Groups Target Medical Mistakes to Save Lives
SCIENCE NEWS December 12, 2006 from ScientificAmerican.com

    A group of health care leaders said on Tuesday they were banding together to make U.S. hospitals less dangerous places to get well.
    The Institute For Healthcare Improvement estimates about 15 million medical mistakes occur in hospitals each year. More people die in U.S. hospitals from medical errors than perish from motor vehicle accidents or breast cancer.
   "No one in health care can feel comfortable with the magnitude of infections, adverse drug events and other complications that hospital patients endure," said Donald Berwick, president of the Institute for Healthcare Improvement.
  To do this, the coalition wants 4,000 of the 5,000 U.S. hospitals to commit to at least one concrete improvement and report periodic quality and mortality data to the group.
   Medication-related errors alone cost the health care system about $2 billion annually, the Institute of Medicine says.

A Dose of Prevention - Local Hospitals Change Procedures as Part of Nationwide Effort to Save More Lives.
Journal Sentinel (Milwaukee, WI) Nov. 25, 2006
The 100,000 Lives campaign proposed reducing preventable deaths by:
1. Preventing patients who receive medications and fluids through a central line from developing infections. The steps for stopping these infections include: proper hand washing, selecting the best site for the central line and cleaning the patient's skin with an antiseptic called chlorhexidine.
2. Taking steps known to reduce the risk of heart attacks, including giving patients aspirin and beta-blockers to prevent further damage to heart muscle.
3. Avoiding drug errors by verifying the patient's medication history and reviewing and updating medication lists, especially when patients move to different units or get released.
4. Preventing patients on ventilators from getting pneumonia, through several steps, including raising their heads to between 30 and 45 degrees to prevent a buildup of fluids, and giving breaks in sedation that help determine the earliest point at which the ventilator can be removed.
5. Dispatching rapid response teams to treat patients before a decline in condition becomes a full-blown crisis.
6. Preventing surgical patients from developing infections through several steps, including timely use of antibiotics and appropriate hair removal.
    "The classic word is preventable deaths," explained Geoffrey C. Lamb, internal medicine physician at Froedtert. "If the system worked in a different way, the outcome would be different."
    Simply put, these deaths - tens of thousands of them nationwide - were caused by hospital failures: medication errors; pneumonia introduced by hospital ventilators; and infections resulting from catheters or surgery. Lives were being lost, too, because hospitals didn't always respond aggressively when patients experienced abrupt changes that weren't deemed life-threatening.
    From July 2005 to June 2006, mortality rate at Froedtert Hospital dropped from 23.4 deaths per 1,000 discharges to 19.5 deaths per 1,000 discharges - an improvement of nearly 17%.

Military Health, HHS Join Forces for Patient Safety
MarineCorpstimes.com November 13, 2006
Twenty years of research and lessons learned in the military health care systems will soon benefit the civilian world.
The Military Health System is teaming up with a division of the Department of Health and Human Services to help improve patient safety in civilian hospitals around the country.
More information and a brief video about TeamSTEPPS are available online.

Family Laments Daughter's Death
Independent       Albuquerque, NM October 17, 2006
    2 year old child with meningitis dies after  Emergency Room doctors ignore her for 22 hours.

Family Laments Daughter's Death
Independent       Albuquerque, NM October 17, 2006
    2 year old child with meningitis dies after  Emergency Room doctors ignore her for 22 hours.

20 Tips to Help Prevent Medical Errors    The Clarion-Ledger  Jackson, MI   October 3, 2006
    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 — more than from motor vehicle accidents, breast cancer or AIDS.
Medical errors happen when something planned as a part of medical care doesn't work out or the wrong plan is used. They can occur in hospitals, clinics, outpatient surgery centers, doctors' offices, nursing homes, pharmacies and patients' homes.
     They can involve medicines, surgery, diagnosis, equipment and lab reports.
  For more information:
  A federal report on medical errors can be accessed online, and a print copy (Publication No. OM 00-0004)
   is available from the AHRQ Publications Clearinghouse: call 1-800-358-9295 or e-mail: ahrqpubs@ahrq.gov.
Related links:  National Guidelines Clearinghouse.  Ask your doctor if your treatment is based on the latest evidence.
          20 Tips to Help Prevent Medical Errors.  Agency for Healthcare Research and Quality, Rockville, MD.

