it was overloaded.

Appendicitis is not a new condition. But high tech hospitals are in some ways worse rather than better at dealing with it. 60 years ago, I would have been held over for observation even if test results came up negative. Today, people are sent home, and endless numbers of risks are taken with people’s health, in order to save money.

margaret reeve panahi

July 20, 2012, 3:44 p.m.

Maybe reducing the pressure to push patients out the door of the hospitals faster and faster would help. The pressure to move people out as quickly as possible is, in my opinion, a terrible basic element of this problem. The mantra is: “what are they doing here?” from the case managers. The care is not patient focused, it is financially based, ultimately, from the institutions as a whole. There are, of course, exceptions but high costs have pushed the length of stay to be as short as possible. Look into early discharges and high readmission rates nation wide.  It is a growing problem.
  The hospital is not a place to rest and recover, it is a place to be diagnosed, stabilized and then to leave from ASAP.  I think that, to try to improve things, that check lists and removing the pressure on the whole staff to not complicate(i.e. find problems which delay) situations and move the patients through, would improve the situation powerfully from two different directions. 
  The egos are big, as well, and the nervousness of not making a mistake, and then possibly losing your status, can be very difficult. It is not an easy environment to work in. And insurance and for profit business, not medical people, are the owners of it all really, so we cannot focus on truly addressing patient needs, we need to address the bottom line, first and foremost.  And as it is in Mc Donald’s, the faster the movements, the fewer interruptions, the greater the profit.  The problem is, that medicine is not an assembly line product. Some hospitals are looking to improve safety, but I wonder if it costs more and slows things down, if the changes needed would be implemented?
  Perhaps if we could seriously look at other medical systems where there are fewer mistakes, maybe we could learn and try and integrate the wisdom, instead of just looking to move on to the next patient to get through. And perhaps medicine is one system that should not be for profit at all.

If the estimates of ~100,000 “excess” deaths per year from errors made in hospital are order-of-magnitude correct, then it’s one more case of penny-wise and pound-foolish.
How long would an airline survive if even one of its airliners crashed every year with all aboard lost?  That’s one airline, one plane, perhaps a few hundred passengers at most, every year?  Now extend that to every airline serving the American public.  How long before the industry would collapse on itself?
So airlines until recently (roughly since deregulation and thinning of the ranks by M&A) had been quasi-fanatical about maintenance and repair and both professional and mechanical quality control.  Problematic airlines folded, problematic airplanes were removed from service.
The willingness of patients to accede to the bullying of some nurses and doctors—and their frequent overweening indifference or fatigue—has led to our accepting this slaughter by medical “error” as just another human failing.  We refuse to hold medicos accountable for what they do or don’t do, what they tell us that’s wrong or deficient, what they don’t tell us but should.  These are deaths, most of them preventable or postponeable. These are deaths every bit as personal and careless—but mourned—as those killed in war or in a Colorado movie theatre.  Perhaps a regular petit jury isn’t up to addressing the often very complex issues in such cases, but it looks like M&M committees aren’t wielding the hammer they can and *should.*  As a scientist, I once trusted that process to work.  No longer.
As long as the estimate remains ~100,000 “erroneous” hospital deaths per year, I’ll stay out of hospitals and happily die at home.

Simple mistakes?  Hospitals deal with large numbers of complex cases every day, 24/7.  Nothing is ever simple and human error will happen even with the best systems are in place.  That said, the best systems should be in place in every hospital so that the numbers of mistakes are kept as low as possible.  Rather than asking people to vent about their bad experiences, why not ask for doctors (who you seem to blame so they probably won’t talk to you) and nurses about solutions that they have come up with to prevent these mistakes?  Also, what hospitals have the best patient safety records and what are their practices?  As veteran health reporters you must have this information. You make it sound so hopeless, but the majority of people come out of hospitals better, not worse.

