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.
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.
Archive for Medical Errors
Consumers Union Documents
- Testimony of Consumers Union on Public Reporting of Medical Harm in MD
Testimony of Consumers Union regarding a bill requiring public reporting of medical harm March 3, 2011.
- Testimony of Consumers Union on Public Reporting of Medical Harm in HI
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
Model Medical Harm Disclosure Act
- Drug overuse threatens nursing home residents
Routine prescribing of powerful medications occurs too often, our investigation finds
- Staying safe in the hospital (pdf)
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.
- Preventable Harm: California Fails to Follow Through With Patient Safety Laws
- CU Letter to CA Department of Health Care Services (pdf)
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 Public Records Act Request to California Department of Public Health (pdf)
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)
- CU Comments to National Quality Forum on Definition of Serious Reportable Events
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
- Consumers Union “To Err Is Human, To Delay Is Deadly” Webcast
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
- Consumers Union Report: To Err is Human-To Delay is Deadly
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.
- State Medical Error Report Links
Reports from the states with laws requiring public reporting of medical errors.
- To Err is Human – To Delay is Deadly
Ten years later, a million lives lost, billions of dollars wasted
- Consumers Union petitions the FDA on drug safety
All too often, drug advertisements fail to present the benefits and risks of using prescription drugs in an accurate and balanced way.
- Testimony of Jim Guest President, Consumers Union, before the House
On PDUFA, Risk Evaluation & Mitigation Strategies, Clinical Trials, and Advisory Committee Conflicts.
- Text of S. 1082 Senate Drug Safety Bill
S.1082
Food and Drug Administration Revitalization Act (Engrossed as Agreed to or Passed by Senate) - Stay safe in the hospital
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.
- Is hospital quality of care data available in your state?
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.
- Avoiding Hospital Blunders (Knowing the Risks and Speaking Up Can Help You Stay Safe)
Consumer Reports on Health gives tips on avoiding hospital blunders.
- How To Find A Good Hospital
Consumer Reports on Health gives tips on finding the right hospital for your special needs.
Consumers Union News Releases
- Report Finds Medical Errors More Common
Consumers Union Calls For Public Reporting of Medical Errors
- California’s Enforcement of Patient Safety Laws Still Lagging
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
Report Finds That Only Half of California Hospital Workers Got Flu Vaccine
- Health Care Reform Law Poised to Make Health Care Safer
New Law Includes Important Patient Safety Provisions That Will Save Lives and Health Care Dollars
- Consumers Union Finds Slow Progress on Patient Safety in California
California Department of Public Health Has Failed to Carry Out Key Requirements of Recent Patient Safety Laws
- CU Report: U.S. Health Care System Fails To Protect Patients From Deadly Medical Errors
Consumers Union Assesses Lack of Progress Ten Years After Institute of Medicine Found Up To 98,000 Die From Preventable Errors
- Legislation shields medical error information but will not interfere with state mandatory reporting laws.
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.
Blog Posts
- New Resource for Those Dissatisfied with a Health Care Experience
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.
- U.S. Congressman dies following surgical error, infection
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.
- Delaying Is Deadly–Join Our Patient Safety Webcast on November 17
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.”
- Hospitals in the Blogosphere
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?
- RFO Encounters in Pennsylvania
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.
- Hospitals Own Up to Errors
Some Find That Confronting Mistakes Reduces Litigation—and Future Mishaps.
- Watch Money-Driven Medicine
A new documentary, Money-Driven Medicine, offers a thoughtful perspective to the health care reform debate that couldn’t be timelier.
- Patient Safety Advocates speak out on Health Care Reform
Read and sign the Patient Safety Advocates’ Statement on Health Care Reform.
- Dead by Mistake
Check out this new collection of medical errors reporting: “Dead by Mistake”
- In Honor of Patients
Join patient safety advocates across the country tomorrow to observe Patient Safety Day.
- Medicare releases data on hospital readmissions
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.
- Patient Safety Activists Represent Consumers at Presidential Health Care Forum
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.
