Here’s our advice on how to prevent infections, drug mix-ups, unnecessary tests, and other common hospital errors
Consumer Reports: About twenty percent of heart attack and pneumonia patients, and a quarter of heart failure patients, find themselves back in the hospital within 30 days, according to our updated hospital Ratings. And our new analysis shows that those rates aren’t getting better. Tips for making your hospital discharge as smooth as possible.
Comments from Consumers Union’s Safe Patient Project and Nile’s Project to the California Department of Public Health on the proposed regulations on hospital administrative penalties, specifically focusing on fines assessed due to a hospital’s noncompliance with laws that has caused or is likely to cause serious injury or death to a patient. CA’s proposed regulations leave several gaps in effectively implementing these fines and we urge that they be revised to provide clarity and to more appropriately fine the worst violators.
Reports from the states with laws requiring public reporting of medical errors.
Here’s a look at some of the important work the Health Ratings Center has done since its creation in 2008.
New video highlights some of Consumer Reports Health Ratings Center’s important accomplishments: assessing hospitals for safety, surgeons for their heart bypass records, and drugs for their effectiveness.
Consumer Reports: We’ve long advised that EKGs are usually not a good idea for healthy adults without symptoms of heart disease. And that view was confirmed today by a new report from the U.S. Preventive Services Task Force.
Consumer Reports explains why some hospitals get top marks with U.S. News but perform poorly in CR’s latest Ratings.
The rates of babies being born too early and dying soon after birth has gone down in the U.S., according to a new government report. But the rates of those events are still higher here than in many other industrialized countries.
6 tips for staying safe in the hospital from Consumer Reports.
Our updated hospital Ratings can help you choose a hospital in your area. And even if you don’t have a choice in hospitals, our Ratings can help you identify and be prepared for potential problems at the hospital you do go to.
We have for the first time rated 1,159 U.S. hospitals for safety, providing a unique way to compare hospitals in your community. Still, our safety Ratings include just 18 percent of all the hospitals in the U.S. Why are so many excluded? Mostly because data on patient harm are still not reported fully or consistently nationwide.
Our new report How Safe is Your Hospital? shares the stories of two patients who were harmed during hospital stays. Before you tell your story, follow these steps to protect yourself:
We rated 1,159 hospitals nationwide for safety and found successful ones throughout the country. The 10 hospitals at the top of our Ratings are in 10 states.
Bad things happen in all hospitals, but they happen a lot in some. That’s one of the conclusions of our first ever Ratings of hospital safety.
Our new Ratings find that some are riskier than others / Consumer Reports magazine: August 2012
The rates of both cesarean sections and childhood obesity have risen steadily in the U.S. over the last couple of decades. Now, a surprising new study suggests the two trends may be linked.
It’s official: The PSA blood test to screen for prostate cancer has been downgraded to the lowest possible rating of “D” (as in “discourage”) from the U.S. Preventive Services Task Force, an influential independent advisory board that basically decides what types of preventive care are worth the bother.
10 procedures to think twice about during your pregnancy
As doctors and hospitals add more expensive high-tech gadgetry to their arsenals, all too often it’s profit—not science—driving decisions on how heart disease is detected and treated in the U.S. Consumer Reports shines a light on excessive testing and overtreatment.
Here’s Consumer Reports Health’s advice for a safe hospital stay, from check-in to discharge. We assume you’ll be staying overnight, but much of our advice applies to outpatient visits, too.
A recent report in the journal Health Affairs suggests that there are lots of cracks even in good hospitals that can lead to gaping and potentially deadly holes in patient care. And unlike the airline industry, the study suggests that safeguards to detect and correct the cracks are inadequate.
Testimony of Consumers Union regarding a bill requiring public reporting of medical harm March 3, 2011.
Consumers Union supports a bill that will require acute care hospitals in Hawaii to report incidences of medical harm to the department of health, which will use the data to create a public report.
Model Medical Harm Disclosure Act
Routine prescribing of powerful medications occurs too often, our investigation finds
Consumer Reports on Health provides a guide to a healthier hospital stay, walking you through a visit from check-in to discharge, describing how to prepare and providing tips on questions to ask along the way.
CU sent a letter to Kathleen Billingsley at the Department of Health Care Services following our meeting on December 16 regarding state implementation of the hospital-acquired infection and adverse event reporting laws. Consumers Union (December 28, 2009)
CU filed a Public Records request for documents related to adverse events and hospital acquired infections made available to the public through legislation passed since 2006. Consumers Union (February 16, 2010)
Consumers Union comments on National Quality Forum’s proposal to change definition of “serious reportable events” from those that should “never” occur to those that should “not” occur. February 2, 2010 Download file
On November 17, 2009, Consumers Union hosted a forum in Washington DC based on the 10-year anniversary of the Institute of Medicine (IOM) 1999 study on medical harm challenging our health system’s progress on preventing medical harm 10 years later. We released a report earlier in the year on this
Ten years ago the Institute of Medicine (IOM) declared that as many as 98,000 people die each year needlessly because of preventable medical harm, including health care-acquired infections. Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.
Ten years later, a million lives lost, billions of dollars wasted
On PDUFA, Risk Evaluation & Mitigation Strategies, Clinical Trials, and Advisory Committee Conflicts.
The January issue of Consumer Reports on Health newsletter tells patients and their relatives how to get the best care and prevent hospital infections and medication errors.
Only Illinois and Pennsylvania have passed specific laws to make hospital-acquired infection rates public, but many states collect and report other hospital quality of care measures, like mortality from specific surgeries.
Consumer Reports on Health gives tips on avoiding hospital blunders.
Consumer Reports on Health gives tips on finding the right hospital for your special needs.
Consumers Union Calls For Public Reporting of Medical Errors
The California Department of Public Health has been slow to implement a number of key provisions of medical error public reporting.
Report Finds That Only Half of California Hospital Workers Got Flu Vaccine
New Law Includes Important Patient Safety Provisions That Will Save Lives and Health Care Dollars
California Department of Public Health Has Failed to Carry Out Key Requirements of Recent Patient Safety Laws
Consumers Union Assesses Lack of Progress Ten Years After Institute of Medicine Found Up To 98,000 Die From Preventable Errors
In 2004, Consumers Union worked with others around the country to ensure that legislation being considered by Congress would not prevent state laws that required public disclosure of hospital-specific infection rates. The bill has now been reintroduced and keeps the language that will permit states to require publication of hospital-specific infection rates.
Hear advice from consumer advocates on patient safety.
On Saturday, October 9, the Empowered Patient Coalition along with Consumers Union’s Safe Patient Project and AARP California will be holding a special training in San Diego for patients and caregivers on how to stay safe in the hospital.
Since 2006, California lawmakers have passed laws to improve patient safety, yet the California Department of Public Health (CDPH) has been moving at turtle speed to enforce these laws.
Guest blog post by Deb Wachenheim, Health Quality Manager at Health Care For All (HCFA) in Boston. HCFA has launched a new website that can help patients in Massachusetts and across the country speak up when something goes wrong in the hospital. There is information on asking for help when you are in the hospital, advice on how to file a complaint, and resources available to help you.
Our leaders in Congress experience medical harm, too. On Monday, Politico reported that Pennsylvania U.S. Congressman John Murtha had died as a result of complications from recent gallbladder removal surgery at Bethesda Naval Hospital.
On November 17, Consumers Union’s Safe Patient Project is hosting a forum in Washington DC based on the 10-year anniversary of the Institute of Medicine (IOM) study on medical errors, “To Err Is Human.”
If your hospital had a blog, would you read it? More importantly, would you expect to see information that every patient deserves – such as hospital infection rates or harmful medical errors happening there?
You’ve heard of UFOs but have you heard of RFOs? 194 Pennsylvanians could tell you about their RFO encounter last year – that’s how many cases of “retained foreign objects” were reported to that state’s Patient Safety Authority in 2008.
Some Find That Confronting Mistakes Reduces Litigation—and Future Mishaps.
A new documentary, Money-Driven Medicine, offers a thoughtful perspective to the health care reform debate that couldn’t be timelier.
Read and sign the Patient Safety Advocates’ Statement on Health Care Reform.
Check out this new collection of medical errors reporting: “Dead by Mistake”
Join patient safety advocates across the country tomorrow to observe Patient Safety Day.
The Centers for Medicare & Medicaid Services (CMS) announced last Thursday that it has added readmission rates for more than 4,000 hospitals across the U.S to its Hospital Compare website. With proper care, most people should not have to go back to the hospital shortly after release. This is a key indicator of quality and varies a lot between hospitals.
Four patient safety activists – all who have been personally affected by medical harm – were among the 164 participants in ABC’s televised health care forum held with President Obama. Understandably, they came armed with questions but didn’t get to ask them. So we wanted to give them a chance to get their questions in front of the public and lawmakers here on this blog.
Guest blogger, Holly Harris from San Diego, shares what she learned at the California Safe Patient Network meeting and calls on us to join and spread the word about preventable medical harm.
Our new report “To Err is Human – To Delay is Deadly” calls attention to the IOM’s unfulfilled call to action.
More people know about hospital acquired infections and medical errors than you might think, and not just from watching Oprah.
I’d like to point you to four brave patients, who debuted their videos to lawmakers at the Massachusetts State House and encouraged them to take an active role to improve patient safety.
Did you catch the Oprah Winfrey Show on Tuesday about medical mistakes? She featured actor Dennis Quaid who recalled the series of hospital errors that nearly killed his newborn twins after they were given one thousand times the amount of the blood-thinning drug Heparin—twice.
It’s official. The Centers for Medicare & Medicaid Services (CMS) will no longer pay for surgery in which certain “never events” occur: wrong surgery, wrong patient, wrong body part.
While he may not be singing about hospital infections specifically, Conor Oberst and the Mystic Valley Band humorously assemble the jolting anxiety we’d feel as a hospital patient trying to get out…
Helen Haskell, founder of Mothers Against Medical Error (MAME), became a patient safety advocate after her 15 year old son died from a medical error in 2000. Watch her story.
The New York Times came out Sunday with a strong call for making the new Medicare rule to stop paying for care needed after hospitals harm their patients apply to physicians too, stating the current policy lets “doctors off scot-free.”
Dianne Parker became a lead patient safety activist after her husband, Willie, died from a combination of medical errors and a hospital-acquired MRSA infection. Watch her story…
“Sex and the City” actor, Evan Handler, had it hard enough fighting leukemia in his early adulthood, and now he’s speaking out about his experience with medical errors and life after cancer.
Effective today, Medicare will stop compensating hospitals for the additional costs to treat patients who suffered from certain preventable infections and errors due to bad medical care.
According to new FDA data, consumers like you make up the majority of drug adverse event reports submitted, replacing physicians.
You may remember Dennis Quaid from The Parent Trap but nowadays he’s speaking out against medical errors…
I needed an antidote. Too many drug ads—smiling people glowing with the pleasure of their successful medical treatments. But of course, they are actors.
Is your doctor listening to you or the drug companies when it comes to pinpointing the cause of your symptoms?
Last night, in a vote of 39-0, the full House Energy and Commerce committee approved legislation that would provide funding for the FDA, with drug safety reforms included. Many reforms are stronger than Senate’s version passed last month. Floor vote expected after July 4th recess.
You can’t pick up a paper or turn on the news this week without hearing about Avandia, the latest blockbuster drug in the spotlight for potentially deadly side effects. This treatment, prescribed to about 6 million diabetics since 1999, is likely to increase cardiovascular disease and heart attacks in its users.
A CDPH investigation found that inadequate care resulted in the death of a nursing home resident.
Study found little relationship between a hospital’s patient satisfaction scores and most quality ratings.
Hospitals make money from their own mistakes because insurers pay them for the longer stays and extra care that patients need to treat surgical complications that could have been prevented, a new study finds.
The study was done to determine the appropriate amount of oxygen levels for premature.
The hospital reports errors to staff through a monthly newsletter in an effort to reduce errors
ProPublica Q&A with a professor who specializes in the aftermath of medical harm to patients.
“On Saturday afternoon, he was given an infusion of a medicine intended for another patient — an infusion that was stopped only after I insisted that the nurse double-check the order.”
Consumers Union Safe Patient Project Director, Lisa McGiffert, participated in a live chat on how to increase accountability in medicine. You can read the chat transcript here.
Founder of Citizens for Patient Safety, Patty Skolnik, member of CU’s Safe Patient Project, quoted in Physician’s Money Digest article about patient-centered care.
Teen dies after wisdom teeth removal procedures, her parents sued for malpractice and the sides settled under confidential terms.
The decision comes after years of patient safety violations and financial struggles that were followed by an unexpected recovery for the hospital.
The 10 most common errors that can occur during your hospital stay. Quotes Safe Patient advocate, Patty Skolnik, founder of Citizens for Patient Safety.
Jordan Rau (Kaiser Health News) reports on hospital ratings, mentions Consumer Reports
Conversation between victims of medical harm and a professor who specializes in dealing with the aftermath of patient harm for both patients and providers.
New law attempts to settle medical error issues through mediation.
Bloomberg reporter: Intestines fall out of woman’s vagina after robot surgery. A review of adverse incident reports sent to the Food and Drug Administration since 2009 shows an increase. As the popularity of robot surgery has grown, injury reports involving the procedures jumped to at least 115 in 2012 from 24 in 2009, while deaths rose to 30 from 11.
The safety of robots made by Intuitive Surgical Inc. (ISRG) is being probed by U.S. regulators, raising questions about the prospects of one of the hottest technologies in health care.
CA woman dies in retirement home after nurse fails to perform CPR.
Missed or wrong diagnoses are common in primary care and may put some patients at risk of serious complications, according to a U.S. study.
University of Florida medical professor, Frederick Southwick, lost his leg due to a preventable medical error that had occurred 17 years earlier.
Patient safety advocate Lenore Alexander interviewed on the Katie Couric show about the medical error tragedy that ended her daughter Leah’s young life.
California Healthline reports: “As part of a settlement with the state attorney general’s office, Skilled Healthcare Group will pay $350,000 annually for two years to cover the cost of an independent monitor that will conduct surprise inspections of the nursing home chain and report back to the attorney general’s office on its compliance with state staffing laws.”