http://www.ahrq.gov/consumer/20tips.htm
Tort Reform Won't Ease Health Care Costs    South Bend Tribune   October 01, 2006    
     Medical malpractice claims do not significantly affect the high costs of medical care in the United States.
     In 2002 the House Committee on the Judiciary ordered the Congressional Budget Office to evaluate the impact of a proposed bill known as House Resolution 4600. H.R. 4600 sought to limit medical malpractice litigation in state and federal courts by capping awards and attorney fees. The Congressional Budget Office is impartial and non-political.
     After a detailed investigation, the Congressional Budget Office issued a report on Sept. 24, 2002, which found that limiting medical malpractice claims would have virtually no effect on health care insurance costs. The CBO found that:
"Malpractice costs account for a very small fraction of total health care spending; even a very large reduction in malpractice costs would have a relatively small effect on total health plan premiums."
      The CBO went on to find that limiting medical malpractice claims would result in savings of less than 1/200th of the cost of health care insurance premiums. In simple terms, if a person spent $1,000 per year in health care premiums, the savings would be just $4 per year.  

Governor Daniels and New Safety Center Hope to Limit Medical Mistakes   CBS Channel 8 News 9/19/2006  (Indianapolis, IN)
    Work is underway on two new fronts to protect patients from medical errors made in hospitals. What happened this weekend at Methodist Hospital illustrates a problem that happens more often than you might think.   
    A mistake during surgery, a medication given in the wrong dose, errors like these happen thousands of times across the country each year. Medication-related errors in hospitals cost roughly $2 billion each year and medical errors kill more people every year than breast cancer, AIDS or motor vehicle accidents.   
    State officials hope requiring hospitals to own up to their mistakes publicly could help cut the number of those mistakes. The Indiana Department of Health will vote Wednesday on a proposed rule to require hospitals to report some of their medical errors.
    The proposed rule outlines 27 potential mistakes hospitals would be required to report to the state. They include giving the wrong dose of medicine. The state will make those errors public in a report every year.
Related story:  Third Newborn Dies from Heparin Overdose; Riley Hospital Issues Statement
The baby was one of six that had been given an overdose of the drug Heparin while in the care of doctors and nurses at Methodist Hospital.

When Deaths Are Avoidable
Daily Courier (Pittsburgh, PA)  Saturday, September 2, 2006
    There were 44,000 to 98,000 deaths attributed to avoidable medical mistakes last year. That is according to a recent segment of a radio newscast.
    An excerpt from an article in the magazine "Mother Jones" stated, "A report from the National Academy of Sciences Institute of Medicine (shows)
 avoidable medical mistakes are the eighth leading cause of deaths in the United States, ahead of car accidents, breast cancer and AIDS. There are
 no federal laws requiring hospitals to report deaths and injuries to patients caused by error."

Medication Administration: One Drug, One Error, One Life
Yahoo Finance  - Wednesday August 23, 6:00 am ET
             Medical Simulation Corporation (MSC) announced today the introduction of the latest addition to the SimSuite® expanding hospital-centric courseware: Medication Administration.
This online course is a flexible, self-paced learning module designed to assess the user's knowledge and proficiency with medication administration. This course is suitable for new registered
 nurses, as a competency assessment for per diem staff, or as an adjunct to ongoing Joint Commission on Accreditation of Healthcare Organizations (JCAHO) compliance for staff nurses.
            A large percentage of adverse drug events (ADEs) have serious consequences, and many of them are preventable. The ADEs identified in a study by Classen et al., half of which
were identified as preventable, added 1.91 days to the mean length of hospital stays, and resulted in increased costs per stay of $2,262.(2) Bates and colleagues determined that an
additional 2.2 days of hospitalization were required for patients experiencing an ADE, at an average added cost of $3,244. For ADEs identified as preventable, patients stayed in the
hospital an average of 4.6 extra days, at an average additional cost of $5,857.(3)