- Insight from California Safe Patient Network
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.
- Not Another Ten Years
Our new report “To Err is Human – To Delay is Deadly” calls attention to the IOM’s unfulfilled call to action.
- Raise your hand if you’ve had a hospital-acquired infection
More people know about hospital acquired infections and medical errors than you might think, and not just from watching Oprah.
- Watch these personal stories — Quality Care Saves Lives!
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.
- Medical Mistakes show on Oprah
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.
- CMS decisions on non-payment for surgical errors
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.
- “I don’t want to die (in the hospital)”
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…
- Mother against medical error
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.
- NYT calls for doctors to be included in Medicare non-payment rules
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.”
- SC activist Dianne Parker fights for safer care
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…
- Actor, cancer survivor talks about being a “bad” patient
“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.
- Medicare won’t foot the bill for medical errors
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.
- You Score Higher Marks than Doctors
According to new FDA data, consumers like you make up the majority of drug adverse event reports submitted, replacing physicians.
- Some Hospitals Provide Rxs for Error, Dissatisfaction
You may remember Dennis Quaid from The Parent Trap but nowadays he’s speaking out against medical errors…
- 100 vs 1
I don’t know how many times I’ve seen the commercial where a beaver is talking to Abe Lincoln at a bus stop about some guy in a suit not being able to sleep. Or Dr. Jarvik (or his double?) rowing in a beautiful lake while telling us how Lipitor is the greatest thing since the last few blockbuster statins.
- 3 minutes of your time could save your life
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.
- No side effects, says who?
Is your doctor listening to you or the drug companies when it comes to pinpointing the cause of your symptoms?
- Next stop: House floor for drug safety
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.
- Avandia added to the growing list of drugs that just might kill you
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.
- Mandatory vaccine sparks controversy
Last week, TX Gov Rick Perry bypassed the state legislature and ordered that all girls entering 6th grade be vaccinated for the HPV virus, linked to cause cervical cancer.
News Articles
- Where We Live: Patient Safety Source: Your Public Media (Tuesday March 6, 2012)
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.
- Yes, Real-Time Monitoring Would Have Saved Leah Source: Pittsburgh Healthcare Report (Thursday February 2, 2012)
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.
- Doctor, Did You Check Your Checklist? Source: Kaiser Health News (Monday January 30, 2012)
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.
- Hospital Errors Persist, State Probes Rare Source: Connecticut Health I-Team (Sunday January 29, 2012)
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.
- Federal suit claims Hamot, heart doctors defrauded Medicare Source: Erie Times-News (Sunday January 22, 2012)
Heart doctors put heart stents into patients who didn’t need them.
- Danger in delivery: Despite technology, U.S. trails entire western world in saving mothers Source: News-Register (Wednesday January 18, 2012)
Cesarean sections, once considered emergency procedures, have become all but routine in the U.S. Experts say the procedure contributes to maternal deaths.
- Number of adverse health events in Minnesota hospitals increases slightly in 2011
Minnesota’s 2011 Adverse Events Report press release
- Northeast Florida hospitals reducing readmissions Source: The Florida Times-Union (Wednesday January 11, 2012)
Area hospitals working to reduce readmission rates, which are often due to poor discharge planning.
- Editorial: Tracking medical errors remains stubbornly inconsistent Source: St. Louis Post-Dispatch (Wednesday January 11, 2012)
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.
- Report Finds Most Errors at Hospitals Go Unreported Source: New York Times (Friday January 6, 2012)
The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.
- Video: Hospital Mix-Ups More Common Than Thought Source: ABC News (Friday January 6, 2012)
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.
- Report: Hospital Errors Often Unreported Source: ABC News (Friday January 6, 2012)
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.
- Patients should have access to data on hospital errors Source: Consumer Reports (Monday January 9, 2012)
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.
- Gone Without a Case: Suspicious Elder Deaths Rarely Investigated Source: ProPublica (Wednesday December 21, 2011)
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.
- Without Autopsies, Hospitals Bury Their Mistakes Source: ProPublica (Thursday December 15, 2011)
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.
