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Health Reform Starts With Avoiding Medical Errors

Posted by Jane Akre
Monday, August 10, 2009 5:42 PM EST
Category: Major Medical
Tags: Medical Errors, Tort Reform, Hospital Infections, Prescription Errors

Diane McCabe bled to death during the birth of her daughter as Dead By Mistake report says, she was a victim of medical malpractice.

Medical Mistakes Blamed for 200K Deaths a year


IMAGE SOURCE: Death By Mistake Victims, SF Chronicle Web site/ image of Diane Rizk McCabe

Sharon Moore's death is included in the Dead By Mistake report by Hearst journalists.
Sharon Moore

Trevor Nelson went into the hospital for a headache, and he never left after being administered a dozen different drugs, reports the Dead by Mistake report.
Trevor Nelson and son

“Dead By Mistake,” a report issued Monday by journalists working for the Hearst Corporation, finds that the preventable medical death toll approaches 200,000 a year. Part of the problem is that no one is monitoring medical errors, the first step to preventing them.

Ten years ago, a federal study by the Institute of Medicine on medical errors, "To Err is Human," had the medical community vowing to reverse the trend and cut the death toll in half. Instead the death toll appears to be increasing with very little oversight by the federal government or states.

Since that time, as many as two million Americans may have died from preventable medical errors. “Dead By Mistake” tells some of their stories.

Diane Rizk McCabe

On September, 2, 2007, Diane Rizk McCabe, 32, was at the Albany Medical Center iin New York awaiting the birth of her second child.

After 10 hours a labor, her obstetrician ordered a c-section, but her uterine arteries were unintentionally cut or torn during the surgery. McCabe lost 60 percent of the blood in her body before bleeding to death. Her daughter, Jenna, was delivered safely.

The family has filed a malpractice lawsuit. Since then they’ve found that during the surgery, McCabe’s obstetrician and critical care physician disagreed over whether she was bleeding internally. They returned her to the operating room ten hours after her baby was born but she could not be saved. A diagnostic machine was not manually switched overto monitor her vital signs after the surgery.

And at the hospital, there was one attending physicians and one resident on duty for 25 to 30 acutely ill patients.

Sharon Moore

Sharon Moore, 58, was a grandmother, a widow, and a smoker who lived in eastern Washington State. Living on disability, she was being treated with pain medication such as methadone, oxycodone, Valium and morphine. They were handed out by Dr. David Earl of Moses Lake, Washington. He is now the subject of a state medical board investigation based on 11 complaints.

One month before she died, a local cardiologist told state investigators that a CT scan showed she was stable from a cardiac standpoint. Yet she was having stroke like symptoms, could no longer drive, and passed out at the dinner table.

She told her daughter she felt the medications were causing her to feel bad. “I’m going to talk to him and try to talk to him and get off some of this stuff because I think that’s the reason why," her daughter says as part of a video that accomopanies the report.

Moore was rushed to a Moses Lake Samaritan Healthcare Hospital on October 14, 2006. Later that day she died.

Dr. Earl was already on the well known by Washington’s Health Department which had received reports about overprescribing without proper physical exams. The staff at Samaritan and pharmacists knew about the concerns, but the public didn’t.

Moore’s daughters said they would have gone to another hospital had they known what others knew.

A University of Washington clinical assistant medical professor, contacted by the state in 2007, concludes from Earl’s records that he doled out excessive, dangerously mixed, unexplained and unwarranted doses of narcotics to seven patients. Moore’s death certificate says she died, “of a lethal dose of medication”.

Dr. Edward Noonan says the combination of methadone, diazepam, and oxycodone killed Moore and she died of cardiac arrest.

Noonan blames Moore’s death directly on Earl and found he contributed to three others’ deaths of people in their 30s and 40s who died from a combination of prescription drugs. Dr. Earl has explanations for each death and has mortgaged his home to pay the cost of defending himself.

None of the deaths associated with Dr. Earl was reported to the state even though Washington requires hospitals to report medical errors and drug-related deaths.

Trevor Nelson

Trevor Nelson was 34, a father of two and a rising star producer at “60 Minutes.” Nine hours after he was admitted to Massachusetts General Hospital with a headache and fever, he was brain-dead.

Nelson had been diagnosed as having symptoms of viral meningitis, a harmless disease that Dead By Mistake reports usually clears up untreated within ten days.

But Nelson received a potentially dangerous mix of more than a dozen prescription drugs and then left him unmonitored during most of his hospital stay. Between 2 and 10 p.m., in the ER he was administered antibiotics, Vicodin, Fioricet, and morphine, two doses of the opiate Dilaudid, Tylenol No. 3, which contains codeine, then Ativan, a sedative. Then two more doses of Ativan and Dilaudid.

The last two drugs can cause respiratory and cardiac depression. Generally one is monitored. At 6:45 a.m. he was found face down in the bed with no pulse. His family took him off life support by 10 that morning, July 24.

Mass General then attributed his death to viral meningitis to cover up their mistake, says the family who has filed a lawsuit. Instead the family should have sent his death report onto an independent medical examiner.

The Institute of Medicine estimates as many as 1.5 million medical errors are preventable that lead to as many as 7,000 deaths. While hospitals are supposed to report adverse events, they can be fined up to $1,000 a day.

The report issued today, “Dead By Mistake,” also includes wrong-side surgeries, misdiagnosis, and hospital infections, among other causes of medical error that cause more than 98,000 deaths a year.

The Centers for Disease Control and Prevention, (CDC) reports that 99,000 patients die a year from hospital-acquired infections such as MRSA, which is preventable. #

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