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100 Hospital Errors A Month By California Hospitals Are Preventable

Posted by Jane Akre
Monday, June 30, 2008 11:59 AM EST
Category: Major Medical, Protecting Your Family
Tags: FDA and Prescription Drugs, Medical Errors, Dangerous Drugs, Wrongful Death

Californians are finding more than 100 medical errors a month under new hospital reporting laws.



IMAGE SOURCE:  ©iStockPhoto/ emergency room/author: thelinke 


They are called “adverse events” but for patients of botched medical procedures, they can mean the difference between life and death.

We are now finding out just how common they are in one state.

Under a new law, California hospitals are now required to report medical mistakes. So far, it’s estimated that 100 Californians a month are being harmed by largely preventable medical errors.

The law requires that hospital report 28 different types of substantial injury to patients, including medication errors, surgical errors, suicide attempts, sexual assault, and death during labor.  

In the ten-month period ending in May, California hospitals report:

  • That foreign objects were left behind in patients after surgery 145 times.
  • The wrong surgical procedure, or an operation on the wrong body part, or on the wrong patient occurred 41 times.
  • A 76-year-old woman died after a nurse gave her two drugs, neither of which was prescribed.
  • One patient was given a painkiller not supposed to be used post-surgery. When she went into respiratory arrest, she was given a medication at a dose 10 times too weak to be effective. She survived.

Altogether, more than 1,000 cases of medical harm have been reported by California hospitals between July 2007 and May 2008 in figures compiled by the California Department of Public Health.

At nearly 100 events a month, the adverse events are largely preventable, and safety experts say they should have never happened.  

The move is generally heralded as a “wake-up call” about the quality of California hospitals, which are moving to become safer by improving procedures and training. 

In San Diego, for example, after a patient died when they received medication from a medicine pump that had been incorrectly programmed, repeated drills are training staffers to examine every step of the process.

Dr. Angela Scioscia, the center's senior medical director, tells the Los Angeles Times, that this is "a great opportunity to make rapid improvements" because hospitals can learn from one another's problems. "We don't want people to be afraid when they come into hospitals, because they are becoming safer and safer all the time.”

Fines are involved for the wrongdoers. So far the health department has issued $25,000 against ten hospitals.   By the year 2015, the medical and medication errors will be posted online. 

In California, a proposal to ban reimbursing hospitals for injuries is under consideration.

At least seven other states are considering moves to protect patients from having to pay for the cost of medical errors.  Maine, Massachusetts, Pennsylvania, and New York are restricting reimbursement for avoidable medical errors.

And beginning this fall, the Centers for Medicaid and Medicare Services will refuse to reimburse hospitals for eight different kinds of medical mistakes, including bedsores, surgical errors and infections acquired during surgery.

Medical errors are costing us billions and leading to preventable deaths according to HealthGrades, a leading hospital rating organization reports in its annual Patient Safety in American Hospitals study.

It finds that from 2004 through 2006 there were 238,337 preventable deaths among Medicare patients.   That cost the program and ultimately taxpayers $8.8 billion. #


Anonymous User
Posted by Stan Goldfarb
Monday, June 30, 2008 2:41 PM EST

As I read this, I kept hoping to read one key number that would have put things into perspective. If, for example, there are 100 cases a month or error, in a total of say 5,000 total cases, hat would be a very high percentage (5%). Even 100 out of 100,000 is 1%, and still too high. But if there were 100 out of 1,000,000 total cases, well, that's 1 out of 1,000 and I'd say it's probably unreasonable to expect human beings to be so perfect that they can improve much on that.

Anonymous User
Posted by John Doe
Monday, June 30, 2008 3:14 PM EST

Enter Six Sigma. The goal for errors should be 3.4 per million.

There is a difference in being human and being careless because of complacency or the long hours a medical staff is forced to work.

If you were the 1 in 1000 your post would be a little bit different I think.

Anonymous User
Posted by jane akre
Monday, June 30, 2008 3:19 PM EST

Editors Note *

If you have experienced a medical error- do you mind telling us about it here? Curious to see first hand experiences... thank you!

Anonymous User
Posted by Mary
Monday, June 30, 2008 3:52 PM EST

My mother was given 10 times the pitosin to induce labor, which caused such severe and rapid uterine contractions that my head was stuck in the birth canal and my heart stopped beating for a fairly long period. We were fortunate that there were no noticable side effects, but they could have been severe. My parents paid the bill, I believe.

Anonymous User
Posted by Money
Monday, June 30, 2008 4:05 PM EST

Maybe if the doctors didn't have to work 80hrs a week and 32hrs continuous on call... I bet a few of these 100/month would go away.

Anonymous User
Posted by R Lewis
Monday, June 30, 2008 7:25 PM EST

It is ironic that an article on medical errors has a spelling (or grammatical?) error - "every stop in the process" I think should be "step"

Jane Akre Injury Board Community Member
Posted by Jane Akre
Monday, June 30, 2008 11:20 PM EST

Thank you!

Posted by Stephen Schimpff, MD
Tuesday, July 01, 2008 7:30 AM EST

My research [see "The Future of Medicine - Megatrends in Healthcare"] suggests that there are three steps to reducing hospital errors. First is to change the culture in the hospital and this must start with the board of trustees. Once they pay more attention to safety than to finances, then the hosptial management will follow their lead. Culture must also change to include accepting that "to err is human" and instituting ways to detect, record, and analyze errors with rapid feedback so that processes can be changed for the future.
Second is to look for human factors that can make a difference. Reducing resident work hours has been effective. So can having a "briefing" before any surgical procedure to be sure that all the team members are informed and aligned. The team members must be trained in conflict managment and issue resolution ala the airline cockpit system of crew resource managment, e.g., the scrub nurse must feel empowered to challange the surgeon when appropriate.
Third are technologies that can assist in preventing errors. Here are just a few: The electronic medical record will help, including the use of electronic prescribing with built in alerts [eg. for allergies] and knowledge [eg., why the prescribed antibiotic is not the best choice]and assistance in calculating the correct dosage. Simulators for procedures should be used by trainees until they prove themselves competent to work on patients under supervision. Robots can assist in the pharmacy to select drugs based on bar codes thus reducing human error.
Tackling these three approaches in parallel can make a huge difference in a short time.

Anonymous User
Posted by Bill Subalusky
Sunday, July 06, 2008 10:16 AM EST

The comments above are right on target except for the gentleman who asks for "perspective." Rationalizing errors based on statistics breeds complacency in an organization. Only 1 death out of a million operations is not very consoling if that death happens to be that of your child or other family member or friend.

A process that is very effectively used in the nuclear power industry to improve performance and reduce human error is that of "observation." By observing caregivers work, while maintaining a non-punitive environment, it becomes a realtively simple task to identify improvements that can be made to processes, behaviors, training,management etc, before errors occur. I have used and trained people on this methodology and seen the fruits of it for decades. I hope the medical field will learn from the experiences of the nuclear industry and addapt a similar methodology -- before more people die unnecessarily.

Comments for this article are closed.

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