MedPage Today reports: “Robotically assisted hysterectomy increased dramatically from 2007 to 2010, despite higher cost and similar complication rates compared with laparoscopic procedures, a review of data from more than 400 hospitals showed.”
Martha Deed, patient safety advocate in NY, guest blogs for KevinMD.com: “Survivors [of medical error] need more assistance than they currently receive. Isolating patients and their families from circumstances surrounding medical errors does not promote healing of patients or their families any more than it helps traumatized medical staff.”
Asking questions, asking for a plan, and making sure you know what to do if your symptoms get worse can help you stay out of the hospital. If a patient’s hospital does not provide similar tools, the Care About Your Care discharge preparation checklist and care transition plan can help patients and caregivers keep track of their care plan after leaving the hospital.
On Wednesday, the California Department of Public Health fined seven California hospitals a total of $775,000 for 10 violations that endangered patients’ health or led to their deaths, Payers & Providers reports.
Family films a video of ants and gnats crawling through their father’s breathing tube while he was in the hospital ICU. They wonder if he may have lived longer if he had proper care.
Patty and David Skolnik tragically lost their only son, Michael, from complications after a brain surgery. Since Michael’s death, Patty founded Citizens for Patient Safety, an organization committed to take action to protect our health and safety from medical errors.
Letter to the editor on reporting medical errors by Paul H. O’Neill, secretary of the Treasury under President George W. Bush and is a former CEO of Alcoa Inc.
Dec 2012 study published in Surgery: About 80 times each week, U.S. patients undergoing surgery experience mistakes that safety advocates say never should happen
Two Op-Eds regarding the controversy over payments hospitals are receiving from facility fees have been published for public viewing today in US News & World Report. The Op-Ed in support of cutting hospital facility fees was written by Health Watch USA.
http://www.usnews.com/opinion/articles/2013/01/28/hospital-facility-fees-raise-out-of-pocket-costs-for-medicare-patients
The Opposing Op-Ed was by Richard Umbdenstock, the President and CEO of the American Hospital Association.
http://www.usnews.com/opinion/articles/2013/01/28/congress-cant-cut-medicare-hospital-outpatient-payments
NYT reprint of Texas Tribune story on a woman who says she was the victim of a medical mistake and Texas tort reform laws.
Trisha Torrey gives advice on how and where to share your medical harm story.
The Virginia Department of Health will no longer provide public access to its hospital complaint investigations after an Associated Press story found inconsistencies in the probe of a woman’s care at Inova Fairfax Hospital.
“This short film by Transparent Health and SolidLine Media shares information with the healthcare consumer on what happens when a medical error occurs.”
Patients and their families are rarely told when hospitals make mistakes with their medicines, according to a new Johns Hopkins study. The study also found that mistakes that harmed patients were more likely to happen in the ICU.
ProPublica’s Marshall Allen interviews new doctor about patient safety lessons she learned from her mother’s death.
New Michigan law is a tremendous win for Michigan’s physicians” NOT Michigan patients who may have been harmed by physician care.
ProPublica filed a Freedom of Information request with CMS and received the unredacted narratives from the nursing home deficiency reports. They have posted them on their website.
KHN: In Medicare’s new program that ties about $1 billion in payments to quality of care, hospitals in Fort Wayne, Ind., are faring the best on average while hospitals in Washington, D.C., are doing the worst, according to a Kaiser Health News analysis of the country’s 212 major health care markets.
New addresses avoiding adverse events by barcoding drug doses that are prepared for individual unit packaging by the central pharmacy of sister hospitals. Hospitals must be certified by the board of pharmacy:
“81% of patients experience provider error, don’t understand meds”
The medical error reporting system only reports the most serious medical errors.
A federal appeals court ruled that a drug company’s marketing of a drug “off label” which means it is marketing the drug for a use not approved by the FDA, is a matter of free speech.
Researchers at Johns Hopkins say that despite efforts to improve surgical safety, 4,044 so-called “never events,” including leaving a foreign object such as a sponge inside a patient’s body, occur in the U.S. each year. Laura Landro reports on The News Hub.
Hospital wanted damaging notes destroyed, ex-worker says.
ProPublica’s Marshall Allen writes: “Many of the people who suffer harm while undergoing medical care do not file formal complaints with regulators. The reasons are numerous: They’re often traumatized, disabled, unaware they’ve been a victim of a medical error or don’t understand the bureaucracy.”
ProPublica features patient safety advocate Veronica James, whose mother suffered a bedsore and had her breathing tube accidentally dislodged in a long-term acute-care hospital. James believes poor care contributed to her 90-year-old mother’s death.
A former nurse writes about the inside knowledge she had about a doctors and other nurses concerning their performance history, including medical errors. But patients don’t have access to that same information.
Bill Heisel comments on the USA Today report on needle injection safety.
Jay Hancock for Kaiser Health News: “The Obama administration Friday urged cooperation between software companies and caregivers to prevent patient harm caused by faulty electronic records. But it stopped short of calling for regulation or a federal requirement to report computer mistakes that pose a risk to patients.”
Johns Hopkins study: U.S surgeons leave a foreign object in a patient at least 39 times a week.
As drug-resistant superbugs and increasingly virulent viruses menace the medical world, patients face a threat that was supposed to die with the advent of the disposable syringe more than 50 years ago: dirty needles.
The Obama administration is leaving it up to caregivers and software companies to prevent patient harm due to mistakes in electronic health records.
“The revised payments, which will begin in January, mark the federal government’s most extensive effort yet to hold hospitals financially accountable for what happens to patients.”
Kai Falkenberg for Forbes: “Many doctors, in order to get high ratings (and a higher salary), overprescribe and overtest, just to “satisfy” patients, who probably aren’t qualified to judge their care. And there’s a financial cost, as flawed survey methods and the decisions they induce, produce billions more in waste.”
CA health officials fined 10 hospitals found to cause errors that led to 4 patients dying and others seriously injured.
The Joint Commission leader: Hospital care is almost 3,000 times less safe than air travel.
Researchers advocate public reporting of mistakes
Two residents died after lapses in nursing homes. The punishments were very different. Read this ProPublica story to find out why.
Reader’s Digest runs Marshall Allen’s (ProPublica) story on Linda Carswell, wife of Jerry Carswell: After an inconclusive autopsy report, Jerry Carswell’s heart remains in a refrigerated cabinet in a hospital lab instead of being buried with him. In a mission to get it back, his wife learned the truth about the shocking flaws in the death investigation process.
The Doctors’ Investigative Reporter, Melanie Woodrow, examines the alarming cases of two Tennessee women who were left severely burned after undergoing a common laser treatment at two different med spas.
CBS’s “60 minutes” covers the high costs of health care in the U.S. It’s estimated that $210 billion a year — about 10 percent of all health expenditures — goes towards unnecessary tests and treatments and a big chunk of that comes right out of the pockets of American taxpayers in the form of Medicare and Medicaid payments.
“The report collects information from 291 hospitals, ambulatory surgery centers, abortion clinics, and birthing centers from around the state. It includes 28 reportable adverse events, including falls, medication errors and some criminal actions.”
The Indiana State Health Department’s 2011 Medical Errors report is now available at http://www.state.in.us/isdh/23433.htm.
Leapfrog’s national report on patient safety gives Ronald Reagan UCLA Medical Center an “F.” Leapfrog is national organization that scores hospital safety.
“Medicare last month began levying financial penalties against 2,217 hospitals it says have had too many readmissions. Of those hospitals, 307 will receive the maximum punishment, a 1 percent reduction in Medicare’s regular payments for every patient over the next year, federal records show.”
Company that runs 2,000 US dialysis clinics accused of giant Medicare fraud
KY court cases calls into question medical error reporting in Kentucky.
“Sharon Van Putten’s final months were spent in misery at a highly rated northern Virginia hospital. During a family visit to northern Virginia, Van Putten’s chronic back problems flared up and she ended up having spinal surgery at Inova Fairfax Hospital. She came out of surgery a paraplegic.”
Washington state elderly woman dies due to an overdose of morphine by an unlicensed, unregistered nurse in a nursing home. Yanling Yu of Washington Advocates for Patient Safety quoted.
Op-ed by Dr. Kevin Kavanagh and Daniel Saman with Health Watch USA. They write: “There are many ranking systems, and all give widely different results and are dependent upon widely varying measures of quality. Some are highly dependent upon reputation of the institution and types of treatment available, others on the ability to follow treatment plans, patient satisfaction or patient outcomes. For patients, it is the outcome that’s most important.”
30 minute program about unnecessary surgery, including hip and knee replacements.
CNN gallery of stories of ten patient cases involving medical mistakes.
Bloomberg’s Kevin Thrash reports on some urologists in Monterey County, California, who are being investigated by U.S. Department of Health and Human Services for possibly putting profits ahead of patients.
Reporting adverse events positively influences the perception of safety and may reduce medical errors in large, multi-site health systems, according to a new study from researchers at the Perelman School of Medicine at the University of Pennsylvania.
According to an article published in the current issue of Wolters Kluwer’s Journal of Health Care Finance http://www.mediregs.com/economics_of_quality_care preventable medical errors may cost the U.S. economy up to $1 trillion dollars in lost human potential and contributions. That estimate is exponentially higher than previous studies, which focused solely on direct medical expenses associated with preventable medical errors.
Empowered Patient Coalition’s Dr. Julia Hallisy special to ProPublica. For more information, see their free Hospital Guide for Patients and Families: http://www.empoweredpatientcoalition.org/downloads/free/ebook_hospital_care_guide.pdf
Mary Alice McLarty special for CNN: Eliminating patients’ rights is not the answer to the nation’s health care problems.
The government says it will use information submitted by patients to make health care safer.
Investigative journalist Jeanne Lenzer with British Medical Journal investigates overtreatment at the heart of healthcare. Overly aggressive treatment is estimated to cause 30 000 deaths among Medicare recipients alone each year. Overall, unnecessary interventions are estimated to account for 10-30% of spending on healthcare in the US.
Every year, an estimated 4,000 cases of “retained surgical items,” as they are known in the medical world, are reported in the United States. These are items left in the patient’s body after surgery, and the vast majority are gauzelike sponges used to soak up blood. During a long operation, doctors may stuff dozens of them inside a patient to control bleeding.
An estimated 15K Medicare patients died in a single month due to harm suffered in hospital.
As of Monday, Medicare will start fining hospitals that have too many patients readmitted within 30 days of discharge due to complications. The penalties are part of a broader push under President Barack Obama’s health care law to improve quality while also trying to save taxpayers money. Dr. John Santa, director of the Consumer Reports Health Ratings Center, quoted.
Nearly 40% of consumers surveyed last year said they use hospital ratings to choose a health care facility, but there’s little agreement between the lists, raising questions about their value.
Marty Makary for WSJ: Medical errors kill enough people to fill four jumbo jets a week. A surgeon with five simple ways to make health care safer.
Nearly three-quarters of patients say they are concerned about the potential for medical errors, according to a poll that sheds light on public perceptions of patient safety.
Latest IOM report lays out how to deliver safer, more effective care by using existing strategies, technology. Arthur Levin, director of the New York-based Center for Medical Consumers, served on the committee that produced To Err is Human and Crossing the Quality Chasm, as well as on the committee that authored this latest report.
UC-Davis confirmed that CMS has asked California officials to investigate the cases of three brain cancer patients at the university who died after receiving experimental treatment.
The Institute of Medicine releases new 382-page report calling for a major overhaul to remove inefficiencies and other barriers to quality care. The report issues 10 recommendations to improve quality of care, and use healthcare resources better.
Hospital executives should not ignore low quality ratings if their hospital gets a low score. Hospitals should not hesitate to “welcome this level of scrutiny and public accountability,” according to a former hospital chief operating officer.
California health officials has collected $9.25 million in fines from hospitals for medical errors – violations or deficiencies constituting an immediate jeopardy to the health and safety of a hospital patient. But the state hasn’t used most of the money to improve patient safety. Consumers Union’s Safe Patient Project director Lisa McGiffert quoted.
Doctors performed unneeded heart procedures on hundreds of people in recent years at Saint Joseph-London hospital to unjustly enrich themselves, the patients have charged in a series of lawsuits.
Maine hospital penalized by Medicare for having high readmission rates.
About two-thirds do outside research to double-check physician recommendations, but few patients inquire about clean hands.
Article about Kent Thiry, the CEO of huge dialysis company Davita.
US News and World Report piece on medical harm and Mary Brennan-Taylor’s advocacy efforts to improve patient safety.
Richard Rosenthal writes: “It is past time that the government and public adopt the same sense of urgency with healthcare deaths.” Richard can be reached at rrosenth@optonline.net.
More than one in four ICU patients had at least one missed diagnosis at death, according to a Johns Hopkins study of acute care patients.
NYT’s Tara Parker-Pope: “When it comes to medical care, many patients and doctors believe more is better. But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.”
Pacific Health Corporation has agreed to pay $16.5 million to resolve allegations that its hospitals recruited homeless patients and provided them with unnecessary health care services in an effort to defraud Medicare and Medi-Cal, according to court documents filed last week, the Los Angeles Times reports (Zavis, Los Angeles Times, 8/24).
ProPublica has designed Nursing Home Inspect to make it fast and easy to search thousands of recent government inspection reports from around the country, most since the beginning of 2011. Following are some tips to help you get the best results.
Drawing on government reports posted online last month, ProPublica launched Nursing Home Inspect — a tool that allows anyone to easily search and analyze the details of recent nursing home inspections, most completed since January 2011.
Consumer Reports’ John Santa MD MPH, explains Consumer Reports first hospital safety ratings and the importance of providing reliable information to consumers to improve health and reduce harm.
Sarah Kliff at Washington Post writes: “Questionable cardiac procedures are at the center of a Justice Department investigation into HCA Holdings, the nation’s largest for-profit hospital chain. In an unusual move, HCA revealed the probe Monday ahead of publication of a New York Times story revealing that cardiologists in some of its hospitals, mainly in Florida, were unable to justify many procedures performed between 2002 and 2010.”
Fewer than 5% of hospitals include information on the costs and complications of robot-assisted gynecologic procedures. Many sites feature emotion-laden marketing language.
Hospitals reported only 8% of the adverse events that they were required to share with state authorities, said a July study from the Dept. of Health and Human Services’ Office of Inspector General.