How Hospital Design Saves Lives
Business Week   AUGUST 15, 2006
   Design changes can cut infection rates, lower physician errors, improve staff performance, and make all the difference in delivering care
In 1999, the Institute of Medicine shocked the health-care industry with its landmark report, "To Err Is Human," which highlighted the staggering human and financial costs of medical error: an estimated 44,000 to 98,000 in the U.S. dead each year as a result of medical errors, more than from motor vehicle accidents or breast cancer, costing the country between $17 billion and $29 billion in health-care costs, disability, and lost income.
   But there is plenty more to be done and one of the most promising areas to focus on is design. "Hospitals are dangerous places because of systems, and systems are a design problem," explains Derek Parker, co-founder of the Center for Health Design, a nonprofit think-tank, and a director in San Francisco at Anshen + Allen Architects, a leading health-care design firm. . . .
 WRONG SIDE SURGERY. Standardizing operating rooms within a hospital minimizes the likelihood of wrong-site, wrong-side, or wrong-patient surgery (a not uncommon occurrence). Arranging nursing stations to improve access to both patients and charts reduces errors and fatigue. And perhaps most important, providing private rooms improves infection control, allows families to help with care, and minimizes environmental stressors such as noise and light.
 PAYS FOR ITSELF.  The Center for Health Design estimates that, all told, these and Fable's other features would add $12 million to the hospital's construction costs. But thanks to reduced patient falls, transfers, nosocomial infections, nurse turnover, and drug costs, as well as increased market share and philanthropy, the Center believes those costs would be recouped within a year.

Colorado A Leader in Hospital Safety
Rocky Mountain News (Denver CO) June 27, 2006
A Harvard physician who oversees a national campaign to end lethal errors in hospitals said Colorado's participation rate in the program leads the U.S.
"The energy level in Colorado is not exceeded by any other state in the nation," said Dr. Don Berwick, president of the Institute for Healthcare Improvement. Berwick's nonprofit says it helped save 122,300 lives since it started a safety campaign in 3,100 hospitals 18 months ago.
Berwick came to Denver on Monday to celebrate the achievement and announce the "six by seven" campaign to encourage participating hospitals to adopt six quality improvement measures by 2007.

Professor Criticizes Medical Court Plan
Herald-Sun (Durham, NC)  Jun 22, 2006
     Neil Vidmar, a Duke University law professor, criticized a proposed medical courts program supported by Duke's medical center at a Senate committee hearing Thursday.
Duke's School of Medicine and Health System is one of six medical centers nationwide interested in being a test site for a proposed court system dedicated solely to medical cases.
       Vidmar said the bill eventually would take away a person's right to a jury trial.

Enzi Wants Overhaul of Medical Liability System
KGWN - Cheyenne,WY, Jun 22, 2006
U.S. Senator Mieke Enzi called for reforms that will deliver quick and fair compensation to injured patients, while providing consistent and reliable results so that doctors can eliminate defensive medicine.
     
We Must Change Use of Emergency System
Reading Eagle - Reading,PA Jun 22, 2006
    The Issue: One report praises hospitals for cutting down on medical errors, while another warns of the dire condition of emergency medicine.
    Our Opinion: We must change the way we use our health-care system, just as the hospitals are changing procedures to cut down on medical errors.
    More than 3,000 hospitals across the country were praised last week by the Institute of Health for altering procedures to cut down on medical errors. The same day the Institute of Medicine released a report indicating the nation’s emergency-care system is in crisis. The facilities that were recognized for changing their procedures included Reading Hospital and St. Joseph Medical Center, which is good news indeed.
    But the good news may have been overshadowed by the institute report on emergency rooms, which indicated that hospitals barely are able to handle the day-to-day emer-gencies, let alone what would result from a bird-flu pandemic or a terrorist strike. The study found 114 million people visited emergency rooms in 2003, an increase of 26 percent from a decade earlier. Only about half of those were true medical emergencies.

