2007-2008
Citations to the Institute
of Medicine Report
that 44,000 to 98,000 People Die
Annually Due to Hospital Errors
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US Medical Errors Cost Nearly $1.5 Billion a Year fluxmedia.com July 29, 2008 Citing journalHealth Services Research July 28, 2008. According to a
new US government report released on Monday medical errors during or
after the surgery may cost employers nearly $ 1.5 billion a year. The
researchers analyzed data on more than 161,000 patients in
employer-based health plans who underwent surgery between 2001 and 2002.
The team concluded
that the effects of medical errors continue long after the patient
leaves the hospital. Medical error studies that focus only on the
inpatient stay can underestimate the costs by up to 30 percent.The
report indicated that one of every 10 patients who died within 90 days
of surgery died because of a preventable error and one-third of the
deaths occurred after the patient was discharged.
44,000 to 98,000
Americans die because of medical mistakes each year, with an associated
cost of $17 billion to $29 billion, a 1998 report by the Institute of
Medicine estimates.
Gray Matters Orlando Sun Sentinel.com July 6, 2008 You're
sick. You need a doctor. Maybe you're headed toward a hospital. Trust
me, now you need someone else by your side: an advocate!
An advocate is a "health partner"-- someone knowledgeable
and feisty, someone to ask questions and not settle for incomplete or
insincere answers. Every year, 1.5 million patients suffer from
what the health-care system deems "medication errors." In plain
language, some dope (well-meaning or otherwise) gives unsuspecting
patients the wrong medicine. (Source: 2006 Institute of Medicine
report.)
An advocate asks, "Does my mother
(the patient) truly need this drug? What are the side effects? How long
will she be taking it? What is the cost? Is there no other recommended
therapy?"
Hospital Tells of Surgery on Wrong Side July 4, 2008 Huddles bring doctors, nurses, others together Statesman Journal .com 7/2/2008 Salem Oregon
The
training program, taught by Tennessee-based LifeWings Partners, teaches
"crew resource management" techniques initially developed for airline
crews to help prevent human error. It aims to strengthen communication,
build teamwork and standardize processes in health-care organizations.
LifeWings
resulted from the publication of a report by the Institute of Medicine
in 1999 that estimated between 44,000 and 98,000 Americans die each
year from medical errors.
Salem Hospital officials began
considering the program in 2006 as part of its push to improve overall
performance, said Judy Marvin, medical director of women's services at
the hospital. LifeWings was brought in last year, with training kicking
off in the fall. Since then, officials have taken the concepts they
learned to develop tools that have become standard behavior at the
birth center.They range from team discussions before surgical
procedures — to make sure everyone and everything is ready
— to detailed reports that follow patients throughout their
hospital stay. Many of the tools center on a checklist or worksheet
that captures and preserves information that used to be subject to
memory, passed on orally and at risk of being lost.
Nurses, for
example, now fill out a worksheet for each patient that includes a due
date, blood type, gestational age and other pertinent information. That
sheet is handed off from nurse to nurse as a patient moves through
different units of care, such as labor and delivery to the mother and
baby unit, Marvin said.
Program takes wing at hospital. Huddles bring doctors, nurses, others together Statesman Journal .com 7/2/2008 Salem Oregon
The
training program, taught by Tennessee-based LifeWings Partners, teaches
"crew resource management" techniques initially developed for airline
crews to help prevent human error. It aims to strengthen communication,
build teamwork and standardize processes in health-care organizations.
LifeWings
resulted from the publication of a report by the Institute of Medicine
in 1999 that estimated between 44,000 and 98,000 Americans die each
year from medical errors.
Salem Hospital officials began
considering the program in 2006 as part of its push to improve overall
performance, said Judy Marvin, medical director of women's services at
the hospital. LifeWings was brought in last year, with training kicking
off in the fall. Since then, officials have taken the concepts they
learned to develop tools that have become standard behavior at the
birth center.They range from team discussions before surgical
procedures — to make sure everyone and everything is ready
— to detailed reports that follow patients throughout their
hospital stay. Many of the tools center on a checklist or worksheet
that captures and preserves information that used to be subject to
memory, passed on orally and at risk of being lost.