ProPublica’s Marshall Allen writes: “New accusations that one of the nation’s largest hospital chains performed more than a thousand unnecessary heart procedures grabbed headlines this week, but the practice is far from unique in U.S. health care.”
Hospital Chain Inquiry Cited Unnecessary Cardiac Work. The New York Times reviewed company internal documents that revealed some doctors were unable to justify many of the cardiac procedures they were performing. In some cases, the doctors made misleading statements in medical records that made it appear the procedures were necessary, according to internal reports.
Hospitals have confidentially reported more than 40,000 “adverse events” since 2007, including wrong-site or wrong-patient surgeries, unexpected deaths, and delays or omissions of treatment
A report designed to reduce hospital errors issued by an expert panel on patient safety was ignored by NY Department of Health according to panel members.
Young woman living in NY dies in the hospital after she was given a strong sedative and may not have been properly monitored. Her mother tells the NY Times: “No one should go to a hospital without someone with you — no one,” she said. “Don’t go unless somebody at least knows you’re there.”
Dr. Sanjay Gupta: Doctors make mistakes. They may be mistakes of technique, judgment, ignorance or even, sometimes, recklessness. Regardless of the cause, each time a mistake happens, a patient may suffer. We fail to uphold our profession’s basic oath: “First, do no harm.”
For people at higher risk of heart disease, a government panel found there was “insufficient evidence” to determine the benefits and harms of screening with the EKG test — either at rest or during exercise — and advised that it be considered case by case basis.
The man accused of infecting patients with hepatitis C at a New Hampshire hospital was fired from a job in Arizona two years ago after testing positive for cocaine and marijuana, a public relations agency for Arizona Heart Hospital said Thursday.
Maine counted 163 such events in 2011, largely “unanticipated deaths,” according to a June report that found “serious under-reporting” in the state.
Manhattan woman dies after botched liposuction.
ProPublica writes about several instances of patient harm in the aftermath of the recent death of a 12-year old boy from septic shock. Why can’t hospitals get it right?
HHS OIG report: An estimated 60 percent of adverse and temporary harm events nationally occurred at hospitals in States with reporting systems, yet only an estimated 12 percent of events nationally met State requirements for reporting. Hospitals reported only 1 percent of patient harm events.
Hospitals are ignoring state regulations that require them to report cases in which medical care harmed a patient, making it almost impossible for health care providers to identify and fix preventable problems, a report to be released today by the Department of Health and Human Services inspector general shows.
NY hospital announces new procedures in direct response to a 12-year-old boy who died of sepsis 3 days after leaving the emergency room. The boy’s parents said the hospital failed to warn them about elevated bacterial levels in his blood, suggesting serious infection.
Video and news story about inadequately trained dentists sedating children, putting lives at risk to add tens of thousands in profit. More than a dozen children have died after being sedated by dentists, according to the Raven Maria Blanco Foundation, which seeks to alert parents to the potential dangers of the increasingly widespread use of oral sedatives on patients as young as 18-months old.
NYT reports on the medical harm story of Rory Staunton, a 12-year-old in New York who died of sepsis.
Story of medical error by Maureen Dowd.
In a California Healthline Special Report by Kenny Goldberg, experts discussed a recent Leapfrog Group report card that gave more than 40% of California hospitals a grade of C or lower for patient safety.
Linda Carswell has been trying to get her husband’s heart so she can bury it with his body for eight years. Houston’s St. Joseph’s Medical Center won’t budge.
“Jean Rexford, founder and executive director of the Connecticut Center for Patient Safety, cited a 2010 federal report that determined preventable mistakes contributed to the deaths of as many as 950 Medicare beneficiaries in Connecticut hospitals.”
State regulators heard very different stories this morning about the risks of outsourcing dialysis services in the greater Bangor area to a private corporation.
The proposed sale of Eastern Maine Medical Center’s dialysis clinics to a for-profit corporation roused concerns Tuesday about the safety of patients seriously ill with kidney disease.
Husband writes about the slew of problems in our health care system that surrounded the sudden and unexpected death of his wife, a well known leader in public health.
Some hospital patients in Westchester might not be receiving care that’s as safe as they may think, according to a Consumer Reports study that analyzed the safest hospitals in the nation and found that two county hospitals scored poorly.
Consumer Reports is out with its new hospital safety ratings. How did hospitals in western New York stack up?
Cheryl Clark for HealthLeaders Media reports on Consumer Reports’ new scorecard for hospital safety.
Founder and executive director of the Connecticut Center for Patient Safety, Jean Rexford, testifies at a hearing by the Senate Special Committee on Aging at the Legislative Office Building in Hartford on medical errors.
By Kevin T. Kavanagh and Daniel M. Saman. References available at: http://www.healthwatchusa.org/references/20120616–healthcare-variation.htm
Second part of a guest post by Helen Haskell on tracking medical harm. She discusses three modern studies that update the IOM numbers on medical harm.
Helen Haskell guest blogs for Reporting on Health with some thoughts on the number of people harmed by medical professionals.
Martha Deed, retired psychologist from New York, offers tips for advocating for your loved ones in the hospital. This article appeared May 2, 2012 in Patient Safety InSight published by the National Patient Safety Foundation.
The California Department of Public Health (CDPH) announced today that 13 California hospitals have been assessed administrative penalties and fines totaling $825,000 after a determination that the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.
CNN reports on medical mistakes: patients’ stories.
A small study suggests surgeons in training are still tired enough to raise their risk of making significant errors, despite new guidelines limiting their work hours.
Christian Lillis, co-founder of The Peggy Lillis Memorial Foundation, blogs about attending a gathering of the NorthEast Voices for Error Reduction (NEVER), a regional coalition of patient safety advocates.
Patient deaths after heart bypass surgeries at California hospitals plummeted 34 percent between 2003 and 2009, newly released statistics show. Public reporting has improved bypass surgery outcomes across the board over a six-year period.
Consumers can search the DHSS website at www.nj.gov/health/healthfacilities/asc_info.shtml for a specific facility or facilities within a region of the state and review and compare inspection reports for the past three years. They can also view corrective action plans—where appropriate—that surgery centers have filed with the Department to rectify any deficiencies found during inspections.
Five Oregon hospitals score worse than the national average on a key measure of patient safety for Medicare patients, according to an analysis released by the Centers for Medicare and Medicaid Services.
Great information and advice by patient safety advocates, Helen Haskell (Mothers Against Medical Error) and Jean Rexford (Connecticut Center for Patient Safety).
Podcast featuring Connecticut Center for Patient Safety director, Jean Rexford, and others, discussing many pressing patient safety issues including adverse events and what patients can do to improve hospital outcomes.
Article by Lenore Alexander, active member of Mothers Against Medical Errors, about her 11-year-old daughter Leah’s tragic death from hospital errors, including lack of monitoring. Since Leah’s death nearly 10 years ago, her mother has continued to ask many questions and learn why this happened to her daughter so that other lives can be saved.
Article on medical harm in the DC area. The District of Columbia reports on injuries occurring in the city’s hospitals, for example, but doesn’t say at which hospital the problems occurred. The public has a right to information about medical harm that is hospital-specific. Article includes tips by Consumer Reports and Dr. Peter Pronovost on how to stay safe in the hospital.
An in-depth article analyzing the Connecticut adverse event report with quotes by advocate Jean Rexford, director of the Connecticut Center for Patient Safety. The new Adverse Event Report, prepared by the CT Department of Public Health, marks the first time that acute-care hospitals and other medical facilities have been publicly identified by name, as they report errors that caused harm to patients.
Heart doctors put heart stents into patients who didn’t need them.
Cesarean sections, once considered emergency procedures, have become all but routine in the U.S. Experts say the procedure contributes to maternal deaths.
Minnesota’s 2011 Adverse Events Report press release
Area hospitals working to reduce readmission rates, which are often due to poor discharge planning.
Medical errors need to be tracked and reported to the public. Right now, Missouri consumers have no way of accessing medical harm information about their local hospital because there is no mandatory public reporting law in the state of Missouri.
The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.
Hospital workers report only 1 in 7 medical mistakes on Medicare patients, according to a new study by the Office of Inspector General. Interview features patient safety activist, Mary Brennan-Taylor of New York, whose mother died from preventable hospital infection.
A new report released Friday by the inspector general of the U.S. Department of Health and Human Services found that more than 80 percent of hospital errors go unreported by hospital employees. The errors included overused or wrong medications, severe bedsores, hospital-based infections and even patient death.
A new study from the Office of the Inspector General finds that hospital employees report only 14 percent of medical errors and usually don’t change their practices to prevent future mistakes. The solutions arrived at in this report take us down the tired and worn out path of secret reporting of medical harm.
ProPublica article on death investigation in America. ProPublica and PBS “Frontline” have identified more than three-dozen cases in which the alleged neglect, abuse or even murder of seniors eluded authorities. But for the intervention of whistleblowers, concerned relatives and others, the truth about these deaths might never have come to light.
Second story in Marshall Allen’s latest investigation for ProPublica on the state of hospital autopsies in America. It is about the implications of performing so few autopsies in hospitals. Decades ago, about half the people who died in the hospital were autopsied. Today, the average is five percent, but it’s close to zero in many hospitals in the country.
First story in Marshall Allen’s latest investigation for ProPublica on the state of hospital autopsies in America. It is a tragic tale of a woman whose husband died unexpectedly after being admitted to a hospital with kidney stones.
The number of medical error reports in Indiana hit an all time high in 2010, according to data collected by the Indiana Department of Health. The most common types of errors reported were pressure ulcers followed by foreign objects left in surgery patients.
An analysis of federal safety reports by the Globe shows that at least 119 people died nationwide between 2005 and May 2011 because of such alarm-related problems. And a separate review by the US Food and Drug Administration uncovered about 800 alarm-related adverse events involving ventilator patients in 2010 alone. Many were deemed ?preventable?? or due to ?human error.?? An unknown number resulted in injuries or deaths.
The California Department of Public Health announced it was imposing $850,000 in fines on 14 hospitals for medical errors that caused or were likely to cause serious patient injury or death.
Another 14 California hospitals have been ordered to pay fines totaling $850,000 in the latest round of medical errors involving immediate jeopardy to patients, state health officials said last week.
“The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. The program means hospitals won’t receive payment for stays that involve cardiac care or orthopedic treatment until auditors have examined the patient records and confirmed that the care was appropriate.”
New England patient safety activists form New England Voices For Error Reduction (NEVER), a group that aims to work regionally for safe health care.
The Texas Observer reports on the history of a Texas doctor who plead guilty to charges of retaliation and misuse of information after prosecuting two nurse whistleblowers.
Couple believes their newborn died from a hospital’s delay in test results.
4-year-old dies during dental surgery and his family is searching for answers to find out what led to his death.
The Ohio Hospital Association is trying to repeal Ohio’s hospital public reporting law that requires disclosure of important patient safety information to Ohio consumers.
Part 2: New York patient safety advocate, Mary Brennan-Taylor, interviewed about the death of her mother due to multiple medical errors and her work giving patient safety lectures at the University at Buffalo. Part 1 here.
Medicare report: Only 28 of 88 immediate jeopardy patient safety complaints reported to Medicare.
New York patient safety advocate, Mary Brennan-Taylor, interviewed about the death of her mother due to multiple medical errors and her work giving patient safety lectures at the University at Buffalo.
Hospital patients and their relatives in Missouri and most of the United States have no way of learning about most adverse events. Most adverse events aren’t publicly reported.
Harbor-UCLA Medical Center has failed to keep its operating rooms clean and safe and to protect its patients from possible infection, according to federal inspection reports recently released to The Times.
The public needs more information about how well their hospitals and doctors perform on ensuring the safety of their patients.
Another major public hospital cited for serious deficiencies by CMS prompted by the death of a 60-year-old patient.
Medicare’s Hospital Compare website allows the public to see how their hospital is doing on a range of patient safety and quality measures. The data provides a snapshot of how hospitals are performing on certain quality measures. Medicare will eventually use this patient outcomes information to base payments to hospitals.
New study of “worst” hospitals identifies low-quality, high-cost hospitals based on Medicare’s reports of how often each hospital followed recommended guidelines of care for basic things like giving heart attack patients aspirin upon admission. As required by the Affordable Care Act, Medicare will reduce payments to hospitals with substandard care at a high price.
Inexperienced physicians performing carotid artery stenting have alarmingly higher rates of 30-day mortality than more seasoned operators, according to a new report published in the Journal of American Medical Association.
A collection of more than 50 patient advocates, including doctors, lawyers and chief executive officers, are asking Congress to allow public access to hospital accreditation surveys.
Metal on metal may be the issue with these implants but research has yet to definitively prove why these artificial hips are failing. But researchers warned more than a decade ago that they release medal debris into the blood system.
A new national study indicates that too many hospitals are fumbling and could face penalties if they don’t improve within a year. Texas hospitals respond.
Physicians think they are too agressive with medical care in their own practice.
A Wichita nursing home is under investigation for patient safety problems after maggots were found in a patient’s shoes and open sores on his feet.
USA Today reports on the lack of safety oversight of doctors who perform cosmetic surgery, which can be painful and deadly.
More than 75% of nurses fear for their patients’ safety due to inadequate staffing levels, poor ward layout and the bad attitudes of colleagues, a Nursing Times survey has found.
Don Esco sought skilled nursing care at a Placerville facility for Johnnie, his wife of nearly 61 years, when she was recuperating from a bout with pneumonia. She died 13 days later. Esco sued, alleging that the medical charts lied about Johnnie’s treatment.
The practice of nursing homes altering patients’ medical records masks serious conditions and covers up care not given. A Bee review of nearly 150 cases of alleged chart falsification in California reveals how the practice puts patients at risk and sometimes leads to death.
Medicare proposed rules would restrict public access to critical data about the performance of doctors. Consumers Union’s Safe Patient Project is urging Medicare to reconsider the restrictions.
NYT coverage of the Joint Commission report on hospital process measures. Consumers Union Safe Patient Project Director, Lisa McGiffert, quoted: “Highlight the poorest performers.”
New hospital quality ratings by the Joint Commission fall short because they look only at preventive steps the hospitals took, not which hospitals did best at preventing bad results, said Consumers Union’s Safe Patient Project Director, Lisa McGiffert.