LI Hospitals Try to Make the Grade
Newsday (Melville, NY)
June 18, 2006
    Nassau University Medical Center scored lowest among Long Island's 24 hospitals in an annual report card, although it ranked among the best in lower infection rates, outranking North Shore University Hospital at Manhasset and Stony Brook University Hospital, among others.
    The 631-bed NUMC scored lower than the state average in five measures: congestive heart failure mortality, acute stroke deaths, hip fracture mortality, postoperative pulmonary embolism, and postoperative sepsis, or blood infections. Last year, the hospital scored average in all categories in which it was rated. In 2004, the hospital scored low in three categories: stroke and pneumonia victims as well as those with gastrointestinal hemorrhages.

Crowded ER’s Signal a System in Crisis
Rising number of visits, dwindling beds force hospitals to divert emergency calls, new report says. But Minnesota is in better shape than the nation.
   Pioneer Press (St. Paul, MN) June 16, 2006
    A national panel of medical experts predicts a "meltdown" in the U.S. system of emergency care unless hospitals reduce overcrowding and the federal government increases support and funding. In a three-volume report, co-authored by a St. Paul physician, the U.S. Institute of Medicine described a wide disconnect between what the public expects and what it receives from emergency care, including hospitals, first-responders and pediatric specialists.
    Crowded emergency rooms are diverting ambulances to more distant hospitals at a rate of one per minute in the U.S. They also "board" patients in ER rooms for hours or days when no inpatient beds are available. These are symptoms of bigger problems in health care, according to the report by the institute, which is an independent scientific adviser to the federal government.

Advances in Technology Are Providing Local Hospitals New Ways to Safeguard Patients Against Medication Errors..
Quad Cities Online June 12, 2006 The Dispatch (Moline, IL) The Rock Island Argus (IL); The Leader (Davenport, IA)
Last month Trinity Regional Health System introduced a bar-coding system to check patients’ medications before they are administered. It's a project that's been in the works for two years, said Cathy Kearns, clinical informatics specialist for Trinity. Nurses have a scanner and wireless computer they take to patients’ rooms. Each medication is identified by a bar code and each patient has a bar code on his or her wristband. Nurses scan the medication and scan the patient's wristband before giving the medication.

Lawsuit Alleges Hospitals Billing Medicare For Mistakes
      The Morning News, Springdale, AR June 8, 2006
     Hospitals or their insurers should pay extra costs of correcting medical errors they caused, not Medicare and taxpayers, said lawyers in a federal suit against the parent company of Northwest Health System. The suit, filed Monday by Wilkes & McHugh law firm in U.S. District Court at Little Rock, attempts to collect millions of dollars it claims Plano, Texas--based Triad Hospitals Inc. billed Medicare for mistakes hospitals caused that harmed patients.Three insurance companies also are named in the suit that uses new Medicare laws that allow a private citizen to file a lawsuit on behalf of Medicare. If the person filing the suit prevails, they are entitled to a portion of damages awarded. "Insurance companies are getting off the hook and the government is subsidizing it," said Ken Connor, an attorney with Wilkes & McHugh.

Investigating Death of Child
 In addition to state, Stony Brook hospital also says it's reviewing all aspects of case involving 11-month-old
Newsday (Melville, NY) May 25, 2006
Following the unexpected death 12 days ago of an 11-month-old girl in an operating room, Stony Brook University Hospital said it was conducting its own internal review as the state proceeds with its investigation.
In 2002, the state fined Stony Brook $54,000 and called for sweeping changes after the death of a 6-day-old boy who was given 10 times the prescribed dose of potassium chloride. The family of the dead infant, Gianni Vargas of Brentwood, sued the hospital. David Raimondo, the lawyer for the family, said the parents received $375,000 from the hospital, one of the highest awards ever given for an infant's death in the state.


Forget the Hippocratic Oath: Doctors, with their packed schedules, apparently do too
Jamaica Observer May 21, 2006 (Kingston)
Those  foreign press stories are something, aren't they? Just when you think they can't get any more bizarre, along comes another that just takes the cake. Take this gem AFP reported last week, for instance. Somewhere in Beijing, there is a man wandering around without an essential part of his anatomy.
The following headline appeared on page five of the Sunday Observers' May 7, 2006 issue: 'A Majority 1,500 Doctors Practising Illegally in Jamaica'.