My elderly dad needed heart surgery involving the veins in his legs.  He’d had those veins “stripped” in the same hospital.  None of the doctors involved in his care checked his past history.  Result:  his chest was “cracked” open on the operating table before anyone noticed that there was a problem.  The hospital was the largest and best in the state and his doctors were at the top of their field.  My family could have sued.  Instead we demanded three things from those involved.

1.  My mother didn’t want any charges forwarded to either their Medicare or their medi-gap insurance.  She been through the Great Depression and understood money.  Although my dad spent two weeks in intensive care and more time in a private room and follow-up care,  there were no bills to anyone from anyone for his care.

2.  My sister wanted the surgeon fired.  Although he wasn’t immediately, he did “retire” at the age of 44 two years later with a big write-up in the largest newspaper in the state. 

3.  I wanted a hospital wide required symposium for all surgeons reviewing this specific case with discussion of how to prevent anything similar regardless of the type of surgery being performed.  Although this occurred years ago, I also suggested a check-list similar to those used by airplane pilots.  As a mathematician I use a pencil or chalk to do computations because I don’t assume I’m not going to make mistakes.
When you ASSUME, you make an ASS out of U and ME.  I wanted that reminder posted through the hospital.  It wasn’t, at least not in the public areas.  Not only did the hospital hold the requested meeting, institute checklists, but also required that patients and family watch a video of what’s involved in the operation.  That held true for at least 18 years after my family’s experience.  I’m not sure if it still does.

I credit my sister with the hospital’s agreement to our 3 “requests”.  She repeatedly corresponded with everyone by certified letters including all hospital officers, the board of trustees at their home addresses, the head of surgery, and all the insurance companies involved…both theirs and ours.  All the addresses are available.  I hope everyone will speak up and defend their loved ones.  Be very pleasant.  Be very firm.  Be very ptofessional.  Don’t ASSUME.

 

 


3.

Susan Meister

July 20, 2012, 6:08 p.m.

A few years ago my organization published a white paper entitled"High Sepsis Mortality- A Preventable Disaster.”. It detailed the Surviving Sepsis Guidelines issued by 18 international organizations.  There are over 750,000 cases of severe sepsis diagnosed every year in the US,increasing about 18 per cent a year.  The strategies recommended by these important organizations could help prevent high mortality, but they are complex and require close cooperation among a variety of specialties.  This is not something that is done well in hospitals.  Moreover, physicians are notably resistant to change.  The compliance rate with the Surving Sepsis guidelines is low. The white paper is available electronically if anyone, especially Pro Publica reporters, would like to read it.  With appropriate public policy focus, many more lives could be saved.

No one’s listening to the patients, either. I was admitted to the hospital for post-surgical pain control and had a long night of mistaken and withheld medications. The hospitality refused to get on the phone with ME, who was noticing the errors, because “I’d already been seen once that shift.” I had no idea what he was saying to the nurses, because they differed, and one refused to give me the prescribed Meds.  Only when I started to walk out the door did they respond with any seriousness.  And this is at an upscale, suburban hospital. We won’t go into the mistaken lab results and nursing incompetence when my daughter was born at a hospital in a poor community.

Washing hands to prevent infection before examining a patient was established before Pastuer’s germ theory.  Washing hands is the most important thing in hospitals.
Cedars Sinai Hospital, a major institution in Los Angeles discovered that its nurses were more rigorous about hand washing than its doctors.  The administration set about to change this with a PR effort that included screen saver reminders, signs on patient room doors and in many other areas.  The doctors’ response went from 10% to 95%.

I work in some crappy labs but don’t call a critical result and face the street. I spend many minutes tracking down some clinician trying to get him to care about a result. We call about stuff we see when they aren’t thoughtful enough to order a test. Medical Technologists save lives. As someone noted earlier, every workplace has errors, but ours kill. I am so aware I show up fit for duty daily.

This article demonstrates why you do not cap damages as part of tort reform. We hear GOP candidates’ talking points about consumer-driven healthcare and the importance of tort reform.