- Why Can’t Linda Carswell Get Her Husband’s Heart Back? Source: ProPublica (Thursday December 15, 2011)
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.
- Indiana medical errors hit five-year high Source: Clinical Advisor (Tuesday December 20, 2011)
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.
- Ventilator errors are linked to 119 deaths Source: Boston Globe (Sunday December 11, 2011)
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.
- Public Health Department Fines 14 Hospitals for Patient Safety Errors Source: California Healthline (Friday December 9, 2011)
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.
- Immediate Jeopardy: 14 CA Hospitals Fined $850,000 Source: HealthLeaders Media (Monday December 12, 2011)
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.
- Hospitals Tumble on Medicare Order for Heart Procedure Audit Source: San Francisco Chronicle (Sunday December 4, 2011)
“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.”
- Patient Safety Advocates Start New England Watchdog Group Source: CT Health I-Team (Tuesday November 22, 2011)
New England patient safety activists form New England Voices For Error Reduction (NEVER), a group that aims to work regionally for safe health care.
- Bad Medicine Source: The Texas Observer (Thursday November 10, 2011)
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.
- Delay In Results May Have Led To Baby's Death Source: KMGH Denver (Sunday November 13, 2011)
Couple believes their newborn died from a hospital’s delay in test results.
- 4-Year-Old Dies During Dental Surgery Source: KCRA (Tuesday November 15, 2011)
4-year-old dies during dental surgery and his family is searching for answers to find out what led to his death.
- Goodbye to Ohio’s hospital performance comparison website? Source: Medcity (Friday October 28, 2011)
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.
- Woman fights to end medical errors Source: WIVB (Thursday November 3, 2011)
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: Improve tracking of serious hospital errors Source: USA Today (Tuesday November 1, 2011)
Medicare report: Only 28 of 88 immediate jeopardy patient safety complaints reported to Medicare.
- Woman's death attributed to medical error Source: WIVB (Tuesday November 1, 2011)
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.
- 'Never events' at hospitals go unnoticed Source: News-Leader (Saturday October 29, 2011)
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 cited for safety violations Source: Los Angeles Times (Saturday October 29, 2011)
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.
- Editorial: Public needs more details on patient safety at hospitals Source: Dallas Morning News (Monday October 17, 2011)
The public needs more information about how well their hospitals and doctors perform on ensuring the safety of their patients.
- Deficiencies at Grady Memorial Prompt CMS Review Source: HealthLeaders Media (Tuesday October 18, 2011)
Another major public hospital cited for serious deficiencies by CMS prompted by the death of a 60-year-old patient.
- How safe is your hospital? New website lets you check Source: msnbc.com (Monday October 17, 2011)
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.
- Things May Get Worse For ‘Worst’ Hospitals, Study Warns Source: Kaiser Health News (Wednesday October 5, 2011)
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.
- Stenting's Steep Learning Curve Linked to High Mortality Rates Source: HealthLeaders Media (Friday September 30, 2011)
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.
- Patient advocates seek public access to hospital accreditation surveys Source: Healthcare Finance News (Thursday September 22, 2011)
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.
- Remedy Is Elusive as Metallic Hips Fail at a Fast Rate Source: NYT (Friday September 30, 2011)
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.
- Hospitals readmission rates under scrutiny Source: Austin American-Statesman (Wednesday September 28, 2011)
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.
- Americans get too much healthcare, their docs say Source: Reuters (Monday September 26, 2011)
Physicians think they are too agressive with medical care in their own practice.
- Maggots found in shoes of man staying at Wichita nursing home Source: WSBT (Wednesday September 21, 2011)
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.
- Lack of training can be deadly in cosmetic surgery Source: USA Today (Friday September 16, 2011)
USA Today reports on the lack of safety oversight of doctors who perform cosmetic surgery, which can be painful and deadly.
- Three quarters of nurses fear for their patients' safety Source: Nursing Times (Monday September 19, 2011)
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.