The U.S. Justice Department is investigating a Texas hospital to ensure that its emergency room patients and others no longer face immediate threats to their health and safety.
The California Department of Public Health fines 12 hospitals for patient safety violations likely to cause serious injury or death.
A dozen California hospitals are fined with a total of $650,000 for patient safety violations. The California Department of Public Health (CDPH) yesterday announced that these hospitals failed to comply with requirements that would likely cause serious injury or death to their patients.
A coalition of state and national patient safety activists, including Consumers Union, are pressing Congress to open reports by The Joint Commission, a non-profit group that performs most of the hospital accreditations performed nationwide. The federal government does not disclose the survey results now. Making the survey results public would give patients more information about hospitals’ operations, including their efforts to prevent hospital-acquired infections, and foster greater transparency.
A California family is claiming that their loved one suffered medical errors at a children’s hospital that lead to his death.
Effective and disturbing graphics and statistics on hospital patient safety performance. (Medical Billing and Coding)
The risk of cancer associated with popular CT scans appears to be greater than previously believed, according to studies published in the Archives of Internal Medicine.
“In a highly unusual move, DePuy has hired a third party — Broadspire Services Inc, which manages workers compensation and other medical claims on behalf of insurance companies and employers — to administer patient claims for out-of-pocket medical costs associated with the recall.”
By the time they graduate, every doctor coming out of the University at Buffalo will have gotten a lesson from Mary Brennan-Taylor. Mary lost her mother to hospital infections and the use of numerous medications.
Only 1 in 5 malpractice claims against doctors leads to a settlement or other payout, according to a new study published in the New England Journal Medicine. Most patients who are harmed are not able to pursue a lawsuit.
These hospitals all had worse readmission rates than the average hospital for heart attack, heart failure and pneumonia patients — the three categories Medicare tracks. You can look up your local hospital’s rates on Hospital Compare by searching for the hospital’s name and then selecting the “Outcomes of Care” tab for that institution.
Patient satisfaction surveys about hospitals don’t tell the whole story of a hospital’s care ; concrete measures like hospital death and readmission rates help give a fuller picture of the patient safety conditions in a hospital.
More than 120 hospitals given top marks by patients for providing excellent care also have a darker distinction: high death rates for heart attack, heart failure or pneumonia, a USA TODAY analysis of new Medicare data has found. Hospital data, such as death and readmission rates, can help patients make better decisions about where to seek care.
The newsletter includes great information about the safety of drug devices.
“Some California hospitals are at risk of having Medicare payments lowered under a CMS final rule that will slash reimbursements to facilities identified as having high 30-day readmission rates for patients with certain conditions, California Watch reports (Jewett, California Watch, 8/3).”
In an effort to save money and improve care, Medicare, the federal program for the elderly and disabled, is about to release a final rule aimed at getting hospitals to pay more attention to patients after discharge. This includes cutting back payments to hospitals where high numbers of patients are re-admitted [often due to infections or medical harm].
After losing her mother to medical error, patient safety advocate is named a University of Buffalo adjunct research instructor. Mary is active with CU’s Safe Patient Project campaign.
Don Berwick editorial: U.S. health care system fails to deliver
Starting in October 2013, Medicare payments to outpatient surgery centers will be affected by the rates of problems at these facilities.
The complaint alleges that from 2004 to 2008, numerous patients suffered serious injuries; five of those patients died. Some of the residents who died went days without baths; they weren’t given enough to drink; and their pressure sores were not treated, leading to fatal infections, the complaint alleges.
So far, lawsuits have been filed on behalf of 34 patients who claimed that in 2009 and 2010 doctors implanted stents, tiny mesh tubes placed into an artery to ease blood flow. Those procedures were not necessary, according to the court filings.
Wrong-site surgeries occur nearly 40 times a week in the U.S., according to the Joint Commission. Oversights, including sloppy scheduling and the choice of marker, can result in tragic mistakes.
Young girl given the wrong vaccine.
Millions of people die each year from medical errors and infections linked to health care and going into hospital is far riskier than flying, the World Health Organisation said on Thursday.
Many ECGs are misinterpreted, which could be detrimental to young athletes if ECGs became a part of routine sports preparticipation screening.
Texas lawmakers passed bills in 2007 and 2009 requiring hospitals to report infections and medical errors to the Department of State Health Services. But the programs have yet to be funded and enforced. CU story sharer Katherine Daniel and CU Safe Patient Project director Lisa McGiffert quoted.
A new study in the Annals of Internal Medicine supports the common perception that medical errors and inefficiencies peak in July, when veteran residents check out of teaching hospitals and new medical school graduates check in.
Doctor authors patient safety checklist. Patient safety activist Kathy Day responds in the comment section.
Doctor authors patient safety checklist.
Angioplasty in patients without symptoms is totally overused. But where is the pressure to stop paying for them?
New federal statistics offer consumers a first-ever look at how well metro Atlanta hospitals are doing at protecting patients from potentially deadly threats; Georgia does not require hospitals to publicly report infection rates and medical errors.
“[t]his safety net hospital for the poor and uninsured now has the lowest mortality rate of any academic medical center in the country.”
Op-ed by Helen Haskell (Mothers Against Medical Error) and Lucian Leape (Harvard School of Public Health) on resident work hours.
A recent Illinois Appellate Court opinion, which reversed the decision of a lower court, will make it easier for all hospital patients who acquire methicillin-resistant staphylococcus aureas (MRSA) to obtain medical records for the purpose of pursuing legal action.
Hundreds of hospitals are routinely performing a type of chest scan that experts say should be used rarely, subjecting patients to double doses of radiation and driving up health-care costs.
Study on medical errors in outpatient settings such as doctors’ offices and urgent care centers.
Some researchers and patient safety experts say the problem of wrong-site surgery has not improved over the years and may be getting worse.
Diagnostic errors, a subset of medical errors, can lead to devastasting harm for patients.
Hundreds of hospitals are routinely performing a type of chest scan that experts say should be used rarely, subjecting patients to double doses of radiation and driving up health care costs.
Nevada’s new reporting laws will help Nevadans make decisions about care and shed light on whether hospitals are reporting their errors accurately.
Has someone called you to offer a free heart scan? Read this ProPublica article first.
“Half of the 91 licensed and unlicensed surgery centers randomly inspected by the state in 2009 and 2010 did not meet federal health standards, healthcare experts testified Thursday. More than one quarter were cited for ‘immediate jeopardy’ violations that caused or can cause serious injury to patients, according to an analysis of inspection reports by the New Jersey Health Care Quality Institute.”
Johns Hopkins plans to use a $10 million gift to launch an institute for patient safety, aiming to reduce medical mistakes that have long troubled health care facilities around the nation. Safe Patient Project Director, Lisa McGiffert, said the institute could step up the pace of study and more quickly turn science into practice.
Join a live chat at noon CT (1 p.m. ET/10 a.m. PT) on Tuesday, June 7, to chat about hospital safety with Tribune reporter Judy Graham, and panelists Dr. Julia Hallisy (Empowered Patient Coalition) and Lisa McGiffert (Director of Consumers Union’s Safe Patient Project).
Lori Nerbonne and Kelly Grasso started advocating for reporting of hospital aquired infections and medical errors after their mother ultimately died of a series of medical errors, including hospital infections. They have since started a non-profit advocacy group called New Hampshire Patient Voices.
Bogdanich discusses his ongoing Times series about the medical and regulatory issues that have arisen as radiation therapies have become more ubiquitous in both dental and doctors’ offices. This includes radiation errors happening across the country, but we don’t know about them because many states don’t require reporting of these errors.
The U.S. Preventive Services Task Force recommends against routine colon cancer screening for most people 76 to 85 — and says for those older than 85, screening risks outweigh the benefits.
South Carolina dialysis patient, Tony Simmons, speaks out against the poor conditions he’s observed and errors he’s experienced, at a SC dialysis clinic. 19 percent of SC clinics had a “worse than expected” mortality rate, appearing more frequently than in neighboring states.
Ohio hospital executives are objecting to data released by Medicare on medical harm occuring at OH hospitals. The federal Centers for Medicare and Medicaid Services last month went live with individual hospital occurrences of eight so-called “never events,” or preventable conditions picked up during a hospitalization.
Ambiguous records at St. John’s and inability to get information frustrate wife and daughter of man, now deceased.
Testing for prostate cancer may be over used by the medical profession as well as exposing patients to bacteria that can lead to deadly infections.
Some surgeons from across the U.S. told Bloomberg News that Laser Spine surgery was either unnecessary or inappropriate for many patients who get it. 15 cases were filed against the company in the past 18 months.
South Carolina hospitals are scheduled to start rolling out operating room surgical safety checklists, aimed at reducing the number of surgical errors that occur every year, according to a Greenville Online news report.
Iowans have no way of knowing how their local hospital is doing when it comes to preventing medical errors, because the reporting is voluntary, aggregately and not hospital-specific. Iowans deserve to have hospital-specific information about medical harm so that they can make informed healthcare decisions for themselves and their loved ones.
According to a 2006 study looking at the frequency of surgical errors in the United States, each year there could be as many as 2,700 mistakes where a surgery is performed on the wrong body part or the wrong patient. That’s about seven per day.
A study of the Veterans Affairs hospitals found that a MRSA prevention program yielded significant results. If other hospitals could replicate the effort, thousands of patients might be saved from needless infections acquired after they entered the hospital.
One-third of hospital patients experience adverse events and about 7% are harmed permanently or die as a result, according to a study that detected patient safety problems at a far higher rate than other methods.
Marshall Allen and Alex Richards wokrdded two years on an investigative report on the safety of Las Vegas hospitals, combing through almost 3 millioin billing records. Read the series The series “Do No Harm: Hospital Care in Las Vegas.”
Nevada has come a long way getting hospital safety information to the public. Five bills this session require public reporting of infections and other medical errors.
A recently announced initiative announced by the federal government aims to reduce medical harm like the kind suffered by William Wittman of San Antonio.
Maggie Mahar blogs on the significant cost savings from the Department of Health and Human Services initiative to invest money to prevent serious errors and frequent hospital admissions,
The Obama administration announced a new patient-safety program Tuesday on the heels of medical journal Health Affairs publishing a study showing that one in three people admitted to hospitals suffers a medical error or accident. Margaret Warner talks with Heath Affairs’ Susan Dentzer about the study and the new plan.
The Obama administration announced Tuesday an initiative aimed at reducing the number of medical errors that occur in U.S. hospitals.
The U.S. Department of Health and Human Services announced a new hospital-safety plan for the nation, but they left out any mention of letting patients know how things are going.
“Nevadans could find out a whole lot more about infection rates and other safety issues at local hospitals and nursing homes, with five bills on such matters up for discussion today in the Legislature.”
CU’s Safe Patient Project Director, Lisa McGiffert, quoted by CNN health blog on the U.S. Department of Health and Human Services (HHS) “Partnership for Patients” initiative.
“When nurse staffing levels fell below target levels in a large hospital, more patients died, a new study [appearing in New England Journal of Medicine] discovered. The finding may provide guidance in an era of nursing shortages and cost-cutting.”
Medicare now offers some information on medical errors to allow patients to compare hospitals’ safety records.
A new study reveals that hospital errors are occurring 10 times the rate previously measured, and are costing billions of dollars a year. Dr. John Santa of Consumer Reports interviewed.
The number medical errors occuring in hospitals might be 10 times greater than previously measured, reports the April issue of Health Affairs.
What kind of information can you find out about your local hospital?
A package of bills to require hospitals and other medical facilities to expand their reporting of infections acquired by patients under their care appears to be gaining support.
Federal regulators say they are moving to make once-confidential data about the performance of kidney dialysis clinics more readily available to the public.
Even though progress has been made, still, some in the health care industry resist the calls for transparency.
Surgeon who performed wrong surgery on a patient admitted his error and wrote up the case in The New England Journal of Medicine.
A transparency battle is underway in Nevada. Nevada lawmakers are considering bills requiring hospitals statewide to publicly report injuries suffered in their facilities and other quality measures.
First, Do No Harm is an extensive series examining medical education and the medical care at Parkland Memorial Hospital, a major trauma center in Dallas.
Several patient safety bills have been filed in the Nevada legislature in hopes of bringing more transparency to medical care in Nevada hospitals.
Interviews with a consumer advocate (Betsy Imholz) and a journalist (William Heisel) about their work to make medical harm information more transparent, and what consumers can do to inform themselves.
A Washington couple encouraged a bill to be filed that would provide more transparency to the medical complaint process. House Bill 1493 has passed the House and is scheduled to be heard by a Senate committee Thursday, March 17, 2011.
An archive of Trudy Lieberman’s recurring series on hospital safety
This is the second in a series of posts that will examine what the media are doing to report on patient safety in their communities.
Local boy who’s battling leukemia contracted bacterial infection from tainted alcohol wipes recalled by the FDA two months later.
“I guess America’s present “Wild West” health care system does allow lots of folks to make a handsome profit. But the rest of us are suffering from high health insurance premiums and unacceptably high fatality rates caused by medical errors.”
The study finds there is a significant gap in the probability of experience a patient safety event between hospitals with good patient safety records and those with lower patient safety performance standards.
Spate of serious infections caused by rare bacteria sparked massive recall, investigation
Patient safety advocate Lori Nerbonne argues that the $1billion spent on new hospital buildings in New Hampshire since 2000 has not resulted in better quality care.
Post-Dispatch Editorial Board: Patients have a right to know a hospital’s track record.
Patients at one of every five Maryland hospitals suffered higher-than-state-average rates of infections, pneumonia and other complications last year, and most of those medical centers will face a financial penalty as a result, regulators say.
Missouri hospitals don’t want people to know when and where medical mistakes happen – and no law requires them to tell.
Two recent reports found issues at University Hospital that could affect patient safety. But a disconnect between regulators means many safety concerns like these are not shared with other agencies — or with the public.
It’s not getting any better when it comes to reducing the rate of medical errors occurring in North Carolina, according to a recent study published in the “New England Journal of Medicine.”
“If you haven’t heard Michael Skolnik’s story, you should.”
2004 death of Jerry Carswell at Katy hospital influenced introduction of HB 1009
“Nurses from EMMC have had to strike over patient safety and safe staffing — so why haven’t EMMC and the EMHS board of directors listened?”