The candidates nor the media decode these talking points. And the need for tort reform is at the top of the list. But this article shows why we need to hold doctors and hospitals accountable and in America that means preserving the right to sue and not being limited by damage caps.

People need to realize that hospitals are not healthy, safe, healing centers.  They are overburdened, germ-infested places because many people who go there are really sick and the health care system is mismanaged.  Staff is under huge pressure to be fast, get to the next patient, and as this article points out hhospitals are ergonomically in the dark ages and ridiculously inefficient. Take the documentation alone that medical personnel are required to do: it’s mostly useless, even false (as the article pointed out with examples from King Drew), since it’s not done for patient care but is often the result of “fixes” for prior violations and to be able to dust off in case of litigation.  The out of control documenting doesn’t encourage staff to actually do what they are documenting,but it sure takes time to constantly write and even gives incentive to chart falsely, since 99% of the time it doesn’t affect care, will never come to light, and they have real work to do—i.e. taking care of the human being who is in front of them.

Regarding NYU’s proposed fix to the tragic sepsis case, the solution often seems to be to “tell the doctor” (I can’t believe that wasn’t already a policy). Should have stopped everything, left his/her other patients waiting (who were probably already irate at their poor and rushed care and themselves maybe very ill) and called and tracked down that poor child’s family? That’s a waste of resources and the doctor’s role: someone else can devote their night in the ER to that, and do it better.  One of the biggest costs and source of errors in healthcare is the endless paperwork/admin/calling/emailing that highly trained and well paid providers are forced to do that takes away from patient care and encourages them to take even more short cuts and actually harms patients.  The solution to simple but deadly mistakes isn’t “retraining” or putting more on doctors and nurses shoulders, it’s taking away many of the useless (overdocumentation) or low-skilled tasks they’re given so that they can take actually take care of people, thoughtfully and thoroughly.  Hospitals don’t improve because solutions are thought up by administrators who want to say—and maybe even believe—that they’ve addressed problems but don’t have the imagination or ability to actually do it.  I suspect that NYU won’t always sustain the cost of an around the clock ER employee dedicated to only calling people back (and ensuring that they get there), but I bet there will now always be documentation after a bad lab stating that “the doctor was made aware.”

Two important factors contributing to the dysfunctioin in our medical care system haven’t been added to this discussion of medical error.

First of all, physicians in the ER as well as throughout the health care system have been draconianly pressured to treat less, not more, in an effort to save medical dollars.  This is a horrendous disincentive to any physician providing thorough, and often, life-saving care. Physicians are told they cannot give antibiotics to patients with pneumonia.  They are told they cannot retest for c. difficile to be sure the infection is gone after treatment with antibiotics.  They are now told they shouldn’t be doing PAP smears yearly or doing PSA tests regularly. 

So before jumping to conclusions about incompetent physicians, please look at the big picture and the health care and government pressure on physicians to NOT treat.  It’s real.  It’s pervasive.  And it’s deadly.

Secondly, the balkanization of medical care has created tremendous opportunity for important medical information to fall through the cracks, such as lab reports.  Medicine has become so specialized that it’s much like one physician treating a right toe, and a different physician treating the left toe. Sometimes these physicians compare notes.  But often, in large health care systems, much falls through the cracks. 

This balkanization problem is compounded by the fact that the specialist often doesn’t know the patient at all, so there is no primary care physician familiar with the patient’s entire history. No electronic medical record can substitute for what’s in the head of a primary care physician who knows the patient well.

We are told that the days of physicians such as Marcus Welby are long gone never to return.  What has been reported in this article is very much the result of a health care system which has made a concerted effort to be sure that Marcus Welby cannot survive.

@ Jon 1:42 pm 7/20/2012—From your logic, a simple mistake is not 100% preventable, so doctors are excused from knowing right from left and following up on critical lab reports - Then what kind of mistakes are they allowed to make when faced with something complex. Better start lining up the carts to the morgue.

