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.
11 Calif. hospitals fined for preventable mistakes
Cheryl Clark writes for HealthLeaders Media that 11 California Hospitals were fined $25,000 each by the state for mistakes that put patients in immediate jeopardy or, in a few cases, even injured or killed them. Among the most egregious mistakes were a “man undergoing a leg amputation for cancer he never had,” a patient being set on fire during an eyelid-related procedure and a laundry list of equipment forgotten inside of patients.
This naming and shaming of errant hospitals has become a regular ritual in California, Clark reports:
Kathleen Billingsley, deputy director for the California Department of Public Health, said the 11 new fines bring the total of 115 monetary penalties against 80 hospitals to $2.87 million under a law that took effect Jan. 1, 2007. She has made public announcements about other batches of fines seven times previously, most recently Sept. 3.
According to the Web site’s “About Us” page, “HealthLeaders Media is a leading multi-platform media company dedicated to meeting the business information needs of healthcare executives and professionals.”
Hearst project looks at toll of medical mistakes
Filed under: Health journalism, Hot Health Headline
A team of reporters from Hearst news organizations across the country contributed to “Dead by Mistake,” a broad investigation into deaths caused by “preventable medical injuries,” of which the reporters estimate there are almost “200,000 per year in the United States.” A decade after a federal report challenged the medical community to halve the accidental death rate, the toll taken by medical mistakes has instead increased even further, the Hearst reporters found. Furthermore, reporters found that “the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago.”
According to the report, the American Medical Association and American Hospital Association are partly to blame, as they have opposed any mandatory reporting of medical accident. Even in the 20 states that have implemented mandatory reporting rules, research indicates that only a small fraction of accidents are actually reported. Despite this “chaotic, dysfunctional patchwork,” the Obama administration is not supporting national mandatory reporting.
Cathleen Crowley and Eric Nalder’s centerpiece, which focuses on hospital reporting of mistakes, is an informative read for anyone interested in the availability of hospital safety data on national and local levels, both now and in the future.
The package as a whole includes local stories for Hearst markets including California, Texas, Washington, Connecticut and New York as well as a number of in-depth anecdotes and stories with a national scope.
Editor Phil Bronstein explains how the project was reported, including compiling and analyzing nine databases and conducting hundreds of interviews. The cross-platform project involved journalists from print, television reporters and the Web. BayNewser has a Q&A with Bronstein about how the project was done.
Poor, rural hospitals have higher death rates
Filed under: Health data, Health journalism, Hot Health Headline
USA Today’s Steve Sternberg and Jack Gillum expanded upon a Centers for Medicare and Medicaid Services report showing higher death rates at the nation’s worst hospitals, adding their own analysis showing that death rates are also higher at hospitals in low-income and low-population counties.
AHCJ publication
Covering Hospitals: Using Tools on the Web
Tip sheets
Tools for covering hospitals: Financial documents
‘A Hidden Shame:’ Tips for reporting on deaths in mental hospitals
Ripping the cover off hospital finances
Computer-assisted reporting basics: Investigating health data using spreadsheets
Sorting out hospital rankings
Finding patterns and trends in health data: Pivot tables in spreadsheets
AHCJ articles
Sunshine Week: Some hospital quality measures online but more could be done
Making sense of hospital quality reports
Deciphering cost reports helps paint picture of hospital’s financial health
N.J. law would publicize detailed hospital error info
In an Associated Press story, Eli Segall looked at proposed legislation in New Jersey that would require hospitals to publish error information and would prevent hospitals from billing patients or insurers for procedures during which mistakes were made.
While current New Jersey law calls for the publication of statewide statistics for preventable mistakes, the proposed legislation would take it a step farther and require data to be shared for individual hospitals. Reports for 2005 and 2006 have been published under the current law; 826 mistakes - 40 percent of which were patient falls - were reported statewide.
According to one of Segall’s sources, patients were only billed for mistaken procedures in isolated cases under existing laws and that in many cases hospitals don’t bill anybody when egregious mistakes have been made and insurers may refuse payment when mistakes have been made.
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Health Journalism 2010, AHCJ's annual conference, features a world-class program with story ideas, sources, stronger reporting skills, chances to meet newsmakers and network with other journalists.
- Health and education: Covering these intersecting beats
- Reporting on the business of health care
- Health reporting resources for journalists on state and local government beats
- Shortened Lives: How location, lifestyle affect health
- Covering a complex story for the long haul
- Aging in the 21st Century: Presentations and tip sheets
- AHCJ calls for better information from Joint Commission Web site