Free Workshop by Patty Skolnik, Founder and Director, Citizens for Patient Safety. Must RSVP. For more information contact Breanna Sakis (Breanna.Sakis@HealthONEcares.com)
http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/02/16/MN4K1HCMNU.DTLA new study found that 20 percent of California patients were readmitted to the hospital within 30 days at an annual cost of $250 million. The study blames poor discharge planning but also patient complications, which we know can often be the result of infections and medical errors. The report by the California Discharge Planning Cooperative can be found here.
A recent study on mdical device recalls by the National Research Center for Women & Families found the majority of recalled medical products were approved without testing. The FDA’s 510(K) process that only requires medical devices be similar to another device on the market to be approved. Find the study in the Archives of Internal Medicine here.
Three CA patients have died after weight-loss surgeries at one clinic alone.
“Leapfrog’s release of 2010 data is the first real evidence that the practice of scheduling newborn deliveries before 39 weeks without a medical reason is common and varies among hospitals even in the same state or community.”
The Centers for Medicare and Medicaid (CMS) found that a Las Vegas hospital was not meeting the conditions for the program. Specifically, it “had failed to ensure the safety of patients and protect their rights, the government said.”
Annual statewide report shows spike in medication errors during previous year.
“While mistakes in the state are still considered rare, officials were hoping for an improvement in the numbers — and say “holding steady” is not good enough.”
About one-third of health care spending is wasted, much of it on care that is unneccessary for patients but lucrative for doctors, author Rosemary Gibson says.
State officials clear three county facilities after investigations. The public can learn only minimal information about these complaints since the California Department of Public Health determined the complaints were unsubstantiated.
Nearly 30% of diagnostic echocardiograms done at Aurora St. Luke’s Medical Center were misread by insufficiently trained cardiologists, resulting in more invasive, unnecessary procedures, according to an internal review done at the Milwaukee hospital.
Hospital probing any possible link to deaths.
The panel: Marshall Allen, Las Vegas Sun health care reporter and author of the “Do No Harm” series; Dr. Timothy McDonald, co-executive director of the Institute for Patient Safety Excellence at the University of Illinois Medical Center in Chicago; Dr. Mitchell Forman, president of the Clark County Medical Society; and Sandra Coletta, CEO of Kent Hospital in Warwick, R.I.
“This report, that came out in December, substantiates not only that those numbers were valid, but that the scope of the problem is far greater than anyone ever thought.” Jean Rexford; CT Center for Patient Safety.
Editorial: Preventable deaths They will continue until there is a national strategy to stop them
Article by Marshall Allen after attending Consumers Union’s Safe Patient Project 2010 summit.
Part 5 in the Las Vegas Sun series Do No Harm: Hospital Care in Las Vegas.
In response to an investigation by ProPublica, U.S. Senator Grassley is demanding answers from federal regulators about the care patients are receiving at U.S. dialysis facilities.
Medical radiation harm can do serious damage to patients and it is unclear what safety measures are in place to prevent future harm.
Interviews with Jean Rexford (CT Center for Patient Safety); Tracy Webber (Propublica); Lisa Chedekel (C-HIT) discuss learning about a doctor’s professional history. A report by the Connecticut Health Investigative Team (C-HIT) shows that many out of state doctors with a history of disciplinary actions are slipping through the cracks of Connecticut’s public health department.
“What for me struck a particularly jarring note was not just the absence of improvement, but the reluctance of the health care leaders interviewed to speak candidly about why progress has been so slow.”
Nearly 60% of Medicare stroke patients die or are rehospitalized within a year of their initial discharge, according to a study by UCLA.
Adequate nurse staffing can help patient safety.
The hospitals that collect the most Medicare dollars for spine fusion play host to many of the surgeons paid by Medtronic
The public gets only glimpses of how often patients die or are injured by unsupervised residents.
In a first-of-its kind bid to make clinical quality performance data available to the public, the Society of Thoracic Surgeons partnered with Consumer Reports in September to rate 221 cardiac surgical groups in 42 states.
Arthur Levin, a member of the Institute of Medicine committee that released “To Err Is Human” almost 11 years ago: “The news that patients are no safer in the hospital today than they were a decade ago should send a strong message to all of those responsible for keeping patients safe from preventable harm to do more, faster.”
A six-year study at 10 North Carolina hospitals showed no decline in so-called patient “harms,” which included medical errors and unavoidable mistakes.
A study shows that many institutions lack a ‘culture of safety’
A medical error turned a routine surgury into a horror story for a New York woman.
Patchwork rules permit facilities to operate without a state license. Private accreditation agencies don’t have to release records of complaints and offices that lose accreditation can quickly be certified by another agency.
A lack of state regulation has allowed many unlicensed and unaccredited cosmetic surgery centers in California to provide services to patients, the Los Angeles Times reports.
Substandard hospital care has roots in a culture of seeking profits, shunning best practices, turning away from problems.
Bill Heisel of Reporting on Health and Antidote adds more ideas he learned at CU’s Safe Patient Project 2010 summit in Austin.
List of 87 California hospitals that have made no medical error reports to the state health department. State officials have given these hospitals until Nov. 30 to verify their records or report past errors.
A new study conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections. Click here to view the study.
Activist Michael Bennett sharing his story in the wake of the Office of Inspector General report on medical errors.
“Five years after the state began collecting and releasing data on deaths associated with heart bypass surgery, the mortality rate associated with the procedure is 27 percent below where it was before, according to a new study by UC Davis researchers.”
An ongoing Las Vegas Sun investigation paints a bleak portrait of hospital care in Southern Nevada. But according to a federal government study released Tuesday, the situation may be much worse.
New report shows that hospital patients are being harmed by medical errors at an alarming rate. Unfortunately, most Americans have no way of knowing whether their hospital is doing a good job preventing medical errors.
New report on medical harm released by the Office of Inspector General for the Department of Health and Human Services finds that in a single month (October 2008), 134,000 Medicare patients experienced at least one adverse event, ranging from a temporary health setback to death, during a hospital stay.
“An estimated 15,000 Medicare patients die each month in part because of care they receive in the hospital, says a government study released today.”
Dangerous dialysis that can harm or infect US kidney patients exposed in a ProPublica’s recent investigation.
“Dialysis patients die or are hospitalized every year as a result of catastrophic hemorrhages during treatment, a ProPublica review of regulatory and court records has found.”
TX woman harmed by knee surgery that leads to additional surgeries, high debt, and eventually amputation.
On Friday, the California Department of Public Health issued $575,000 in fines to 12 CA hospitals for serious medical errors than can lead to injury or death.
Surgeon goes public with his operation mistake.
“Tracking and preventing errors is a key to reining in health-care costs. The Society of Actuaries reported this month that medical errors cost hospitals $19.5 billion in 2008.”
A new study found that Joint Commission-required timeouts for surgical procedures are skipped or rushed, and surgeries performed on the wrong body part or the wrong patient persist.
How can patients stay safe in the hospital if they are too ill to be vigilant about their own care?
How do hospital CEOs handle conversations with family members that occur at their hospitals?
The CA Senate Health committee held a hearing to discuss the California Department of Public Health’s status on implementing hospital infection public reporting and preventing adverse events in California hospitals. Consumers Union has found that the Department has been lagging in these areas leaving patients at risk.
Five years after her death, family struggling to find answers about the death of their infant at a Toronto hospital.
Family members of medical error victim left in the dark due to hospital cover up.
Mothers will lead a patient safety training sponsored by Consumers Union’s Safe Patient Project.
A new SC law requires county coroners or medical examiners to be notified if a patient dies within 24 hours after being admitted to a hospital and within 24 hours following an invasive surgical procedure.
Follow up story to a Hearst investigation published on Seattlepi.com about under reporting of medical errors in Washington State.
Though Washington is one of 27 states that require hospitals and other facilities to report serious medical errors, just a fraction the errors that likely happen here are reported.
Read doctors’ confessions about medical errors and what has to improve to keep us safe.
In the New York analysis, there were 84 cases of foreign objects left behind after surgery, only four fewer than the previous year. These include items like sponges, clamps, scissors, catheter tips, drill bits, needles and more.
Boston Globe editorial: doctors need to fess up when they harm patients.
A huge surgical sponge is left inside a Florida man after an operation.
Is it necessary to rush men with prostate cancer to the operating room?
A series in the Seattle Times newspaper highlighted problems and deaths due to neglect at adult family homes in Washington State.
For-profit hospitals across the state are performing cesarean sections at higher rates than nonprofit hospitals, a California Watch analysis has found. The CDC found a 27 percent increase in severe maternal injuries in the U.S. associated with higher rates of C-sections.
This is the summary of all of the articles the Las Vegas Sun has done on medical harm.
In a state where gamblers can easily access the odds on any video poker machine, Nevada patients have had no way of knowing their odds of being injured in a hospital, the Las Vegas Sun told its readers in part one of a splendid series on hospital safety. The series, by reporters Marshall Allen and Alex Richards, aims to change that.
Patient safety advocate Lori Nerbonne and her sister Kelly Grasso have been working to make hospitals safer in New Hampshire and have now officially become and non-profit and launched a website: http://www.nhpatientvoices.org.
Only 52 percent of California hospital employees have received flu vaccinations, a Consumers Union study shows. And the advocacy group says that is detrimental to the state’s health.
UC Davis responds to Consumers Union’s report on low flu vaccination rates at California hosppitals.
Consumers Union’s report on low flu vaccination rates among California health care workers is based on inacurrate data according to the head of the CA Department of Public Health who provided the data to Consumers Union.
Feeding tube hospital errors causing serious injury or death signal problems with hospitals, medical device companies and FDA.
As part of a two-year investigation, Sun reporters have uncovered some of the dangers patients have unknowingly encountered as they enter delivery rooms, surgical suites and intensive care units, including thousands of cases of injury, death and deadly infection associated with stays in Las Vegas hospitals.
Blog post by Maggie Mahar, author of Money-Driven Medicine, on the need for hospitals to report medical errors so that they can be prevented.
New York Times investigation on radiation overdoses during CT brain perfusion scans, and the long-term risks radiation overdoses can have on patient health. The FDA began an investigation but has yet to provide a final report on what it found.
Tragic story of a young girl who was suffocated in a bean bag chair at a hospital that had been warned by state and federal regulators that patients weren’t safe.
Hear from a journalist about how difficult it is to find information about a serious medical error. No matter what source you turn to, you are left with few answers.
A 300-pound sedated patient who was awaiting a routine procedure fell off an operating table and later died. Accidents like these should be prevented before it’s too late.
Hospital mix up in patient identification causes newborn to be breastfed by wrong mom.
A recent study in the July issue of Archives of Surgery found that surgery patients are more likely to suffer sepsis or septic shock than blood clots or heart attack.
The American College of Obstetricians and Gynecologists released guidelines that state it is safe to have a vaginal delivery after a previous delivery by cesarean delivery.
“Diagnosing the earliest stage of breast cancer can be surprisingly difficult, prone to both outright error and case-by-case disagreement over whether a cluster of cells is benign or malignant, according to an examination of breast cancer cases by The New York Times.”
The New York Times finds that early diagnosis of breast cancer can be prone to error on whether the cells are benign or malignant, leading to unnecessary treatment and psychological distress.
Astronaut turned patient safety expert interview on what patient safety advocates can learn from NASA.
A recent study finds that deaths from medication errors increase by 10 percent during July, a so-called July effect as students graduate from medical school and enter residency programs.
Is the “July Effect” a myth. A study shows that deaths due to medication errors spike in July at teaching hospitals where new residents are just starting their residency. Medical records from 1979-2006 were analyzed.
Sun’s investigation of Nevada hospital data shows 969 incidents of inpatient injuries — some that can be deadly
If you get admitted to a hospital, chances are way too good that you’ll be back before long — maybe more than once
Blog post series by Maggie Mahar on resident work hours.
A new study finds medication error rates spike 10 percent in the month of July.
“One-fourth of California’s 450 acute care hospitals have been fined a total of more than $1 million so far—one hospital received five fines totaling more than $130,000—for failing to promptly report adverse events.”
“In the latest fiscal year, California hospitals reported 197 cases of “retained foreign objects” for a total of 350 incidents over the past two years. They accounted for 14 percent of all preventable errors reported during those two years. That’s out of 2,446 adverse events reported in California from July 1, 2007, through Dec. 31, 2009, according to the state Department of Public Health.”
Reporting medical errors, such as surgical fires, to outside agencies can help prevent them, medical safety experts say. But Ohio doesn’t require it.
Maine health care advocates held a press conference to make sure health reform is implemented properly, including improving the quality and safety of health care.
The article highlights quality and safety provisions in healthcare reform. “The legislation contains dozens of provisions, including fining hospitals, to reduce medical errors, hospital-borne infections and costly preventable readmissions.”
The Empowered Patient Project has created a patient oriented survey on adverse medical events. Aggregate information from the surveys will be posted on their website.
“The California Department of Public Health has consistently failed to enforce new laws designed to reduce medical errors and infections at California hospitals.”
View the report here: http://www.safepatientproject.org/CAPatientSafetyReportFinal_2.pdf
Guest blog post by our Director Lisa McGiffert on the slow progress of California’s Department of Public Health to implement patient safety laws.
Health Care For All hosts event to publicize the release of the Massachusetts Department of Public Health first hospital-specific report about Health-care associated infections (HAIs) and the second report on Serious Reportable Events (SREs).
On Tuesday, the California Department of Public Health announced its latest round of fines, charging seven state hospitals for serious patient safety violations, the Los Angeles Times reports.
State health regulators Tuesday cited staffers at Scripps Mercy Hospital in San Diego for leaving a surgical sponge in the abdomen of a cervical cancer patient, who required two additional surgeries to remove it.
View California Department of Public Health (CDPH) Hospital Administrative Penalties 4/13/2010
“California regulators have fined hospitals more than $1 million for failing to report serious medical errors in a timely manner…”
CU’s Betsy Imholz interviewed by KPBS about the state of California falling short on monitoring patient safety. Our recent report found that the California Department of Public Health has been slow to implement a number of key provisions of new patient safety laws.
