UK hospitals fail to comply with safety alerts
Filed under: Europe, Hospitals, Hot Health Headline
Following medical errors and patient safety issues, the United Kingdom’s National Patient Safety Agency issues national safety alerts so that hospitals can change their practices and avoid repeat occurrences. As The Daily Telegraph’s Rebecca Smith reports, a patient advocacy group has found (28-page PDF) that two-thirds of UK hospitals have failed to meet the implementation deadline on at least one alert.
The group blames haphazard enforcement and monitoring for the lapses.
Action against Medical Accidents warned that despite repeated warnings that the alerts were not being complied with, there was no central policy or guidance on which organisation should be monitoring compliance and what action should be taken.
Smith focused on two particularly serious issues, the inappropriate administration of oxygen and injectable medicines. The report groups instances of noncompliance by hospital and by alert.
Hospital infections on rise in Nev., reporters find
Filed under: Health journalism, Hospitals, Hot Health Headline
Part two of Marshall Allen and Alex Richards’ Las Vegas Sun hospital investigation series “Do No Harm” takes on hospital-acquired infections. Even though no agency in the state tracks such things, the duo managed to find 2,010 instances of drug-resistant bugs in local hospitals between 2008 and 2009. That number included 647 instances of hospital-acquired MRSA.
In the story, the explain how they overcame industry resistance to dig up the data themselves:
No health agency tracks these cases. In fact, hospitals derailed proposed legislation in 2009 that would have required them to publicly report cases of MRSA in their facilities.
However, hospitals are required by law to submit to the state billing records based on each patient visit. The Sun obtained that information from 1999 to 2009 and analyzed the 2.9 million hospital billing records as part of its two-year investigation, “Do No Harm: Hospital Care in Las Vegas.”
Because of how the records are coded, the Sun was able to identify the number of infections by the two bacteria, and for the years 2008-09 further identify the cases in which the records say the patients acquired the bacteria while hospitalized.
While it’s hard to put their numbers in a national context because of widely varying methods of measurement and reporting, the duo can say that such infections jumped 34 percent from 2008 to 2009. Allen and Richards then establish two facts:
- Some institutions have developed ways to keep MRSA and friends under control.
- None of those institutions are in Las Vegas, where inspections show that hospitals could be doing a lot more.
Efforts to force Nevada hospitals to disclose MRSA cases withered under heavy industry opposition, though the legislature is now considering a watered-down version that would not public the MRSA rates of specific facilities.
It’s worth noting that the paper has published responses from readers who have plenty of their own hospital horror stories. The website includes their input both in text and through excerpts of some of the voicemails Allen has received since the first part of the series was published. They are heart wrenching but serve as an excellent example of how reporters can involve readers in a project.
Reporters encounter hospital’s lack of transparency
Filed under: Health data, Health journalism, Hospitals, Hot Health Headline
Blythe Bernhard and Jeremy Kohler of the St. Louis Post-Dispatch investigated a string of serious mistakes at a local hospital and found the story of a 16-year-old girl who suffocated in a bean-bag chair after being sedated. It’s a remarkable and chilling story on its own and, as AHCJ Immediate Past President Trudy Lieberman points out, it’s made even more valuable for health journalists thanks to Kohler’s willingness to explain his investigative process.
Acting on multiple tips referring to a botched 2007 kidney removal, Kohler began the laborious process of triangulating the error. You should really take a minute to read his entire explanation, but if you really don’t have time, just take note that his path was something like this: Tips from sources -> Joint Commission -> Missouri Division of Insurance -> National Practitioner Data Bank -> Missouri Department of Health and Senior Services -> Missouri Board of Professional Registration for the Healing Arts -> The actual hospital.
And even then, he was unable to get clear confirmation that surgeons had removed the wrong kidney from a patient. Instead, the hospital cited privacy regulations.
Last week, officials with SSM Health Care, the St. Louis-based corporation that operates DePaul and several other hospitals, said they could not speak about specific patient cases because of federal privacy laws. “The desire to defend ourselves and paint an accurate and full picture does not outweigh our patients’ right to privacy,” they said in a statement.
Even a subject like this, which clearly involves what Kohler calls “information that patients in need of a surgeon would be interested in knowing,” the obstacles between readers and the truth about a “never event” appear insurmountable.
Quaid releases documentary about medical errors
Filed under: Health journalism, Hot Health Headline
Those of you who attended Health Journalism 2008 may remember actor Dennis Quaid’s appearance at the event, telling the harrowing tale of the heparin overdoses that almost killed his infant twins.