- Woman's death raises questions about nursing home medical records Source: Sacramento Bee (Monday September 19, 2011)
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.
- Falsified patient records are untold story of California nursing home care Source: Sacramento Bee (Sunday September 18, 2011)
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.
- Health-Care Reform Rules Would Restrict Public Reporting Source: ProPublica (Thursday September 15, 2011)
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.
- Report Finds Improved Performance by Hospitals Source: New York Times (Wednesday September 14, 2011)
NYT coverage of the Joint Commission report on hospital process measures. Consumers Union Safe Patient Project Director, Lisa McGiffert, quoted: “Highlight the poorest performers.”
- Rater: 16 South Florida hospitals among nation's best Source: Sun Sentinel (Wednesday September 14, 2011)
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.
- Justice Department investigating Parkland Memorial Hospital patient care, billing Source: Dallas Morning News (Friday September 9, 2011)
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.
- 12 hospitals are fined over medical errors Source: Los Angeles Times (Thursday September 8, 2011)
The California Department of Public Health fines 12 hospitals for patient safety violations likely to cause serious injury or death.
- Hospitals fined $650k for patient safety violations in California Source: Fierce Healthcare (Thursday September 8, 2011)
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.
- Groups push for Congress to open hospital accreditation reports Source: Lexington Herald-Leader (Thursday September 8, 2011)
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.
- Family: Errors at Children's Hospital Contributed to Boy's Death Source: KTLA (Friday September 2, 2011)
A California family is claiming that their loved one suffered medical errors at a children’s hospital that lead to his death.
- How Hospitals Harm Us Source: Daily Beast (Wednesday August 31, 2011)
Effective and disturbing graphics and statistics on hospital patient safety performance. (Medical Billing and Coding)
- CT Scans Linked to Cancer Source: Wall Street Journal (Tuesday December 15, 2009)
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.
- Insight: DePuy's handling of hip recall sparks questions Source: Reuters (Monday August 22, 2011)
“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.”
- NY woman, university fight against medical errors Source: Wall Street Journal (Monday August 22, 2011)
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.
- Just 1 in 5 medical malpractice cases end in settlements or judgments for patients, study says Source: Washington Post (Wednesday August 17, 2011)
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.
- Seven Hospitals Share Distinction Of Highest Readmission Rates Source: Kaiser Health News (Tuesday August 9, 2011)
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.
- Medicare data can help patients fill perception gap Source: USA Today (Friday August 5, 2011)
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.
- Medicare data show gap in hospital performance, perception Source: USA Today (Friday August 5, 2011)
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.
- Patient Safety America Newsletter
The newsletter includes great information about the safety of drug devices.
- Some Calif. Hospitals Could Lose Medicare Funds Under CMS Rule Source: California Healthline (Thursday August 4, 2011)
“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).”
- Medicare rule would decrease payments to hospitals with high re-admission rates Source: The Washington Post (Saturday July 30, 2011)
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].
- Mary Brennan-Taylor, advocate for change Source: Lockport Union-Sun & Journal (Monday August 1, 2011)
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.
- U.S. health care system fails to deliver Source: Politico (Sunday July 31, 2011)
Don Berwick editorial: U.S. health care system fails to deliver
- Medicare To Examine Quality Of Care At Outpatient Surgery Centers Source: Kaiser Health News (Tuesday July 26, 2011)
Starting in October 2013, Medicare payments to outpatient surgery centers will be affected by the rates of problems at these facilities.
- U.S. Attorney says nursing home's 'worthless' care led to deaths, injuries Source: Kentucky Herald-Leader (Tuesday July 19, 2011)
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.
- 72 suits could be filed against Excela Source: Tribune-Review (Thursday July 21, 2011)
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 risk reduced during pilot project Source: American Medical News (Monday July 18, 2011)
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.
- Our pediatrician gave my daughter the wrong vaccine Source: Salon (Wednesday July 20, 2011)
Young girl given the wrong vaccine.
- Going into hospital far riskier than flying Source: Los Angeles Times (Thursday July 21, 2011)
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.