“California regulators have fined hospitals just over $1 million for failing to report incidents such as leaving a foreign object in a patient after a surgery or operating on the wrong person, according to data released to California Watch by the California Department of Public Health.”
AARP: Older Adults Still the Most Affected by Dangerous Medical Errors
Public Citizen’s 2010 annual ranking of state medical boards shows that most states, including one of the largest, are not living up to their obligations to protect patients from doctors who are practicing substandard medicine, according to the report released today.
Consumers Union’s Safe Patient Project mentioned in Kaiser Health News.
Editorial on the patient safety provisions of the health reform bill.
Betsy Imholz of Consumers Union challenges the decision the California Pharmacy Board has signaled it will adopt regarding presription drug labeling standards.
“When a car breaks, a computer fails or a toaster flames out, the manufacturer is often liable under the product warranty. But that is not how the multibillion-dollar orthopedics industry tends to work, according to doctors, industry experts and three of the biggest device makers. “
Checklists that spell out exactly how to care for patients with common conditions have dramatically reduced hospital deaths, say doctors.
More reforms are needed to protect patients from preventable medical harm, but the new health reform law creates a solid foundation that will help ensure that the health care we are paying for is safe.
How we can save billions by cutting out unnecessary procedures that kill tens of thousands a year.
What’s taking the California Department of Public Health (CDPH) so long to implement a program to prevent hospital acquired infections? That’s what Consumers Union has been trying to find out since December, but the watchdog group isn’t getting answers.
Patient Safety Advocates Launch Campaign to Reduce Resident Physician Fatigue, Boost Patient Safety
Hearst Newspapers (March 22, 2010)
Safety problems at Albany Medical Center Hospital and Glens Falls Hospital landed the two Capital Region facilities on the Hearst Newspapers investigation’s “watch list.”
The federal government can’t thoroughly detect medical errors in hospitals without employing physicians or other clinicians like gumshoes, according to a recent federal study.
Merrill Goozner points out another little-noticed provision in the bill: “Drug and device companies will soon have to report payments to physicians in a national database, thanks to a little noted section of the health care reform bill called the Physician Payments Sunshine Act.”
Americans have more information about the safety of their cars than about the hospitals that treat them at their most vulnerable moments.
According to a study published this month in the journal Medical Care hospital occupancy, weekend admissions, nurse staffing and the seasonal flu are major factors that increase the risk of dying in a hospital.
The following films from Transparent Learning are the first in a series of educational stories that feature patient safety advocates including Helen Haskell, Rosemary Gibson and Dr. Lucian Leape.
Consumers Union’s has been reviewing hospital infection and medical error laws passed in recent years to determine if the state has begun implementing and enforcing these laws and concluded that California has not done it’s job. The state estmates 240,000 Californians a year get a hospital infection and 13,500 die.
Leading patient safey advocate Dr. Lucian Leape released report. He makes a strong statement on public reporting: “Transparency is an idea whose time has come and both hospitals and the public will be better off because of it.” His statement and report are online now.
Health Care For All has created an informative website, www.assertivepatient.org, to assist patients on how to navigate the complaint process when something goes wrong at the hospital.
Author Rosemary Gibson says when medical care is overused, it can cost patients their health and their savings. To attend Rosemary’s March 9th talk at Health Care for All, 30 Winter St., e-mail Deb Wachenheim: dwachenheim@hcfama.org.
Patty Skolnik, Founder of Citizens for Patient Safety, makes CNN’s “Intriguing people” feature. Patty was a speaker on CU’s consumer panel on medical harm at our “To Err Is Human, To Delay Is Deadly” forum in DC. She is a lead advocate in Colorado and nationally on patient safety and doctor accountability issues.
“Some of the nation’s leading orthopedic surgeons have reduced or stopped use of a popular category of artificial hips amid concerns that the devices are causing severe tissue and bone damage in some patients, often requiring replacement surgery within a year or two.”
“Since 2004, 116 people in Connecticut have died as a result of medical errors in hospitals — most of which were kept secret because of a “gaping legal loophole,” according to the Connecticut Attorney General Richard Blumenthal.
Review of Dr. Peter Pronovost’s new book on challenging a “toxic” medical culture that doesn’t crack down on medical errors.
Preventing harm will save money
Reusing one-time-use tools cuts waste, stirs some concern
If the New Hampshire Hospital Association has its way, the euphemistically named New Hampshire Health Care Quality Assurance Commission will continue operating without accountability to the public, in closed and secretive sessions and with only hospital and human services representation. That’s a dangerous problem for consumers of health care and for patient safety.
For some medical conditions, the cost of care does not directly correlate to the quality of care according to a study in the Archives of Internal Medicine.
“Hospitals can reduce medical errors and cut unnecessary hospital-related infections with the use of a checklist.”
“The Naval Medical Center in Bethesda, Md., confirmed Thursday that it is conducting an inquiry into Rep. John P. Murtha’s gallbladder surgery and his medical care there in late January.”
The National Naval Medical Center has opened a review of the surgical care provided to the late Congressman John Murtha after the Pennsylvania Democrat died following surgery, a senior U.S. military official told CNN Wednesday.
More California women dying from pregnancy complications; state holds on to report
“With all the hand wringing about health care costs, it is possible to cut costs without harming patients. Even better, costs can be reduced while making patients better off. Here’s how.”
The death Monday of Rep. John Murtha (D-Pa.) after complications from gallbladder surgery raises questions about whether the lawmaker was among the nearly 100,000 people who die in U.S. hospitals annually due to preventable medical errors.
Dallas-based Methodist Health System had two hospitals with bloodstream infection rates double the national average, according to a Consumer Reports study.
Consumer Reports has made an online system available which gives consumers access to hospital infection rates.
A comparison by Consumer Reports of Mercy with hospitals in Turlock and Modesto shows Mercy lags in all areas, including the average cost of a hospital stay.
The Consumer Reports Hospital Ratings study, released Tuesday, says North General Hospital’s so-called central line infection rate was 394% worse than the national average – and the worst in the city.
NC makes it easier to find malpractice reports.
Radiation errors can cause severe harm or death for cancer patients.
California’s largest health insurer is teaming with hospitals and doctors throughout the state to better share ways to improve patient safety and cut costs, leaders of the initiative said Tuesday.
NH plans to make medical errors and hospital infection information available to the public but does not have a date that they will be available. A very compelling video of medical error victim is also on this page.
Canandian medical error survivor Rhonda Nixon organized “The Empowered Patient Conference: Including the Patient in Patient Safety” conference. Speakers included Helen Haskell and Julia Hallisey, authors of “The Empowered Patient.”
According to the California Medical Board, half of the doctors seeking to get lost licenses reinstated this past fiscal year were successful.
A December 2008 report by Health Affairs does find “unmistakable progress,” despite setbacks. Critics say mandatory disclosure of medical errors is the key to breakthrough safety improvement.
Medically Injured Trauma Support Services (MITSS) honors Patty Skolnik for her work on patients safety through the organization she founded- Colorado Citizens for Accountability.
An LA Times/ProPublica investigation on nurses who were disciplined for medical errors in one state who hold nursing licenses and may continue to practice (and harm patients) in other states. Using public databases and state disciplinary reports, reporters found hundreds of cases in which registered nurses held clear licenses in some states after they’d been sanctioned in others, often for serious misdeeds. In California alone, a months-long review of its 350,000 active nurses found at least 177 whose licenses had been revoked, surrendered, suspended or denied elsewhere.
The Centers for Medicare and Medicaid Services estimate 7 percent of the state’s nursing home residents developed bed sores from 2007 to 2008. During the same time period, the state had the third-highest ranking for pressure ulcers in the country.
Leapfrog sites only five of U.S. News’ 21 best hospitals. View Leapfrogs press release on the top hospitals list.
The Providence Journal (December 2, 2009)
Firms that supply temporary nurses to the nation’s hospitals are taking perilous shortcuts in their screening and supervision, sometimes putting seriously ill patients in the hands of incompetent or impaired caregivers.
A study published in the December 2nd Journal of the American Medical Assn. by an international group of researchers examined data on 13,796 adult patients from 1,265 hospitals in 75 countries who were unlucky enough to be in an intensive care unit on May 8, 2007. Here’s a summary of what they found: Fifty-one percent of ICU patients had some sort of infection, the longer you’re in the hospital, the more likely you are to become infected. The mortality rate for ICU patients with an infection was 25%, compared with 11% for patients without an infection. Infection rates in North America were slightly below average, at 48%, but the lowest rate was in Africa, at 46%. The highest infection rate was 60%, found in Central and South America.
To Err Is Human jump-started a movement to improve patient safety. How far have we come? Where do we go from here? Five patient safety “stakeholders” were interviewed for this article, including the Director of Consumers Union Safe Patient Project, Lisa McGiffert.
The forum was called “To Err is Human, to Delay is Deadly” in order to highlight the lack of progress the U.S. health care system has made since the Institute of Medicine’s report “To Err is Human.”
A state law intended to protect patients by making them aware of hospitals’ errors has ended up making it easier for hospitals to avoid scrutiny. That’s because when hospitals notify the state, the health department keeps most of those reports secret from the public.
Interview with Don Berwick, President of the Institute for Healthcare Improvement on the quality of care and patient safety.
The Joint Commission, which accredits hospitals, reports that wrong-site, wrong-side and wrong-patient procedures occur more than 40 times each week in the United States.
Rep. Bruce Braley highlighted the importance of improving patient safety in order to reduce medical malpractice.
Consumers Union Safe Patient Project Director Lisa McGiffert comments on wrong site surgery.
A new documentary film, “Money-Driven Medicine”, tackles the economic underpinnings of an American healthcare system that kills four times as many people through medical error and preventable infections as die in highway accident. Consumers Union has encouraged activists to view this film and take action to make our health care system safer.
“Money-Driven Medicine” examines the medical industrial complex, and what’s wrong with our healthcare system. Watch the movie for free here until November 10 and sign our petition for reform.
For decades, the U.S. health care system has paid doctors and hospitals by the services performed, even if those services harmed the patient. Beginning in October 2008, Medicare will no longer pay for some major hospital mistakes.
Broward General Medical Center patients received reused IV bags and have tested positive for some infectious diseases.
Health care legislation now before Congress takes only modest steps to address a problem that is far more deadly than inadequate medical insuance — medical error.
Many MRI patients are injected with a GE dye to enhance images. If they have weak kidneys, they might develop a rare and sometimes fatal disease.
The New Jersey Health Department has released the 2009 Hospital Performance Report.
The Dallas Morning News investigates the many holes in the Texas Medical Board review process over the past seven years, leaving patients at risk.
Of 11 facilities cited by the state, about half were penalized for leaving objects in patients after surgery.
Readmission rates were lower, but some death rates were up
Josie King, an 18 month old went to the hospital for burns from hot bath water and later died in the hospital from dehydration and medical error.
“The Derrick newspaper in nearby Oil City reported yesterday that “a failure to follow equipment sterilization guidelines” at the hospital resulted in “the notification of more than 100 surgical patients. “
“The American hospital, the center of health care, is a cottage industry in the post-industrial world, and we can save billions of dollars by bringing them into the modern world.”- Clare Crawford Mason.
A determined breed of patient-safety advocates have forged their personal pain into a dedication to improving medical safety.
Mark your calendars for the MITSS (Medically Induced Trauma Support Services) annual dinner on Thursday, November 12, 5:30-9:30pm, at the Boston Marriott Copley Place. This is an opportunity to support an organization that does unique and important work supporting patients, families and medical providers impacted by adverse medical events. Learn more on the MITSS website.
Gov. Jon Corzine signed legislation yesterday giving residents more information about major preventable medical errors that occur in New Jersey hospitals. The law requires the state to release data identifying the hospitals responsible for making certain mistakes — such as surgery performed on the wrong body part, the wrong person, or a sponge or medical tool left inside a patient following a procedure — and the frequency they occur. It also prohibits hospitals from charging for some preventable medical errors.
A closer look at how families are calling for hospital rapid-response teams directly or at least to demand immediate medical attention from a senior physician if they feel a patient is in trouble and their concerns aren’t being met.
Tragic loss and patient advocacy has moved some hospitals to explore family-activated rapid-response teams. Patient advocates, Helen Haskell and Julia Hallisy, will launch a website later this month–empoweredpatientcoalition.org–that will help patients navigate the hospital system and encourage them to alert hospital staff if they sense something has gone wrong.
Bob Wachter writes: “I remain enthusiastic about ‘no pay for preventable adverse events’ as a clever way to use payment policy to goose the system into focusing on patient safety prevention practices. But for ‘no pay…’ to make a difference, there must be evidence-based prevention strategies to implement.”
Letter to the editor on health care reform by patient safety activist Michael Bennett, President of the Coalition for Patients’ Rights.
Features film trailer for “The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman” (son of patient safety activist Helen Haskell). This is the first in a new patient safety film series that addresses several critical health care issues: prevention of medical errors; how providers and institutions respond when care has caused harm; the important role patients and families can take in their care.
The Adverse Event Reporting System (AERS) contains over four million reports of adverse events and reflects data from 1969 to the present. Data from AERS are presented here as summary statistics. These summary statistics cover data received over the last ten years.
A dozen New Jersey hospitals are paying doctors as an incentive to save the hospitals money.
Medical records were concealed at a Texas hospital involving the medical error death of Linda Carswell’s husband. There was no follow up by the Texas Health Department on any complaints related to concealing or tampering with medical records at any hospital in the state, according to this KHOU investigation.
Despite an authoritative federal report 10 years ago that laid out the scope of the problem and urged the federal and state governments and the medical community to take clear and tangible steps to reduce the number of fatal medical errors, a staggering 98,000 Americans die from preventable medical errors each year and just as many from hospital-acquired infections.
Dead by mistake was researched and written by a team of journalists from across Hearst newspapers and television stations. Hearst describes medical errors as “a critical and neglected health care issue.” Consumers Union’s Safe Patient Project published a report on medical harm, “To Err is Human, To Delay is Deadly” in May 2009.
Consumers Union supports nationwide “MVP” reporting: mandatory, validated (meaning hospital data is audited) and public disclosure at a facility-specific level. Most state reporting systems now divulge only statewide information, which isn’t much help to consumers.