Dennis Quaid spoke about medical errors at Health Journalism 2008. (Photo: Pia Christensen)
Quaid continues his crusade against medical errors with a documentary that will debut April 22 (and airs on the Discovery Channel on April 24) and co-authoring an article in the Journal of Patient Safety.
The article, which focuses on the use of anecdotes and storytelling to improve patient safety, is not typical journal fare. It’s equal parts how-to manual, anecdotes and sermon, and Quaid’s commitment comes across forcefully.
As you finish reading this narrative and return to your life in health care, we challenge you to think about your own story. If every story has a hero, a victim, a villain, a crisis, and a resolution, we want you to see yourself as a hero. It is time to write your own story. Turn that light into heat and focus it on your villain: the villain that protects the status quo, the way we have always done things. A best friend of this villain is survival-centered, blind cost-cutting that drives enormous safety risk and harm to patients.
Quaid spoke about the topic yesterday at a National Press Club luncheon (video), where he also announced that his nonprofit Quaid Foundation has merged with the Texas Medical Institute of Technology.
Tracking medical errors amid health tech push
Filed under: Government, Health policy, Hot Health Headline
Fred Schulte and Emma Schwartz are still hot on the trail of health information technology at the Huffington Post Investigative Fund, now exploring the timeline and tactics involved in tracking medical errors as part of widespread stimulus-funded HIT adoption. Colleague Amanda Zamora’s companion graphic helps provide both an at-a-glance overview and in-depth understanding of how errors are tracked now and how they will be monitored in the future.
Schulte and Schwarz write that a federal panel hopes to create a national database of HIT-related errors, but that it won’t be functional until 2013, a date many experts fear is unnecessarily distant.
The draft proposal would require doctors and hospitals to report problems as a condition of receiving stimulus money, starting in 2013. The panel, which is expected to finalize the plan next month, also wants to require that manufacturers alert customers when software glitches are discovered and require all users of the systems to undergo safety training
…
But many early adopters, who often have spent a decade or more and tens of millions of dollars working out kinks, say that even additional oversight can’t stave off every potential hazard. And they are becoming increasingly vocal about the downside of rushing into buying the highly complex technology.
“There is a great fear among many people that we are asking organizations to go too far too fast,” said Justin Starren, who directs health technology at the Marshfield Clinic in Wisconsin. “It’s a foregone conclusion that with this many installations that some people will make some mistakes.”
Schulte will be taking part in a panel about “Tracking health-related stimulus money” at Health Journalism 2010. Joining him on the panel will be ProPublica reporter Michael Grabell and Phil Galewitz, a reporter for Kaiser Health News and member of AHCJ’s board of directors.
Report details errors in waiting-room death
The Philadelphia Inquirer’s Tom Avril reports on how hospital errors led to the death of a 63-year-old north Philadelphia guidance counselor. Avril opens his story by painting a picture of hospital operations, one based on documents released after a state investigation.
Photo by exvertebrate via FlickrTwice, when an emergency-room nurse called out the name of Joaquin Rivera and he did not respond, she had no idea he’d already suffered a massive heart attack.
The reason: The nurse did not venture beyond the waiting-room doorway and simply did not see him where he sat, unattended, for nearly an hour.
Avril reported that the hospital has already taken steps to prevent a similar occurrence in the future, including:
- Increasing security by more than 30 percent
- Creating new training for registration staff, with an emphasis on communication with nurses
- Instituting a policy of calling patient names every 10 minutes if they don’t answer at first
- Identifying a location on the waiting-room floor from which all parts of the room can be seen and marking it with tape so that triage nurses know where to stand when calling out names
- Hiring an architectural firm to see if further improvements can be made
Network to warn pharmacists of drug errors
Filed under: Health data, Hospitals, Public health
The Wall Street Journal’s Laura Landro spotlighted a new national network designed to send e-mail alerts to as many as 55,000 pharmacists.
The network is designed to alert pharmacists of dangerous and life-threatening errors as well as to educate them on how to prevent those specific errors from also occurring in their own respective practices. The system is intended to help the same errors from being repeated time after time across the country.
Photo by jypsygen via Flickr.Landro wrote that “Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States,” and added that there are some indications that the weakening economy has had a negative impact on medication safety.