Keeping Track of Medical Mistakes     Hospitals Join New Commission, Agree to Report Their Errors
  Portland Tribune (Oregon)  Fri, May 19, 2006
     Nationally, the movement to reduce medical errors gained traction in the late 1990s after a series of well-publicized tragedies. In 1994 Betsy Lehman, a 39-year-old breast cancer patient and Boston Globe health columnist, died after receiving the wrong dose of a chemotherapy drug. In 1995 a surgeon in Tampa, Fla., amputated the wrong leg of a patient. When the Oregon Legislature decided in 2003 to create the Oregon Patient Safety Commission, they didn’t make it easy for Jim Dameron, the commission’s administrator.
    The Oregon program to report mistakes is voluntary. Also, the Legislature did not give Dameron funding to run the commission. The idea was that participating hospitals would pay a fee to be part of the reporting system, and the money from the hospitals would run the program.
      Some national health care experts scoffed at Dameron’s quest — getting hospitals to voluntarily join a program to admit their mistakes, and paying for the privilege. The experts were wrong.
   As of Wednesday, Portland’s three largest hospital systems — Legacy, Providence and Oregon Health & Science University — had enrolled in the commission’s reporting program. In fact, 44 of the state’s 57 hospitals have agreed to participate.
  
Checklists Help Prevent Surgical Mistakes
     NBC 17 - Raleigh NC May 18, 2006
-- Medical errors are one of the nation's leading causes of death, killing between 44,000 and 98,000 U.S. hospital patients a year, according to a 1999 report by the National Institute of Medicine.
To eliminate such dangerous mistakes before surgery, WakeMed two years ago adopted what hospital officials refer to as "pause for the cause," a mandatory patient safety checklist that is part of the preparation routine before every surgery.
The checklist, which other area hospitals have also implemented, prevents so-called wrong-site surgeries by rechecking to make sure surgeons have the right patient, the right procedure and equipment -- and the correct side of the body. "It brings the whole team together so that it's that last check," said Sharon McNamara, WakeMed's director of surgical services. "We have in this country had patients go into the wrong rooms and have the wrong surgeries performed. We've had the wrong leg removed, the wrong ear operated on."

Doctors Misidentify Some Pills on Sight
Forbes USA  (HealthDay News)  May 1, 2006 
-- Just by looking at them, doctors and pharmacists could not correctly identify three common pills more than one-third of the time, a new study found.
The study appears in the May 1 issue of the American Journal of Health-System Pharmacy.
Schiff said he envisions a standardized, international coding system whereby each pill would be identified by its generic, chemical makeup. The solution should not lie in more training for already overburdened health-care professionals, he said.


Aramco Releases Pharmacy System for SAP ITP.net  Sunday, 9 April, 2006
Saudi Aramco, the world's largest oil producer, has released a pharmacy software system for the SAP healthcare module, in conjunction with T-Systems, ACN can exclusively reveal.
One of the major risks in every health care environment deals with prescribing the wrong medication or the wrong dose. A 1999 study, 'To Err is Human: Building a Safer Health System', by the Institute of Medicine, found that inadvertent medical errors are responsible for 44,000 to 98,000 deaths in the United States each year, and 7,000 of those deaths are a result of medication errors - this study informed Aramco's drive to develop a new system.

Technology to the Rescue: Hospitals Invest in Digitizing Medical Records to Cut Deadly Errors
The Register-Guard (Eugene OR) Sunday, April 9, 2006
    "In the heart of health care today, the most important tool a physician can have is accurate, good clinical information to make a good clinical decision," said Michael O'Rourke, chief information officer of  Triad Hospitals Inc. of Plano, Texas. Triad is launching a 10-year, $1.3 billion information technology project. 
   "If you want to improve the quality and safety of care, you have to support a physician's ability to make the best decision every time they make a decision."