Nurses, for
example, now fill out a worksheet for each patient that includes a due
date, blood type, gestational age and other pertinent information. That
sheet is handed off from nurse to nurse as a patient moves through
different units of care, such as labor and delivery to the mother and
baby unit, Marvin said.
Medicare to No Longer Pay for Medical Providers' Mistakes Health Care Killed 212 Floridians Last Year. News-Journal Online Dayton Beach, FL May 5, 2008s
Eighty-two others in 2007 had to have surgery to remove a foreign object left in during a previous surgery.
Another
140 had a surgical procedure unrelated to their diagnosis, according to
reports amassed at the Florida Agency for Health Care Administration
from the state's 291 hospitals. And some say that's not nearly the
extent of the problem of medical mistakes.. See list of complications that will be excluded from Medicare reimbursement.
German Surgeons Operate on Woman's Bowels Instead of Leg
USA Today March 24, 2008s
When it comes to a surgical mistake, this incident may
take the cake: A 78-year-old German woman went into the hospital last
month to have surgery on her leg. Because of a mixup, Frankenpost
reports that she left the Hochfranken-Klinik in Münchberg,
Germany, with an artificial anus. (Colostomy).
The paper says some members of the surgical team have been
punished in connection with the series of mistakes that led them to
operate on the wrong patient.
Prosecutors are said to be
looking into the incident. As for the unidentified patient, she still
needs knee surgery and plans to file a lawsuit.
By the way, there is such a thing as an "artificial anus." Shosaburo Abe and Yoshikatsu Abe filed a patent application in 1991.
Fremont Hospital Cited, Fined for Fatal Mistake - Woman Was Given Wrong Medications Mercury News 03/21/2008
An elderly heart patient
being treated at Washington Hospital in Fremont last year died after
she was mistakenly given methadone and other medications typically used
to treat drug addicts, state officials revealed Thursday.
The hospital was one of 11 in California, including the Los Angeles
hospital that treated the twin babies of actor Dennis Quaid, cited and
fined for medical errors that injured or caused the death of patients
in their care.
The $25,000 maximum penalty
issued to Washington Hospital came after the 87-year-old woman was
given another patient's methadone and desipramine - medications
frequently prescribed to treat drug addictions - as well as at least
two other medicines not intended for her, state records show. The
woman, who health officials have not identified, went into respiratory
and cardiac distress and died Aug. 19.
Thursday's action was only the second time the California Department of
Public Health has levied the $25,000 fines and widely publicized the
sanctions against hospitals for their failure to follow a licensing
requirement that "caused, or was likely to cause, serious injury or
death."
USA Today March 24, 2008s
An elderly heart patient being treated at Washington
Hospital in Fremont last year died after she was mistakenly given
methadone and other medications typically used to treat drug addicts,
state officials revealed Thursday.
The hospital
was one of 11 in California, including the Los Angeles hospital that
treated the twin babies of actor Dennis Quaid, cited and fined for
medical errors that injured or caused the death of patients in their
care.
The $25,000 maximum penalty issued to
Washington Hospital came after the 87-year-old woman was given another
patient's methadone and desipramine - medications frequently prescribed
to treat drug addictions - as well as at least two other medicines not
intended for her, state records show. The woman, who health officials
have not identified, went into respiratory and cardiac distress and
died Aug. 19.
Thursday's action was only the
second time the California Department of Public Health has levied the
$25,000 fines and widely publicized the sanctions against hospitals for
their failure to follow a licensing requirement that "caused, or was
likely to cause, serious injury or death."
Many in N.J. Are Medical Error Victims The Record.com (North Jersey) Thursday, March 6, 2008
More
than a third of New Jersey residents surveyed say they or a family
member have been a victim of a medical error, and 90 percent would like
the state to publicly report the number of errors at each hospital and
health care facility.
That's the finding of a
survey commissioned by the AARP's New Jersey chapter, which has backed
recent laws requiring hospitals to report hospital-acquired infections
to the state and to screen patients for certain drug-resistant diseases.