- Screening ECGs For Young Athletes Present Interpretation Challenges Source: Internal Medicine News (Wednesday July 13, 2011)
Many ECGs are misinterpreted, which could be detrimental to young athletes if ECGs became a part of routine sports preparticipation screening.
- Texas hospital mistakes to be reported, new tools for patients Source: WeAreAustin.com (Tuesday July 19, 2011)
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.
- UCSF Study Backs Idea That Medical Errors Go Up in July Source: California Healthline (Thursday July 14, 2011)
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.
- The hospital patient’s safety checklist, part 2 Source: Bangor Daily News (Monday July 11, 2011)
Doctor authors patient safety checklist. Patient safety activist Kathy Day responds in the comment section.
- Patient co-pilot checklist for safety — Part 1 Source: Bangor Daily News (Monday June 27, 2011)
Doctor authors patient safety checklist.
- Heart Treatment Overused Source: Wall Street Journal (Wednesday July 6, 2011)
Angioplasty in patients without symptoms is totally overused. But where is the pressure to stop paying for them?
- When the treatment makes patients sick Source: The Atlanta Journal-Constitution (Sunday June 12, 2011)
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.
- Denver Hospital Sets the Bar for Patient Safety Source: PBS (Thursday June 30, 2011)
“[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: Limiting resident physicians' work hours to save lives Source: Los Angeles Times (Friday July 1, 2011)
Op-ed by Helen Haskell (Mothers Against Medical Error) and Lucian Leape (Harvard School of Public Health) on resident work hours.
- Illinois Appellate Court Ruling Means Hospitals Must Release Data about Incidents of MRSA Infections Source: dBusiness News (Wednesday June 29, 2011)
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.
- Many hospitals overuse double CT scans, data show Source: Washington Post (Saturday June 18, 2011)
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.
- Mistakes In Outpatient Care Raising Concerns Source: Kaiser Health News (Tuesday June 28, 2011)
Study on medical errors in outpatient settings such as doctors’ offices and urgent care centers.
- Effort To End Surgeries On Wrong Patient Or Body Part Falters Source: Kaiser Health News (Monday June 20, 2011)
Some researchers and patient safety experts say the problem of wrong-site surgery has not improved over the years and may be getting worse.
- Medical misdiagnoses can have fatal consequences Source: The State Journal-Register (Sunday June 26, 2011)
Diagnostic errors, a subset of medical errors, can lead to devastasting harm for patients.
- 'Double' Chest Scans Increase Costs And Exposure To Radiation Source: Kaiser Health News (Saturday June 18, 2011)
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.
- Grave errors often not reported, data suggest Source: Reno Gazette-Journal (Sunday June 19, 2011)
Nevada’s new reporting laws will help Nevadans make decisions about care and shed light on whether hospitals are reporting their errors accurately.
- Body Imaging Business Pushes Scans Many Don't Need — Including Me Source: ProPublica (Tuesday June 7, 2011)
Has someone called you to offer a free heart scan? Read this ProPublica article first.
- N.J. bill targets unlicensed surgery centers Source: NorthJersey.com (Thursday May 26, 2011)
“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 receives $10 million to open patient safety institute Source: Baltimore Sun (Thursday May 26, 2011)
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.
- Live health chat: Staying safe in the hospital Source: WPMT (Tuesday June 7, 2011)
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).
- Patient advocacy group aims to educate Source: Littleton Courier (Friday May 20, 2011)
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.
- Reporting On Hidden Dangers Of Medical Radiation Source: NPR (Monday May 16, 2011)
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.
- Study: Many elderly get colon screening too often Source: USA Today (Monday May 9, 2011)
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.
- 21 dialysis clinics in S.C., including 1 in Moncks Corner, listed as having alarmingly high death rates Source: The Post and Courier (Saturday May 7, 2011)
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.
- Medical error rate report questioned by Central Ohio hospitals Source: Business First (Friday May 6, 2011)
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.