Here’s Landro explaining the new network:
The non-profit Institute for Safe Medication Practices, which is certified by the federal government to collect error reports and other information about quality breaches, and the American Society of Health-System Pharmacists are launching a new National Alert Network for Serious Medication Errors. The network, which was unveiled last month, will be used to send email alerts to 35,000 pharmacists working in hospitals and health systems, as well as physicians and nurses, when a dangerous or life-threatening error is reported to ISMP. The two organizations are also in discussions to extend the network to as many as 26 other organizations that promote safe medication use. The hope is that widely spreading the word about such errors will cause doctors and pharmacists to be more cautious—and ultimately prevent future mix-ups. Relevant alerts will also be sent to 20,000 drugstore pharmacists.
Landro also mentioned ISMP’s consumer med safety alert portal and the FDA’s consumer-focused error reporting tool. She also goes into greater detail as to how drug mishaps happen, and into what can be done to prevent them.
Related
Getting patients home safely after a hospital stay
New America Media’s Paul Kleyman explores the effects of hospitals cutting corners when it comes to patient transitions from hospital to home, a problem his sources call one of the biggest gaps in the health care system. Citing a widely reported 2009 New England Journal of Medicine article on preventable rehospitalizations, Kleyman explains why the current transition system is both expensive and broken, then chronicles the efforts of advocates and legislators to change the system or, at the very least, fill in the gaps.
Kleyman on the latest legislative attempt to change the system:
These findings led members of Congress to introduce the Medicare Transitional Care Act of 2009. According to the bill, “Insufficient communication among older adults, family caregivers and health care providers contribute to poor continuity of care, inadequate management of complex health care needs and preventable hospital admissions.” The Act would set up demonstration projects to test ways for improving patients’ continuity of care.
AHRQ interviews Ornstein, talks medical errors
Filed under: Health data, Health journalism, Hospitals, Public records
Robert Wachter, M.D., (bio), editor of AHRQ WebM&M (Morbidity and Mortality), interviewed AHCJ President Charles Ornstein, of ProPublica, for a recent issue (get the audio version here). Their conversation began as a general discussion of health journalism, then zeroed in on hospital errors and the Pulitzer Prize-winning series on King/Drew Medical Center in Los Angeles that Ornstein did with Tracy Weber when both were at the LA Times.
The whole thing is worth a read. In this excerpt Ornstein discusses how health journalists find stories:
Good reporters have a variety of sources of information. Reporters who routinely cover the hospitals in their communities should be constantly looking at state inspection reports, lawsuit data about payouts, their Joint Commission accreditation, and how they’re doing with their training program. All these types of things should be on the radar screen and monitored regularly. But nothing can replace talking to employees in the facilities and the patients that receive care there—trying to get an on-the-ground perspective.
In a companion piece, Wachter reflected on the role the media has played in shaking the medical profession out of a dangerous rut of complacency:
What do we need from reporters who cover the medical errors beat? … reporters need to know enough about error science that they appreciate the importance of searching for systems factors, without immediately zeroing in on more dramatic and obvious sharp-end errors. They need to get the facts right. And, while raising the appropriate concerns, they need to avoid sensationalism and place the error, or the topic, in broader context. When they do these things, they are providing a unique and critical service to patients and caregivers.
Feds take Columbia to task over decade-old study
Filed under: Conflicts of interest, Health data, Hospitals, Hot Health Headline, Nursing, Pharmaceuticals, Studies, Tools
The run of intriguing health journalism from the Huffington Post Investigative Fund continues this week, as Jeanne Lenzer and Shannon Brownlee look at the federal government’s entrance into an internal conflict at Columbia University’s medical center over the legality and morality of a heart-related study that took place from 1999 to 2001, one in which some experts say it was “virtually guaranteed” that some patients would suffer hemorrhaging.
Columbia has already conducted three internal investigations on the matter. Now, the federal government has asked for a full account of what happened to the study’s participants and ordered that Columbia write a letter to the study’s participants and disclose the “true nature” of what some contend was a deceptive study.
NOTE: In addition to the story itself, the reporters have posted a selection of key documents online.
Lenzer and Brownlee explain that the study went wrong when participants (some of whom were “Spanish-speaking patients who lived in low-income neighborhoods near the hospital”) “were not told that they could be given high doses of the fluids or that they faced a risk of serious bleeding.” Then, despite protests from hospital doctors that patients hadn’t been informed of what were serious possible health risks, the local Institutional Review Board allowed the study to continue. This was followed by years of internal fighting, and finally capped by the HHS’ Office of Human Research Protections entrance into the fray.
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