Jeffrey Turner

July 21, 2012, 9:08 a.m.

We have places on the web like “Angie’s List” that evaluate outcomes of service.  How about a website that evaluates doctors and hospitals from the patient. Healthcare is driven by profit not outcome.  Until that changes, like a single payer system, the healthcare system will take shortcuts.

Kathleen Richardson

July 21, 2012, 9:10 a.m.

Myrna’s comment is spot on, as the Brits like to say. I know as a nurse who went right from nursing school with very little on-the-job practice to sticking things into people’s body cavities that I had never stuck anything into. Very scary! Training is a joke for a new graduate - none of the other nurses have time, and if you do ask for help, they grab the instrument, or whatever, out of your hands and do it themselves.

Another problem is lack of inept diagnosticians in the ER. If they don’t know what the person has, all they have to do is look up symptoms online. An idiot can do that!

And then there is a long-standing hatred in the medical field for whistle blowers. From experience I know that the tattle-tale runs the risk of being shunned, or worse, fired. It ain’t worth it.

My kids have strict instructions not to admit me to the hospital unless it looks as if I’m dying. The hospital staff will then hasten the process and I won’t have anything else to worry about.

Jeffrey Turner

July 21, 2012, 9:11 a.m.

We have places on the web that evaluate outcomes of service by the end user.  How about a website that evaluates doctors and hospitals from the patient. Healthcare is driven by profit not outcome.  Until that changes, like a single payer system, the healthcare system will take shortcuts.

Karen, I’m puzzled at what appears to be your notion that I was claiming physicians should not be accountable for errors. I apologize if I somehow gave that impression.

I was not exonerating anyone for mistakes in the health care system. Rather, I was suggesting that the pressures put on physicians by big business medicine, the government, and insurance companies to provide less care rather than more will result in patient deaths.

And suggesting it’s quite possible both the fact that the ER physician sent the patient home rather than admit him, and then the fact that the ER physician never received notice of a critical lab could be part of the problem. 

Not an excuse for it.  But an observation regarding contributory factors in what makes our health care system dysfunctional, factors which are not always obvious to patients.

Can anybody tell me why their is no law in our country for continuous post op monitoring?
DEAD IN BED should not exist in 2012, due to a heavily sedated patient being checked every 2-4 hours.
If we cant get something a basic as that done, it’s a very scary thing to think of going into a hospital

Bruce Ramshaw

July 21, 2012, 5:06 p.m.

After studying this for three years full-time, I think the problem is a lack of understanding of how to solve complex problems in complex systems.  All of healthcare (and everything involving a biologic organism) involves complex systems.  The reason we have not seen improvement is that only simple system type solutions have been tried- like surgical site marking, checklists/time-outs, blaming a nurse or doctor, etc. 
According to systems science, we will not see significant or sustainable improvement until we change the system structure for how we deliver care.  The individual physician/physician specialty and silo and hierarchical medical center system structures will need to be replaced with team-based care (the patient being the most important member of the team). 
The current model results in increased fragmentation when complexity increases, while teams developed around definable patient groups can simplify processes and improve value in the face of increased complexity.  These teams/communities will need to define the dynamic processes of care and outcomes that measure value (for definable patient groups and problems) and then apply principles of continuous learning and clinical quality improvement. 
I believe designing team-based care coordination for the entire cycle of care (with caring relationships developed with patient and family) and applying principles of quality improvement with team-based accountability (transparent outcomes) can lead to significant and sustainable improvement in healthcare.
The challenge to implement this type of system structural change is that the current system structure benefits those at the top of the hierarchy where resources are controlled.  A new system structure requires resources and authority to reside in the teams (with accountability to show results).

Nobody has all the answers for sure, but I sure have a lot of suggestions.  Mandates, which Hospitals AND caregivers hate…have to be part of it and if they are voilated sanctions and/or punishment must follow.