“You can’t say we weren’t warned. And you can’t say we’ve done enough to address those warnings about the degree of avoidable deaths in hospitals in New York and across the country.”
Six years after the “To Err is Human” report, the Washington state Legislature responded with a law mandating medical error reports. State Rep. Tom Campbell, a bill sponsor, envisioned a day when patients could click on a Web site and compare hospitals’ safety records.
Despite efforts to prevent medication errors, mix-ups like this are occurring across the country with alarming frequency.
The report, “Back to Basics,” analyzed the results of scientific studies of treatment protocols for chronically recurring, avoidable medical errors.
The hospital accreditation experience of a Long Island hospital.
It’s part of a nationwide trend spawned by a patient-safety movement after studies a decade ago found that errors in hospitals account for an estimated 40,000 to 90,000 deaths per year.
Op-ed by Jim Hall, former chairman of the National Transportation Safety Board. The Obama administration should take a lesson from the transportation safety board’s successes and establish an independent agency charged with identifying and eliminating the causes of medical error.
Letter to Editor from Lori Nerbonne thanking lawmakers for passing hospital infection and error reporting legislation.
There’s a movement to make hard numbers the basis for rankings among hospitals, instead of reputation or word-of-mouth.
City-run hospitals faked records and covered up dozens of botched operations, deadly accidents, malpractice and other medical screwups, a Daily News investigation has found.
Kansas City Star (July 11, 2009)
Though A Common Medical Procedure, Many Are Performed At Hospitals Unprepared If Something Goes Wrong
The Washington Post (July 21, 2009)
Under laws that took effect last year in Virginia and a few years earlier in the District and Maryland, hospitals must report to health regulators many serious injuries that patients suffer in the course of treatment.
The board charged with overseeing California’s 350,000 registered nurses often takes years to act on complaints of egregious misconduct, leaving nurses accused of wrongdoing free to practice without restrictions, an investigation by The Times and the nonprofit news organization ProPublica found.
Our state needs to take an active and aggressive policy of mandatory public reporting and tracking of HAI. Kentucky should become a leader in health care, but if Kentucky always waits for the majority of other states to act, we will be relegated to being below average.
Important new information was added today to the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Web site that reports how frequently patients return to a hospital after being discharged, a possible indicator of how well the facility did the first time around.
Too many people die needlessly at U.S. hospitals, according to a sweeping new Medicare analysis showing wide variation in death rates between the best hospitals and the worst.
This increased transparency is one of the great hopes among health care reformers for tackling the high cost of American medicine.
Former Treasury Secretary Paul O’Neil comments on reducing health care costs: “The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years.”
The only economically feasible and, indeed, humane way to improve the system is to reduce the number of senseless and tragic medical errors in our hospitals. In its report, Public Citizen calls on Congress to put safety measures in place that would set the nation on course to meet the IOM’s goal of cutting the number of avoidable deaths in half in five years.
READ the report: http://www.citizen.org/documents/NPDB_Report_200907.pdf
Federal officials Thursday warned that about 5,700 surgery patients, including 1,000 at a Colorado Springs surgery center, are at risk of having been infected by an operating room technician with hepatitis C.
There were at least 89 serious medical errors last year in Utah hospitals and surgical centers, up 56 percent from the 57 logged in 2007, according to a Utah Department of Health report requested by The Salt Lake Tribune. These errors may include surgery on the wrong body part or leaving foreign objects like sponges in the body.
Public Citizen’s report on ineffective hospital peer review (and under-reporting bad doctors to the National Practitioner Data Bank) made ABC World News on Sunday evening, June 21st. Doctors who perform medical errors are not always reported, and hospitals are not penalized for failing to report bad doctors.
NYT story about a Philadelphia VA hospital where many patients received botched cancer treatments.
On July 1, the state’s hospitals will receive financial incentives based on the steps taken to prevent complications, including collapsed lungs and infections of the urinary tract and in the blood.
The VA started a nationwide safety campaign at it’s 153 medical centers calling attention to potential infection risks from improperly operating and sterilizing the equipment.
Lori Nerbonne of New Hampshire Patient Voices writes in support of a bill for funding hospital infection rate reporting and an adverse event reporting bill, which will require hospitals to report serious, completely preventable errors to the state.
The hospital failed to notify the Department of Health that a patient had died and that at least seven others suffered serious harm last year as a result of mistakes by the medical staff.
Single-patient rooms are now viewed as an important element of high-quality health care.
Consumers Union Assesses Lack of Progress Ten Years After Institute of Medicine Found Up To 98,000 Die From Preventable Errors
The Consumers Union report said lawmakers largely have failed to enact patient safety reforms recommended by a 1999 report by the Institute of Medicine that found that medical errors cost the U.S. as much as 29 billion U.S. dollars a year.
53% of orthopedic surgeons reported medical errors in the past 6 months!
Despite a landmark report a decade ago detailing the deadly nature of the U.S. health care system, a consumer group finds that little has been done to prevent errors that cost the nation $17 billion to $29 billion and kill as many as 100,000 patients annually.
Report Shows 10-Year Effort to Curb Medical Errors Yields Few Results
Despite a decade of promises, little has been done to fix the problem of preventable medical errors that kill nearly 98,000 people in the United States each year, a consumer group said on Tuesday.
The Massachusetts Public Health Council approved regulations to implement major patient safety reforms passed last year, including public reporting of hospital infections and serious medical errors, no-pay policies for certain preventable medical errors, and requiring every hospital in the state to have a Patient and Family Advisory Council and a rapid response system that can be activated by patients and their families.
Two annual government reports released Wednesday show that progress in improving the quality of health care and narrowing health disparities among ethnic groups remains agonizingly slow, and that patient safety may actually be declining.
Billing patients or their private insurance company for the cost of medical mistakes would change under a bill that’s cleared the state Senate and is now before the Assembly. The bill would prevent hospitals from charging anyone for serious medical errors. The legislation would also require the state to make public individual hospitals’ errors.
Electronic records might make medicine safer and cheaper. But it might just digitize the worst flaws of today’s system, where errors are rampant and basic recommended treatments often fall through the cracks.
From February 2005 through December 2008, New Jersey hospitals reported 1,817 medical errors to the state’s Department of Health and Senior Services. Of that number, 251 resulted in deaths. But consumers have no way of knowing where these errors occurred; the law keeps hospital-specific information secret. A bill making its way through the legislature would lift that veil.
The state Senate today concurred unanimously with the House in passing tough new procedures to help prevent the spread of infections acquired in hospitals and other health facilities.
A couple whose day-old baby was given to the wrong mother to nurse in a hospital is demanding answers about how it happened.
New Jersey legislation would give public hospital-specific information on medical errors.
NH bill will require public reporting of adverse events.
A group of Ohio business leaders and 24 hospitals has launched what it hopes will become a statewide effort to reduce hospital medication errors and infections. Solutions for Patient Safety, as the effort is called, takes place as the state is preparing to publish hospital quality data, including some infection rates, on the Web for consumers.
The main topics of the conference were healthcare acquired infections, never events and healthcare transparency. Lisa McGiffert (Director of Stop Hospital Infections.org) is a featured speaker.
Issues surrounding hospital-acquired infections and other medical events “that should never happen” will highlight a health care conference in Lexington next week.
Legislators are considering passing a law requiring New Hampshire’s 26 hospitals to publicly report their “never events” to the state.
Unlike 27 other states, New Hampshire does not require hospitals to report serious, preventable medical errors to the state, to the patient or to the family left behind if the patient dies as a result of the mistake.
And in another development, federal officials late last week approved a new company to begin inspections as part of its often criticized hospital accreditation program.
Medicare is right to stop paying hospitals for treating reasonably preventable medical errors
On Wednesday, Medicare will start applying that logic to American medicine on a broad scale when it stops paying hospitals for the added cost of treating patients who are injured in their care.
New federal regulations target 11 hospital-acquired conditions that are considered reasonably preventable.
As the federal Centers for Medicare and Medicaid Services moves to deny Medicare payments for conditions caused by hospital mistakes, hospital executives here are watching private insurers in Tennessee and nationwide follow suit.
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.
11 states waive fees for worst mistakes, but most will charge you or insurer
Medicare will start hitting hospitals where it hurts in October, and other insurers are hot on the trail.
CMS said that the new rules will not only improve the quality of care for Medicare benificiaries, but will save millions of taxpayer dollars every year.
HealthGrades shows rise in post-operative sepsis
Katie Couric interviews Dr. Donald Berwick about the Institute for Healthcare Improvement’s campaign to reduce medical errors, including hospital infections.
New reports reveal pattern of deadly and expensive, yet preventable, medical errors.
A $21 million grant coming to South Carolina aims to improve patient care and prevent unnecessary hospital deaths.
A new report by HealthGrades concludes that as many as 950 preventable deaths occur each day from medical errors and other patient safety incidents, including hospital infections.
A new article in the Journal of the American Medical Association reports that little progress has been made in the past five years to reduce deaths caused by medical errors in U.S. hospitals.
Report finds that most nurses and doctors witness medical errors, but few speak up when they see them. Requires a short registration.
When a report came out last week from a private group claiming that nearly 200,000 hospital patients die each year from preventable medical errors, it promptly sparked a fierce controversy.
Voluntary reporting systems to track and improve hospital error and infection rates don’t work well. Only public disclosure and reporting laws passed in some states have been successful. “Americans concerned about their health care should urge their senators to kill the misnamed Patient Safety and Quality Improvement Act,” states the editorial.
The United States Senate is on the verge of approving legislation that could decrease the quality of hospital care in New York and elsewhere around the country. It needs to take a moment to be sure it doesn’t. The Patient Safety and Quality Improvement Act allows hospitals to shield medical error data from public scrutiny. It adopts a popular and plausible theory that holds that doctors will own up to mistakes, thereby improving the practice of medicine, if they feel they are not sacrificing their careers. But the bill may have other, more insidious effects, if critics such as Consumers Union are correct.
Free online training courses for patients, family members, caregivers, etc
This tip sheet explains steps you can take within the hospital to deal with your concerns about quality of care. It tells you how to contact the places that regulate or oversee hospitals.
This tip sheet explains steps you can take within the nursing home to deal with your concerns about quality of care. It tells you how to contact places that regulate or oversee nursing homes.
Care About Your Care Discharge Checklist & Care Transition Plan
This month’s topics include injury risk from common medications, unnecessary testing, and unsafe injection practices in outpatient settings
Patient safety news collected by Health Watch USA.
Article by Dr. Harlan Krumholz on a condition of generalized risk after patients are discharged from the hospital.
KHN: Last fall, seeking to improve care and save money, Medicare announced penalties to hospitals to which too many patients returned within a month. Both payment changes are applied to payments for every hospital stay of a Medicare patient. This chart shows the effect of each of those programs on hospitals’ Medicare reimbursements per hospital stay, and the combined effect for the federal spending year that runs from last October through September 2013. Hospitals could gain up to 1 percent in payments or lose as much as 2 percent from the two programs combined.
AHRQ Case and Commentary by Charles Vincent, PhD: Patient story of wrong-site surgery
John James, Ph.D., Patient Safety America: “This month I address the discriminatory medical care system in this country. Why are the poor left behind when they need competent medical care? Next – why does Medicare keep spending your tax dollars on procedures that are not “necessary and reasonable?” What is behind the 29+ deaths that resulted from injection of the fungal-contaminated medication from a compounding company? The answer might surprise you. On the controversial front, I summarize an article critical of overuse of mammography screening. Why do prescription pain killers kill at least 16,000 Americans per year? How can a medication be dispensed to you when your doctor has ordered it stopped? Be wary of these potentially dangerous practices.”
Patient safety news collected by Health Watch USA.
Medical Malpractice Caps by State [Infographic]
Wrong-site surgery procedures in Minnesota are beginning to change practices and outcomes
John James, Patient Safety America: “This month I write about the so called ‘war on cancer’ in terms of those who are losing the battle to stay alive. Do they know that the chemotherapy that is making them so ill is not going to cure their disease? Do those who undergo screening for cancer know the risks they are taking on? What should we do about the overuse of imaging? Why do we continue to do human experimentation on premature babies with uncontrolled and unapproved procedures? Isn’t it time to stop this potentially risky practice on these little one? The obesity epidemic is growing like a plague in the United States – Are there new drugs that could reverse the trend toward more obesity and more chronic illness? Nursing homes are risky places for infections – here’s one you may not have thought about – norovirus. Finally, would you like electronic access to your doctor’s notes?”
Patient safety news collected by Health Watch USA. Health Watch USA 2012 Conference Information Now Online. Over 140 participants were at the 2012 Health Watch USA Conference. Topics included Shared Decision Making, Overutilization, Value Purchasing and Patient Engagement. Presentations now online include: Dr. Leana Wen, Dr. Joycelyn Elders, Dr Said Abusalem, and Rosemary Gibson. To view presentations and PowerPoints go to: http://www.healthwatchusa.org/conference2012/index.html
New Data has been posted for 2010 for CMS’s policy of recouping money for Healthcare Acquired Conditions. The data is not much different from the previous year. See Chart F Estimated Net Savings of Current HACs.
Review of book “Unaccountable” by Marty Makary, MD. The first two articles deal with medical errors – the first on diagnostic errors and the second on errors of omission. On page 3 I take a look at recent misdeeds of big Pharma, and then deal with ethical issues associated post-marketing drug testing on patients. A business model suggests that providers should start giving us what we really want – health – not medical care. Finally, we have a look at why hospital prices continue to escalate.
Patient safety news collected by Health Watch USA.
Patient safety article on bed rails and bed rail deaths. According to BSS, the FDA has reports of more than 525 deaths associated with the use of bed rails. The Consumer Product Safety Commission (CPSC) has reports of more than 155 deaths as well.
Free hospital care guide to help patients navigate the health care system and avoid harm.
1) The first order of business is to mark the passing of Dr. Barbara Starfield, a champion of improving medical care, especially through more emphasis on primary care.
2) Most of us have had a urinary catheter inserted for some reason or other, and it seems that the vast majority of the time infections associated with these are not evident in billing records.
3) Several articles that I review deal with overbilling and over-diagnosis, two pillars of our current medical industry.
4) A troubling article from Archives of Surgery enumerates the dependence many surgeons have on use of alcohol. You might be surprised at the findings.