Protecting the patient  Altoona Mirror. (PA) Saturday, April 1, 2006
- Communication Between Medical Staff and Those Seeking Help Critical for Good Healthcare
    Altoona Regional is among more than 3,000 hospitals that have joined the Institute for  Healthcare Improvement’s 100,000 Lives Campaign, ‘‘an initiative to engage U.S. hospitals in a commitment to implement changes in care proven to improve patient care and prevent avoidable deaths,’’ according to the IHI Web site. The institute is a not-for-profit organization, established in 1991 and based in Cambridge, Mass., dedicated to improving healthcare in the United States.
- This initiative is aimed at saving 100,000 lives from January 2005 to July 2006 by practicing six initiatives.
Five steps to safer healthcare
1. Ask questions if you have doubts or concerns and make sure you understand the answers. Take a relative or friend with you to help you ask questions and understand the answers.
2. Keep and bring a list of all the medicines you take. Give your doctor and pharmacist a list of all the medicines that you take, including nonprescription medicines.
3. Get the results of any test or procedure. Don’t assume the results are fine if you do not get them, call your doctor and ask for your results.
4. Talk to your doctor about which hospital is best for your health needs and if you have more than one hospital to choose from.
5. Make sure you understand what will happen if you need surgery.
Source: Agency for Healthcare Quality and Research; Web site www.ahrq.gov

Protecting the patient  Altoona Mirror. (PA) Thursday, March 30, D1
People put their faith in the medical community to make them well, but sometimes that doesn't happen.
According to the 1999 Institute of Medicine report, "To Err is Human,'' in 1997 an estimated 44,000 to 98,000 people died in hospitals as a result of medical errors, said Farah Englert, spokeswoman for the Agency for Healthcare and Research Quality. She added that the figure is low because there is "no requirement for mandatory reporting [medical errors]." For more details, see Page D1 of the Thursday, March 30, Altoona Mirror.

Rapid Response Teams Strive to Prevent Avoidable Death
 Tribune Star  Terre Haute, IN
February 20, 2006
The patient had trouble breathing, but was in the hospital for another reason. Concerned about his well-being, a nurse on his floor phoned the hospital operator and asked for assistance.
Rapid response teams such as the one that responded in this case are popping up in hospitals across the state and nation.
Prompted by the Institute for Healthcare Improvement’s 100,000 Lives Campaign, the teams are geared at preventing avoidable deaths. The goal is to catch the earliest signs of complications or illnesses, long before they lead to a catastrophic cardiac or respiratory failure.
“Basically what you’re doing is taking the ICU to the patient,” said Dr. John Bolinger, who helped develop treatment guidelines for Regional’s team, which started last month.


State Starts Project to Track Serious Hospital Mistakes
The Oregonian (Portland)Wednesday, February 01, 2006
     Public Health - Participation Is Voluntary and the Confidential Information Will Be Used to Reduce Errors
  The Oregon Patient Safety Commission on Tuesday launched its effort to get hospitals to report -- and reduce -- serious medical errors. The Oregon approach, unique in the nation, is a mix of voluntary and mandatory features. Hospitals can choose to participate, or not, but refusal to join will be reported on the commission's Web site.
   The Oregon commission relies on voluntary reporting because its members believe that doctors, nurses and hospitals B1 are more likely to disclose errors and share data if they can do so confidentially and without fear of penalty. They say it's more important to look at root causes and prevent an error from recurring than to affix blame.

Indiana Tackles Medical Errors
     South Bend Tribune - Editorial January 11. 2006
     Indiana has become one of only two in the nation in which medical errors must be reported by hospitals and the information made public. Credit this major change in policy to an executive order last January from Gov. Mitch Daniels.
     The Indiana JCAHO official figure of 36 deaths and injuries caused by hospital errors from 1995 through 2004 is probably low by many thousands. The Joint Commission acknowledges that its data probably is just the tip of the iceberg. This is a guesse. No one really knows. And that's the problem.
      It is crucial for the health and well-being of Hoosiers that this problem be defined so that it can be addressed. Under the rules, which are modeled after Minnesota's (the only other state with public disclosure), hospitals must report any errors from a list of 27 different types.
       In the past, Indiana has set an example for misunderstanding the extent of medical errors. Now it has become a leader in addressing the problem.