Safe nurse staffing levels at all times during all shifts go a long way to make patients safer.

Cleaning…hands, rooms, instruments, etc with effective MRSA and C Diff killing disinfectants and cleansers are necessary.

Pre operative screening for infections, early enough to allow decolonization treatment, isolation and contact precautions. 

Check lists and bundles for prevention of complications and infections.

Communication between caregivers, doctors and departments in facilities.  Most don’t know their own patient safety data!

Real time public availability of statistics about a facility’s complication and infection rates.

InalienableWrights

July 22, 2012, 8:50 a.m.

So much for medical licensing protecting the patients.  It really is used to protect the doctors from competition, and for big pharma to control them.

Get rid of the medical monopoly and let the free market clean this mess up. Monopolies always lead to messes like this.

I doctors knew the first thing about nutrition, and counseled their patients in it.

90% of their business and their mistakes would go away. And yes IW medicine being a monopoly speaks directly to the problem. Modern medicine is the equivalent to the US post office in that respect.

Timothy Loftin

July 22, 2012, 9:56 a.m.

The title of the piece “Why Can’t Medicine Seem to Fix…” illustrates the disconnect here (as in many other places) between how the universe works and how we expect it to work, or how we want it to work.

‘Medicine’  in the title is a mechanical term, treating ‘Medicine’ as if it were some kind of structural entity , a thing apart from the people involved.  We use the same construct for the ‘Economy’.  We comprehend the economy as something above and beyond humans, with its own behavior patterns, its own laws of cause and effect. We recommend economic policies and practices without considering the primary-particle role played by the humans involved.

We can’t affect the behavior of ‘Medicine’ but we can affect the behavior of people. We will be much more successful at reducing the problems described if we think of them in terms of “How can the people engaged in this medical activity be induced to change their behavior?”  It may make us feel sophisticated and intelligent to recommend systemic changes to the medical profession, but in truth, nothing happens without changing the people involved.

So you ask yourself “How can this individual human, right here in the room with me, be made less careless?” and “Should that individual human over there be in a position to make these decisions?”

I think we get too attached to universal, arm-waving pronouncements and it interferes with our ability to see what’s going on.

Tim, their are literally thousands of ways to prevent accidents.  It is done in most other free market endeavors. But doctors are Gods in their own minds so they largely because of the medical monopoly can ignore and resist such common sense solutions. 

Many European hospitals have lowered the infection rates in their hospitals drastically in large part because doctors are not deities in their minds.

Jim, do not assume all physicians think they are Gods.  Some physicians are arrogant, but there are many who are not.  From your experience, you may feel that physicians think they are Gods, but physicians do not have the last say in medical decisions, as I’ve written about in a previous post here. Don’t categorically sweep up all the problems with our health care system and dump it in the “doctors think they are Gods” bin.

It solves no problems resorting to name calling.  There have been many posts here pointing out the complexity of the problems with medical error. Persisting in trying to assign the blame to a single entity simply further distorts the picture and makes genuine problem solving more difficult.

Diane
I speak in generalizations like everyone else does. And I restate that I believe that the biggest problem with our very broken medical model is arrogant doctors. (No this is not name calling it is using the English language to describe my observations.) With the monopoly nature of medicine being right up there in creating both the problems and the implementation of any solutions. 

The free market works best in every enterprise,, and it would work best in medicine also   The Rockefeller’s who owned the pharmaceutical companies created the current monopoly less that 100 years ago with legislation that they wrote and got congress to pass.

I was an RN for 11 years and have worked as a health IS systems analyst and project manager for 16. I have worked in loss prevention for a physician med mal group and work today on the design and implementation of the systems that support the work flow and documentation of all that doctors and nurses do at two major AMC’s in a major east coast metropolitan city.

While I share the author’s concern, I am disappointed that they chose not to balance their article with examples of hospital systems whose job number 1is patient safety.