The survey, "Does it Make You Sick? Public Opinion on
Health Care Quality in New Jersey," also found widespread support for a
ban on billing patients or insurers when health care providers make
preventable errors.
In New Jersey, the state
Department of Health compiles hospital reports of preventable mistakes
and releases the aggregate numbers two years later -- without telling
the public which institutions made the mistakes. Hospitals reported a
total of 376 errors in 2005 and 450 in 2006. These resulted in 57
deaths in 2005 and 42 in 2006, according to the state. The most common
errors reported were patient falls, bedsores and surgical errors such
as wrong-site surgery.
In the AARP survey of
805 adults, 21 percent said a family member had experienced a
preventable medical error, 14 percent said they themselves had
experienced such an error, and 2 percent said both they and a family
member had. Ninety percent support public disclosure of the number of
preventable errors at individual health care facilities.
Well-designed Hospital Facilities Help Staffs Provide Safest Medical Care The Tennessean .March 5, 2008
The
National Highway Traffic Safety Administration recently reported that
there were 42,642 automobile-related fatalities in 2006, an average of
one every 12 minutes. More than half of those people were not wearing
the most basic safety precaution in their vehicle: a seatbelt.
Safety
precautions in automobiles such as seatbelts, airbags and anti-lock
brakes have been tested and proved to be effective. As a society,
Americans have been educated on the benefits of these safety
precautions and as a result, the number of automobile-related
fatalities has declined in the past five years.
In 1999, the
Institute of Medicine published a landmark study estimating that 44,000
to 98,000 people die in U.S. hospitals each year as a result of medical
errors, averaging 275 people each day. The number of auto-related
fatalities that year was 41,717.
The health-care industry has been
scrambling since the report to identify their "seatbelts" and "airbags"
to reduce the number of patients who are harmed or killed in their
facilities. Many advances have been made in medication distribution and
operational processes, but one of the most dramatic developments has
been the re-evaluation of the health-care vehicle - the hospital. This
vital component can contribute to or inhibit the health-care delivery
process.
How to Make Your Hospital Stay Safer The Daily Breeze Torrance, CA 01/09/2008
Here are some suggestions from Health and Human Services.
Hospital stays Go to a hospital that has experience with your condition.
Ask health-care workers if they washed their hands. Surgery/ Initial the site to be operated on. Medicine. Be
sure all of your doctors know all of the medicines you are taking,
including prescription and over-the-counter drugs. Once a year,
consider placing all of your medicines in a brown bag and taking them
with you on a medical appointment. No news. Don't assume that no news about a test result means the test was negative. Always call.
Aviation Principles Applied to Improve Safety Poughkeepsie Journal Sunday, June 10, 2007
If you've had surgery at Vassar Brothers Medical Center, you might have wondered: What's with all the questions?
You might be asked your name, your reason for being there and to
state your surgery site multiple times by multiple people - from nurses
and doctors to anesthesiologists.
All those questions are part of the City of Poughkeepsie hospital's
participation in Life-Wings, a program in place since late 2005 to
improve patient safety and quality of care, and decrease mistakes.
An estimated 44,000 to 98,000 Americans die each year from mistakes
made in medical settings, the Institute of Medicine says. Dr. Daniel
Aronzon, president and CEO of Vassar, acknowledges such grim
statistics, "The fact is that medical errors are the sixth-leading
cause of death in U.S. hospitals." LifeWings, a
company in Memphis, Tenn., is based on Crew Resource Management - a
system of training, safety tools and teamwork born in the aviation
world. Applied in the hospital setting, it helps to prevent and detect
costly errors that can harm or kill people.
Vassar has tools and terminology, checklists, modes of communication
- and redundant systems to check that, for example, the correct surgery
is being done on the correct person and body part.
Crises and emergencies occur more frequently in hospitals than in
aviation, Aronzon pointed out, and military and aviation prepare for
how to escalate communication during emergencies despite a hierarchical
rank structure.
Death of Infant from Hospital Error Probed San Francisco Chronicle March 10, 2007
State and Federal Authorities Are Investigating a
Medication Error at Kaiser Permanente's Santa Clara Hospital That Led
to the Death of an Infant, Kaiser Officials Confirmed Friday.
