An article titled "To Err Is Human" published in 1999 detailed errors by doctors during surgery and triggered many reforms in the health care field. However, despite reforms of oversights, approximately 4,000 "never events" continue to occur in U.S. hospitals throughout the nation each year, including Colorado."Never events" are major surgical errors. They include leaving surgical items in patients such as sponges, operating on the incorrect site or performing surgery on the incorrect patient. While these events are rare, they can cause permanent damage to patients, and the cost of settlements is a huge financial burden. Some experts suggest that if protocols and checklists are followed in the operating room, the rate of "never events" could be reduced to nearly zero.
There are procedures in place in hospitals to ensure that patients get the correct medication. However, patients in Colorado can also take control of their own health care by being aware of the medications they are taking and being honest about their use of over-the-counter drugs, herbal supplements, vitamins and recreational drugs. These efforts and disclosures may help in preventing medication errors.Another way patients can be proactive in helping themselves and their doctors is to keep a list of all medications being taken on a small card and carry it at all times. Having this information on hand is invaluable to caregivers and emergency room staff as it is an easy way for them to know what medications the patient is taking. This simple step can help avoid contraindicated or duplicate drugs from being administered.
The American Registry of Radiologic Technologists and Exeter Hospital in New Hampshire face lawsuits because a radiologist stole syringes filled with fentanyl and injected himself with the painkiller. It is also alleged that he refilled the used syringes with saline and that they were used to inject patients. The radiologist suffered from hepatitis and now at least 32 patients have been diagnosed with his strain of the virus. Medication errors like this one may be of interest to Colorado residents because AART is a national organization and this radiologist could've been hired by a Colorado hospital. At least two patients are including ARRT in their lawsuits, because they claim the organization failed to investigate a complaint against the radiologist in Arizona. They continued to credential him, which allowed him to be hired by Exeter. The Arizona hospital fired him after he was discovered unconscious in the hospital locker room with needles and syringes in his possession.
A case regarding medical malpractice and a wrongful death claim may make it all the way to the State Supreme Court of Colorado. A widower is fighting Catholic Health Initiatives over a lower court ruling that stated since his twin sons died in their mother's uterus, they did not meet the state's definition of living. This excludes the babies from the wrongful death suit their father filed. In 2006, the man took his 31-year-old wife to the St. Thomas More Hospital emergency room. She was 28 weeks pregnant with twin boys and experiencing vomiting and shortness of breath. She had a heart attack and died a short time later. Her twins were delivered, but they had died in the womb. Her husband filed a wrongful death suit for all three of them. The court sided with the hospital attorneys' claim that according to state law the babies were not considered living people due to the fact they died in the uterus. The case of the wife's death was dismissed for unrelated legal issues.
There are approximately 50 million surgeries performed in the United States each year. Denver readers might find a recent study of medical malpractice claims rather interesting in that researchers discovered that there were about 10,000 cases of what are commonly referred to as "never events" over a ten year period. Never events include instruments or sponges being left in the patient, wrong site surgery and even surgery done on the wrong patient.
Denver readers may be interested in a study that found more than 3,000 incidents of errors in Electronic Health Records (EHR). The study shows an increase of double the number of health safety issues in a one year period. Sixteen cases in question were noted as causing "some kind" of harm. However, only one medication error was considered to have caused significant harm.
Surgical "never events" encompass incorrectly operating on the wrong patient, conducting the wrong procedure on the correct patient, performing wrong-site surgery, improper organ transplant or leaving surgical equipment inside the patient such as operating tools or sponges, and they cost healthcare facilities billions of dollars in the form of surgery malpractice claims. These surgical errors or mistakes, performed by careless surgeons or negligent operating staff and their improper use of surgical equipment, may result in serious injury or even death. Research results from 1990 to 2010 estimated that malpractice costs paid out to patients reached $1.3 billion; the research results were provided by the National Practitioner Data Bank (NPDB), a federal reserve of medical malpractice claims. An estimated 96 percent of claims were settled and never went to court, but findings show higher compensation was paid to patients who proceeded to trial, sometimes tripling the amount of payment with court settlements. Over 4,000 yearly claims were estimated in the research time frame for surgical "never event" mishaps.
An Illinois neurosurgeon faces four lawsuits stemming from accusations of medical malpractice. The case closest to going to trial involves a woman from Poplar Grove, Illinois, who had surgery on the left side of her back. Her lawsuit claims that after the surgery, problems in her right foot became worse. While practicing medicine in Colorado, the doctor admitted to four serious surgical errors and agreed to allow her Colorado medical license to be placed on inactive status. At the time she accepted this plan, the state did not consider such an agreement to be a disciplinary action. This policy has since been changed.
In 2012, the Institute for Health Care Improvement and two other groups conducted a study as part of the Retooling for Quality and Safety initiative. The study concluded that integration of interprofessional teamwork should be included in the curricula of both medical and nursing schools in an effort to prevent medical errors. The University of Missouri and five other universities participated in the study. One of the most important aspects of this study was that many of the universities gave students the chance to work with actual patients in a hospital setting. This gave the students an opportunity to apply some of the safety concepts that would help prevent medical errors. The University of Missouri, for example, allowed students to assess the risk of falling, which is the most common hospital injury. The patient charts were reviewed by students from different professional tracks and each patient was given a unique fall prevention plan.
An abstract of a study, recently presented at the American Society of Health Systems-Pharmacists meeting, indicates that having a pharmacy team in the emergency department of a hospital can significantly cut down on the number of medical errors caused by incorrect medications or dosages. Among the 185 patients studied prior to the arrival of a pharmacy team in the emergency department, there were 1,750 discrepancies. The most common disparity, occurring in 55 percent of cases, was failures in collecting information on the date and time of the last dosage. A smaller percentage included incorrect orders and omissions. After a pharmacy team was placed in the emergency room, a total of 25 errors occurred. This is a significant drop when compared to the control group, which had 425 errors.