We pioneered the use of the surgical checklist. We designed and implemented systems costing millions and millions of dollars to anticipate potential points of failure in the flow of patient care whether that care was delivered by a nurse, doctor, anesthesiologist, surgeon, resident or attending.

Huge progress is being made all the time by organizations willing to take on the hard work of transforming their systems and culture to stand in a place where Patient Safety is the first and last thing on their mind.

We are here and we are spreading the word and transformation as fast as we can, which will never be fast enough.

To the author’s I offer the old Yiddish saying; “to a worm in hose- radish, the world is horseradish.”

Temper your cynicism and shed a little light on the efforts of those who strive to do it right.

Joe, thank you for clarifying that your experience indicates that arrogant doctors are the biggest problem with our broken health care system. 

But then you go on to talk about the monopolistic businesses that own our medical care, and suggest that the free market is the solution. I certainly don’t dispute that monopolistic pharmaceutical companies are a problem in our health care system.

However, let me ask you to consider that perhaps the free market (something great in theory, but which almost always falls prey to bigger and bigger corporate control in practice) isn’t the best model for health care.

First, the free market depends largely upon consumers having a choice in which washing machine to buy, or which car.  Consumers can shop around and find the best price.  I believe there are now some attempts to put procedure prices on line by medical facility so consumers can choose to go to a facility which offers the best price (I think this is Massachusetts).

I have no problem with this. 

What I have a problem with is that with health care, consumers often really have no opportunity to educate themselves enough to make wise choices. Physicians spend years in school, and now consumers are supposed to read about their condition on the internet and make a medical decision.

Medicine is an art, not a science. 

The experience of a physician seeing many similar cases over time gives a physician a perspective no internet reading can replace. A physician may know from seeing hundreds of cases of X that this particular patient will not respond to the “standard of care.”  The internet isn’t going to give anyone this information, including many of the persons doing statistical studies of outcomes.

How do you put a price on this kind of care?

Physicians have lost malpractice suits because their patients, even though they were treated and got well, didn’t receive the “standard of care,” which would not have made them well.

Second, many consumers are too ill to shop around, or too ill to make informed decisions about their care.  There is no opportunity for the free market decision making in these cases.

You mention that the Rockefellers monopolized pharmaceutical companies.  Whenever profit drives a decision, as in the free market, the health care of the individual will be constrained by profit.  What you see today is health care driven by profit, not quality of care.

Once large corporations discovered they could turn a profit on health care when Medicare legislation was passed, we saw the very quick market-driven takeover of doctor-owned and run hospitals by corporations. With this takeover, we also saw the disappearance of medical decisions determined by physicians, but replaced instead by decisions of hospital CEOs whose attention was profit, not patient care. Please also note that there is no certification or licensing requirement for hospital CEOs, who tell physicians how they may or may not treat their patients.

The only way for health care to improve is for the medical decisions about health care to be returned to what I call the treating physician, the Marcus Welby tradition, if you will. 

Did these physicians make mistakes?  Yes.  But they were there to help fix the mistakes and tell you they were sorry.  There was no corporate “risk control” person telling the physicians they couldn’t talk to the family.

When physicians were able to actually make decisions for their patients, consumers could still seek out another physician for consult. There was choice in health care, but no one now seems to remember. 

Choice isn’t really the issue with cost containment. From my perspective (and I know it is not a majority opinion), big business medicine masquerading as the free market is what has destroyed health care in this country.  Physicians are the pawns of these organizations.

Until the health care system and consumers return the decisions about patient care to the treating physicians, all else will simply be arranging napkins on the Titanic.

*Don’t know why you wrote a tome but let my try to address a few key *points….


However, let me ask you to consider that perhaps the free market (something great in theory, but which almost always falls prey to bigger and bigger corporate control in practice) isn’t the best model for health care.

*Yes it is theory because we really don’t have free market in anything.
*What you are critical of is corporatism.