The Feb. 24 death is the third mortality caused by a
medication error at Kaiser's Santa Clara medical center since 2004.
Kaiser officials blamed the latest death on human error, rather than
procedural shortcomings. After the earlier deaths, Kaiser initiated new
policies designed to prevent future deaths by medication errors.
Indiana Medical Errors Report Released Carroll County Comet (IN) March 7, 2007
Governor Mitch Daniels and state health officials Tuesday released the
first preliminary report of the Medical Error Reporting System (MERS),
designed to provide reliable data on medical errors and improve patient
safety. According to preliminary data, 77 medical errors were reported
for 2006. Seventy-two events happened at hospitals, and five events
occurred at ambulatory surgery centers.
Reported events include:
* Twenty-one events of retention of a foreign object in a patient after surgery.
* Nine events of surgery performed on the wrong body part.
* The remaining 24 events fell in the remaining categories, which can
be found in the report on the State Department of Health Web site.
Video: AHRQ and Ad Council Encourage Patients to Ask Questions and Get More Involved With Their Health Care PR Newswire.com March 7, 2007
WASHINGTON, March 7 /PRNewswire/ -- HHS' Agency for
Healthcare Research and Quality joined with The Advertising Council
today to launch a national public service advertising campaign designed
to encourage adults to take a more proactive role in their health care.
The campaign is being launched during national Patient Safety Awareness
Week (March 4-10, 2007).
To view the Multimedia News Release, go to: http://www.prnewswire.com/mnr/adcouncil/26473/
Medical mistakes occurring in hospitals account for an
estimated 44,000 to 98,000 deaths each year or a minimum of 120 deaths
per day, according to the Institute of Medicine. That means that these
mistakes lead to more deaths per year than motor vehicle accidents,
breast cancer or AIDS.
Research shows that consumers who get more involved with their
health care can greatly improve the safety of their care, but patients
are generally unaware of what to do to help prevent medical mistakes.
According to a recent study conducted by AHRQ and the Kaiser
Family Foundation, 57 percent of Americans do not believe that
preventable medical errors occur often.
Error Report Designed to Improve Care Journal and Courier - Lafayette, IN, March 8, 2007
Gov. Mitch Daniels signed an executive order at his 2005 inauguration
that mandated the public reporting of medical errors. Reportable errors
fall under certain criteria established by the state and include 27
event categories.
Between 44,000 and 98,000 people die annually from medical errors that
occur through the nation's hospitals, according to a study issued in
2000 by the Institute of Medicine. Called "To Err is Human," the study
provided the impetus for the gubernatorial executive order, which made
Indiana the second state in the nation to require such reporting.
There's a reason why the institute, which provides guidance to
policymakers and health professionals, called the study "To Err is
Human" rather than "Hospitals: Enter at Your Own Risk."
R.I. Lawmaker Targets Hospital Errors
InsuranceJournal.com San Diego, CA 92108 February 27, 2007
Between 44,000 and 98,000 patients die each year in
U.S. hospitals because of mistakes, infections and other adverse
situations. That's more deaths than those caused by breast cancer, AIDS
or car accidents.
Most of those deaths are avoidable, according to Rhode Island Sen.
Charles J. Levesque (D-Dist. 11, Portsmouth, Bristol), who has
introduced legislation aimed at reducing their occurrences in hospitals
in his state.
Common ways hospitals can increase patient safety
include standardizing safety, communication and sterilization
procedures. Computerizing patient information to the greatest extent
possible is also a way to reduce
the possibility of human error. According to a 1999 Institute of
Medicine report, To Err is Human, costs of preventable "adverse events"
in hospitals are estimated to be between $17 billion and $29 billion
every year.
"Mistakes in hospitals hurt everyone. They
tarnish the health care industry, they cost everyone money in the form
of higher health care and insurance costs, and worst of all, they cost
lives. I commend the hospitals
in Rhode Island that are already taking the initiative to reduce errors
and infections, and I hope this legislation formalizes this process and
ensures every hospital's full compliance," said Senator Levesque.