5) The refusal of Jehovah’s Witness patients to accept blood transfusions after heart surgery offered an opportunity to study the need for such transfusions, with surprising outcomes.
6) Finally, I summarize information suggesting that a lot of money could be saved each year if drug-eluting stents were used with more evidence-based discrimination in patients receiving coronary artery stents.
The Institute of Medicine releases a new report “Best Care at Lower Cost,” that identifies three major imperatives for health care system change: the rising complexity of modern health care, unsustainable cost increases, and outcomes below the system’s potential. Issues recommendations to achieve needed transformation.
A Guide to Speaking Up When You Are Dissatisfied With A Health Care Experience by Health Care For All.
Carl Elliott, M.D., Ph.D. examines the policies that don’t protect injured clinical research subjects in the US.
Use this ProPublica tool to search more than 20,000 nursing home inspection reports, most completed since January 2011, and encompassing nearly 118,000 deficiencies. You can search by state or by the severity level of the deficiencies cited. The default search ranks results by the severity level of the problem found.
New report by New Yorkers for Patient & Family Empowerment and the New York Public Interest Research Group urging hospitals to have patient-centered visiting policies and to respect the patient’s right to decide who can visit.
The Government Accountability Office (the group that inspects activities happening within government agencies) has recently released a report on injection safety efforts currently underway at CDC and CMS. See page 26 of the report for a summary list of all of the outbreaks associated with unsafe injection practices.
Newsletter by John James, Ph.D.: This month’s newsletter includes a book review of “The Last Collaboration,” an artistic chronicle of a mother trying to help her seriously ill daughter run the gauntlet of hospital care. Other articles address the patient’s unfortunately small role in identifying drug side effects, a new way to make wise choices in your care, a dangerous surgery that the FDA has warned against, over-diagnosis of pulmonary embolism, and heart risks from a commonly used antibiotic. In addition, I have discussed two cancers – ovarian cancer and melanoma. You need to know about these.
Patient safety news and links from Health Watch USA.
HHS OIG report: An estimated 60 percent of adverse and temporary harm events nationally occurred at hospitals in States with reporting systems, yet only an estimated 12 percent of events nationally met State requirements for reporting. Hospitals reported only 1 percent of patient harm events.
In this issue: Book review of The Take-Charge Patient–discussed risks associated with dual-chamber implanted defibrillators, and surveyed the promise of comparative effectiveness research. The latter holds hope that one day we will be able to make informed and cost effective decisions about medical care. Last article deals with how difficult it will be to control healthcare spending in the face of of monumental waste in healthcare costs.
Newsletter features a detailed discussion of screening procedures, potentially dangerous medical devices and health care costs.
CesareanRates.com is a snapshot of online cesarean rate reporting in the United States as of January 2012. The site compiles the most current hospital-level data accessible to the public online, whether reported directly by a state’s department of health or gathered from state hospital association web sites via pull-down menus.
Newsletter covers topics of over diagnosis and overtreatment, the underreporting of medical harm events, and allowing the voice of patients to be heard in reporting medical errors.
The CT Department of Public Health releases its first hospital specific adverse event report.
Monthly patient safety newsletter by John T. James, Ph.D. of Houston, TX.
Maternal mortality is increasing in VA
Medicare hospital oversight failed to address serious medical errors such as medication and surgical errors, physical abuse by hospital staff, and patient suicide.
Response letter from The Joint Commission President, Mark Chassin, to patient safety advocates who called on the organization earlier this month to improve responsiveness to patient complaints.
Study: Nearly half of all primary care physicians in the United States think that their own patients are receiving too much medical care, and more than one-quarter believe that they themselves are practicing too aggressively.
Patient safety consumer groups, including Consumers Union, seek Senator Harkin to help in making Medicare accreditation surveys public.
A coalition of patient safety consumer groups, including Consumers Union, wrote a letter to the Joint Commission to improve responsiveness to patient complaints.
Information about the quality of care in your state by the Agency for Healthcare Research and Quality. Charts and individual state performance summaries based on more than 100 quality measures such as preventing pressure sores, screening for diabetes-related foot problems, and giving recommended care to pneumonia patients.
In the year 2000, 8000 children died of medical error in hospitals. Parents and advocates have joined together to try to improve quality and change healthcare policy.
Past and future webinars on patient safety.
Presentation by Kevin Kavanagh, MD on Healthcare Acquired Infections and public reporting which was given to the Kentucky Joint Senate and House Committee on Veterans, Millitary Affairs and Public Protection.
This tip sheet explains steps you can take within the nursing home to deal with your concerns about quality of care. It tells you how to contact places that regulate or oversee nursing homes.
This tip sheet explains steps you can take within the hospital to deal with your concerns about quality of care. It tells you how to contact the places that regulate or oversee hospitals.
New Jersey Department of Health and Senior Services information on the issues surrounding quality in ambulatory surgery centers. Info on how to file a complaint about an ambulatory surgical center and how to get a copy of individual inspection reports.
Report by the Center for Healthcare Decisions describes consumer perceptions of health care quality and provides new insights for those involved in public reporting.
The number of people treated in U.S. hospitals for illnesses and injuries from taking medicines jumped 52 percent between 2004 and 2008 – from 1.2 million to 1.9 million – according to the latest News and Numbers from the Agency for Healthcare Research and Quality. These medication side effects and injuries resulted from taking or being given the wrong medicine or dosage.
U.S. Department of Health & Human Services description of its new patient safety initiative.
When nurse staffing levels fell below target levels in a large hospital, more patients died, a new study discovered.
Report of four case studies of hospitals with low readmission rates.
Medicare released hospital specific data on hospital-acquired conditions – preventable errors that happened to hospital patients covered by Medicare over a 21-month period. This spreadsheet, which is available in a ZIP FILE, reveals only a small fraction of the 1 in 4 hospital medical errors, but is the first time this information has been made public. Later this year, the information will be presented on Hospital Compare in a more consumer-friendly format.
Editorial by Rosemary Gibson and Deborah Grady on the “Less Is More” series in the Archives; publishes research to help identify areas of medical care in which harm outweighs benefit. While most medical care is helpful or even lifesaving, not all medical care is good.
Advice and resources for dealing with quality concerns
Advice and resources for dealing with quality concerns
“Last year there wasn’t a single fatal airline accident in the developed world. So why is the U.S. health care system still accidently killing hundreds of thousands? The answer is a lack of transparency.”
Steps you can take if you are concerned about the quality of care in a NY nursing home.
Study finds one in four hospital patients are harmed.
An estimated 134,000 Medicare beneficiaries (13.5 percent) experienced at least 1 adverse event in hospitals during the 1-month study period.
“The California Department of Public Health (CDPH) announced today that 12 California hospitals have been assessed 14 administrative penalties after a determination that the facilities’ noncompliance with licensing requirements has caused, or was likely to cause, serious injury or death to patients.”
Abstract: Colorado study of physician self-reported adverse occurrences finds high frequency of surgical errors despite implementation of a surgical protocol that seeks to prevent them; researchers identified a total of 25 wrong-patient and 107 wrong-site procedures between January 2002 and June 2008.
Article about the common errors (including infection) that occur in dialysis units.
Graphic of some of the adverse events reported by California hospitals over the past two fiscal years.
Over a 2-year period, roughly one-quarter of all hospital patients were readmitted for the same conditions that prompted their initial hospitalization, according to the latest data from the Agency for Healthcare Research and Quality.
“Nearly one in five adverse events is due to erroneous diagnoses made by physicians.”
A series of articles on medical malpractice in Health Affairs outlines the real cost of malpractice in the U.S.
The magnetic field of the MRI scanner may exert forces on certain implanted objects that are susceptible to the effects of the magnetic field, potentially causing the object to move within the body, which could result in serious harm. Learn how you can help protect yourself.
Know what steps you can take to prevent a wrong-site surgery from happening to you or a loved one.
Patient injury reports indicate that it is important to use radiopaque sponges during any IR procedure in order to prevent the retention of foreign objects following IR procedures.
In 2008, the Pennsylvania Patient Safety Authority received approximately 150 reports describing events in which the magnetic resonance (MR) clinical screening process was inadequate and, in some cases, erroneously permitted patients with implanted pacemakers and other ferromagnetic objects into the MRI scanner room.
Nearly 1,000 event reports submitted to the Pennsylvania Patient Safety Authority specifically mentioned medication errors that occurred in care areas providing radiologic services.
PA annual report on state activities relating to hospital infections and medical errors.
Steps you can take if you are concerned about the quality of care in a CA nursing home.
What to do if you are concerned about your hospital’s quality of care and links to resources that can help. It addresses steps you can take within a hospital or with organizations that regulate or oversee hospitals.
The Hearst Newspapers have created a color coded map of state reporting systems for medical errors. States collect a variety of data in different ways. The amount of information available to the public also differs from state to state.
OIG report on the sad state of medical error reporting.
When our health care system remains silent about preventable medical harm it only creates more problems.
In 2008, there were 57,852 readmissions in Pennsylvania, amounting to approximately $2.5 billion in charges. In reported events involving the use of insulin products, 52% of the events led to situations in which a patient may have or actually received the wrong dose or no dose of insulin.
Des Moines hospital posts rates of hospital infection and patient falls, two common medical harm events.
Between June 2004 and October 2008, the Pennsylvania Patient Safety Authority received 316 reports involving shoulder dystocia. Neonatal injuries were identified in 124 (39%) of these reports and included fractures, brachial plexus injuries, and death.
Wrong site surgery incidents are decreasing, but analysis of anesthesia related errors indicates that “time out” should be done prior to administration of anesthesia, instead of prior to incision.
Learn about Maryland’s efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
Learn about Minnesota’s efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
Learn about Kansas efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
Learn about Missouri’s efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
A new report on state and federal nonpayment policies for preventable hospital acquired conditions and events that harm patients.
A new report on state and federal nonpayment policies for preventable hospital acquired conditions and events that harm patients.
U.S. Department of Health and Human Services (Jan 2010)
The Nevada Hospital Association has a list of all sentinel events for 2005, 2006, 2007, 2008 by hospital type; sentinel event type and sentinel event outcome.
The Rhode Island Department of Health cites Rhode Island Hospital for surgical errors; the full deficiency report, indicating failure to follow standard safety procedures, and compliance order can be found at: http://www.health.ri.gov/discipline/hospitals/RhodeIsland200911.pdf
A report shows that PA hospitals had a significant decrease mortality rates associated with hospital readmissions compared to the previous year. Readmissions often are due to complications or infections – in this case, the cause of 22,094 of PA readmissions, which accounted for almost $1.1 billion in charges and 157,000 hospital days. The report found that readmissions for complication or infection comprise 38.2% of all readmissions in PA.
See if hospitals in your county have had administrative penalties issued by the California Department of Public Health.
Texas Department of State Health Services
Analysis on how to prevent “retained foreign objects” or “RFOs” from the PA Patient Safety Authority.
Has the U.S. made any progress on patient safety since the Institute of Medicine (IOM) released To Err is Human in 1999?
Report date: August 25, 2008
A study of Medicare hospital records from 2003 and 2004 found that 1 in 5 patients was readmitted within 30 days, and half of non-surgical patients were rehospitalized without having seen an outpatient doctor in follow-up. In 2004 Medicare paid $17.4 billion to hospital for these readmissions. Readmissions are often avoidable and connected with problems in the hospital (like an infection) or with aftercare.
According to the CDC, the overall annual direct medical costs of hospital acquired infections to U.S. hospitals ranges from $28.4 to $33.8 billion.
Department of Health and Human Services, Office of Inspector General report on issues ranging from public and confidential reporting of adverse events, variations in estimates of adverse events, underreporting, measurements and nonpayment policyies for adverse events.
Agency for Healthcare Quality and Research (AHRQ) website for Patient Safety Organizations. The concept of PSOs is to collect data on medical harm while shielding the information from the public in order to encourage reporting by hospitals and doctors. All information obtained by the PSO’s is confidential and voluntary, which fails to inform consumers about how well their health care providers are doing on patient safety.
A comprehensive study issued today by the Office of the Comptroller William C. Thompson Jr., found that many New York City hospitals substantially underreport “adverse events” to the New York State Department of Health (DOH).
This GAO study found that 15% of hospitalized Medicare beneficiaries in two selected counties experienced an adverse event during their hospital stay.
Department of Health and Human Services Office of Inspector General Report
Department of Health and Human Services Office Of Inspecter General Report
The consequences of service deficiencies during off-hours include higher mortality and readmission rates, more surgical complications, and more medical errors. Given the health care industry’s renewed focus on ensuring patient safety and providing high-quality medical care, why hasn’t the situation changed at the “other hospital”?
Rules go into effect October 1, 2008.
The Institute for Healthcare Improvement has now signed up over 2900 US hospitals to participate in their 100,000 Lives campaign. The purpose of the campaign is to save lives by using proven methods to prevent hospital-acquired infections and medical errors. Consumers should know about these life-saving practices and if
Minnesota releases adverse events report released. The report identifies 27 different “medical errors” (such as operating on the wrong part of the body or wrong patient) and “adverse events” (such as patient falls, suicide, and abduction), it does not include hospital-acquired infections. A new bill filed in the MN legislature (HF 87) will require inclusion of hospital infections in the future.
GlaxoSmithKline (GSK) performed an analysis of suicidal behaviors in their paroxetine pediatric clinical trial database, and found that there was a statistically significant increase in suicide-related adverse events for paroxetine-treated subjects compared to placebo.
On November 14, 2003, I suffered two brainstem strokes after having an upper neck manipulation. Initially, I lost speech, feeling in my right side, had a facial droop and slurred speech. When admitted to the stroke center, I found out that this is a known risk of chiropractic upper neck manipulations.
In 1976 I had my back operated on (because I had a ruptured disk) and the doctor fused my back wrong. In 1978, a neurologist tried to fix it, but the damage was too extensive. I have had chronic pain every since.
98,000 people die each year needlessly because of preventable medical harm. Efforts to reduce this are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require it), scarce data does not paint a picture of real progress.
In this report (PDF) we give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.
The Safe Patient Project is a Consumers Union campaign focused on eliminating medical harm, improving FDA oversight of prescription drugs and promoting disclosure laws that give information to consumers about health care safety and quality.