What I have a problem with is that with health care, consumers often really have no opportunity to educate themselves enough to make wise choices.

*If people want to be stupid that should not negate my freedoms. An if *they do perhaps they should just keep going to an AMA approved *doctor just like they are doing now.


Medicine is an art, not a science.

* A non sequitor…. what’s your point?

The experience of a physician seeing many similar cases over time gives a physician a perspective no internet reading can replace. A physician may know from seeing hundreds of cases of X that this particular patient will not respond to the “standard of care.”  The internet isn’t going to give anyone this information, including many of the persons doing statistical studies of outcomes.


* A non sequitor…. what’s your point?

How do you put a price on this kind of care?

* A non sequitor…. what’s your point?

Physicians have lost malpractice suits because their patients, even though they were treated and got well, didn’t receive the “standard of care,” which would not have made them well.

* A non sequitor…. what’s your point?

Second, many consumers are too ill to shop around, or too ill to make informed decisions about their care.  There is no opportunity for the free market decision making in these cases.

* A non sequitor…. what’s your point?
* Then let them choose the AMA approved doctor like they have been *doing. Don’t infringe on my rights because of your specious *arguments.

You mention that the Rockefellers monopolized pharmaceutical companies.  Whenever profit drives a decision, as in the free market, the health care of the individual will be constrained by profit.  What you see today is health care driven by profit, not quality of care.

*What we see today is a eugenics program driven by bankers that own *the pharmaceutical companies and the doctors through their *monopoly licensing.

*Profit always drives decisions in any business under any economic *system at any time or place—-  and lawsuits and the free market *constrain the reckless pursuit of only profits.


ENOUGH…..

Andy M:  Keep fighting the good fight and don’t let the cynics get you down.  We need more people like you who work tirelessly every day to fix the defects in our health care system.  We all know there are safety issues in hospitals; is that really news?  Not everyone knows about the people that work tirelessly to try to do away with these defects that hurt people and what is working.  If the media reported on these unsung heros and what they are doing, both health care practitioners and patients would be better informed and therefore safer. The horror stories are interesting but every one loves a hero too.  Write about that.

I was a nurse for 40+ years. In that time there were several significant paradigm shifts that altered everything. In the 70s DRGs and then managed care which put the emphasis on the bottom line and empowered people with little or no medical background to make delivery decisions based on a print out of qualification criteria. Management efficiancy companies were paid a great deal of money to determine how many tasks a nurse performed were “license specific” and nursing staffs were cut accordingly; in the instance of the unit I worked on by 1/3. These nurses were replaced by aides with little or no experience. This corresponded with the “welfare to work program” which resulted in a lot of angry, beligerent people, especially women being put into a lottery. Those who “lost” ended up in inpatient positions which were particularily offensive. They were very effective in creating chaos resulting in the limited number of licensed nurse being forced to take a larger assignment and limited ancilary support. In my case, I was part of a group of nurses who were given the task of orienting these new employees to the tasks they were to perform. I came to find out that several had asked that I continue on a regular basis to hold instructional and discussions sessions because they like the way I presented information, they got it and didn’t feel intimitated. However, the was a nurse pracitioner on the unit whose job description was “education” so it unpolitical for me to lead these sessions so a valuable learning opportunity was if not lost then at least made much more difficult and took a lot more time.These things are never talked about and are never part of the discussion about any crises in the health care system, so the problem goes on and is never addressed.

This article is part of an ongoing investigation:
Patient Safety

Patient Safety: Exploring Quality of Care in the U.S.

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment.

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Too many patients suffer harm instead of healing in U.S. medicine. That’s why ProPublica’s reporters have investigated everything from deadly dialysis centers and dangerous hospitals to the failure of state boards to discipline incompetent nurses.


This page allows patients, providers and readers to join the patient safety conversation. Our goal is to find out why so many patients are suffering harm and highlight the best ways to solve the problem. Here you’ll find regular updates, and places to share your stories, views or expertise.

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