Source: R.I. Legislative Press Bureau.
Patient, Protect Thyself
Vigilance Is New Watchword in Preventing Medical Errors The
Enquirer, Cincinnati , OH Saturday. Feb.10, 2007
It was 4 a.m., but Gillian Trumbull was wide awake. Trumbull has
learned the value of staying alert in the hospital.
One in a Chicago hospital, Trumbull was waiting to be taken for a heart
test. Instead, an employee announced he was taking her for dialysis, a
treatment for kidney failure. The employee - who had confused Trumbull
with the patient in the next bed - ignored Trumbull's protests and
began wheeling her out the door.
"We were halfway down the hall before someone heard me yelling," says
Trumbull, then 20. "A nurse manager stopped him and said: 'She's pretty
lucid. I think she knows what she's saying.' "
Hospitalized patients can expect to experience at least one medication
error a day, says the Institute of Medicine, which advises Congress on
health policy.
Eight ways to help get the best treatment
- Bring an advocate.
- Prepare a "health profile."
- Avoid wrong-site surgery.
- Double-check all your medications and treatments before accepting
them.
- Take notes.
- Follow up.
- Educate yourself.
- Guard against superbugs.
Few Dollars Are Spent on Preventive
Care
Sun, Jan. 28, 2007 Miami
Herald.com
The United States spends huge amounts on treating illnesses and very
little on keeping people well.
Only three in five kids get basic preventive medical and dental care
that could help keep them healthy for a lifetime, according to the
annual health report of the Commonwealth Fund, a Washington healthcare
research group.
Only 49 percent get mammograms, Pap smears, blood pressure and
cholesterol checks within an appropriate time frame, according to
Commonwealth. And only 31 percent of those without insurance get the
tests.
Other reasons for America's high-cost care:
• Administrative costs: The paperwork of insurers and the providers
reporting to them eat up 7.3 percent of healthcare expenses. That's
more than twice the rate in Britain, Canada, Japan and France, where
single-payer government systems require far less in administrative
costs.
• Racial disparities: The Institute of Medicine has produced detailed
studies showing that, regardless of income level or quality of
insurance, black men and women in the United States tend to get worse
care than whites.
• Geographic disparity: Costs vary widely in the United States
depending on region, with South Florida among the very highest.
• Costs: Prices are just flat-out higher. A study by Gerard Anderson
and colleagues found that an average day in a hospital in the United
States in 2002 cost $2,434 -- three times the price as most other
industrialized countries.
These high prices are scaring people away from treatment.
''Forty percent of U.S. adults report not getting needed care because
of cost,'' Commonwealth President Karen Davis recently testified before
Congress.
Minnesota Department Of Health
Publishes Annual Report On Adverse Events In Minnesota Hospitals And
Surgical Centers All
American Patriots.com - January 17, 2007
January 17, 2007 -- The Minnesota Department of Health (MDH) today
released the third annual report on preventable adverse events in
Minnesota hospitals, ambulatory surgical centers and regional treatment
centers.
According to the report, between October 7, 2005, and October 6, 2006,
154 adverse events were reported by 49 facilities, and 24 deaths and 7
serious disabilities resulted from the events.
Related links: 27
“never never” events include wrong side surgery, wrong
patient surgery, infant discharged to wrong person. Adverse
Health Events Reporting Searchable data base . Minnssota DOH
Patient Safety .
Contrary to Popular Myth, Few Injured
Americans File Lawsuits. CivilJusticeDefense.org
January 10, 2007
At the highest level, the estimated number of medical injuries
(in hospitals and otherwise) is more than 1,000,000 per year;
approximately 85,000 malpractice suits are filed annually. “With about
ten times as many injuries as malpractice claims, the only conclusion
possible is that injured patients rarely file lawsuits.”
The Number of Tort (Personal Injury) Cases Is Declining.
From 1995-2004, the total number of tort filings for 15 states
reporting showed a general downward trend. There has been a
general downward movement in tort filings since 1990.
Tort cases were even outnumbered by probate cases.
.