- Patient's family seeks answers Source: St. Louis Post Dispatch (Thursday May 5, 2011)
Ambiguous records at St. John’s and inability to get information frustrate wife and daughter of man, now deceased.
- Prostate Exam Deaths From ‘Superbugs’ Spur Inquiry Into Cancer Tests Source: Bloomberg (Thursday May 5, 2011)
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.
- Laser Spine Surgery More Profitable Than Google Sees Complaints Source: Bloomberg (Wednesday May 4, 2011)
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 Roll Out Checklists to Reduce Medical Errors Source: Becker's ASC Review (Thursday April 7, 2011)
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.
- Iowa Doesn't Require Reports of Medical Errors Source: KCRG-TV9 (Sunday April 9, 28)
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.
- Patients, beware of wrong-side surgeries Source: CNN (Thursday April 28, 2011)
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.
- Editorial: Hospitals Shouldn’t Make You Sicker Source: New York Times (Sunday April 17, 2011)
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.
- 1 in 3 patients harmed during hospital stay Source: American Medical News (Monday April 18, 2011)
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.
- Las Vegas Sun named Pulitzer Prize finalist for series on hospital care in Las Vegas Source: Daily Reporter (Monday April 18, 2011)
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.”
- Health care transparency bills clear state Senate committee Source: Las Vegas Sun (Thursday April 14, 2011)
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.
- Partnership for Patients aims to cut errors Source: San Antonio Express-News (Friday April 15, 2011)
A recently announced initiative announced by the federal government aims to reduce medical harm like the kind suffered by William Wittman of San Antonio.
- Reducing the Cost of Medical Errors: Spend A Little To Save A Lot Source: Health Beat Blog (Wednesday April 13, 2011)
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,
- Obama Administration Introduces Plan to Reduce Preventable Medical Errors Source: PBS (Tuesday April 12, 2011)
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.
- White House targets medical errors Source: Los Angeles Times (Wednesday April 13, 2011)
The Obama administration announced Tuesday an initiative aimed at reducing the number of medical errors that occur in U.S. hospitals.
- New hospital-safety plan leaves patients in the dark Source: Consumer Reports Health (Tuesday April 12, 2011)
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.
- How Safe is Your Hospital? NV Legislation Addresses the Issues Source: Public News Service (Tuesday April 12, 2011)
“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.”
- HHS takes aim at medical errors, health care costs Source: CNN Health (Tuesday April 12, 2011)
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 Drops, Mortality Rates Rise: Study Source: Business Week (Wednesday March 16, 2011)
“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 releases data on hospital errors Source: St. Louis Post-Dispatch (Thursday April 7, 2011)
Medicare now offers some information on medical errors to allow patients to compare hospitals’ safety records.
- Hospital errors are costing $17 billion a year Source: Marketplace From American Public Media (Thursday April 7, 2011)
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.
- Medical errors in hospitals go undetected, study suggests Source: LA Times (Thursday April 7, 2011)
The number medical errors occuring in hospitals might be 10 times greater than previously measured, reports the April issue of Health Affairs.
- Warning flags: How safe is your hospital? Source: Chicago Tribune (Thursday March 31, 2011)
What kind of information can you find out about your local hospital?
- Hospital infection disclosure bills gaining support Source: Las Vegas Sun (Tuesday April 5, 2011)
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.
- Feds to Follow ProPublica, Release Dialysis Clinic Data Source: ProPublica (Tuesday March 29, 2011)
Federal regulators say they are moving to make once-confidential data about the performance of kidney dialysis clinics more readily available to the public.
- A century later, openess still gets tepid embrace Source: Las Vegas Sun (Sunday March 27, 2011)
Even though progress has been made, still, some in the health care industry resist the calls for transparency.
- Mistake admitted, respect earned Source: Las Vegas Sun (Sunday March 27, 2011)
Surgeon who performed wrong surgery on a patient admitted his error and wrote up the case in The New England Journal of Medicine.
- Admitting harm protects patients Source: Las Vegas Sun (Sunday March 27, 2011)
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: An examination of medical education and medical care at Parkland Memorial Hospital
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.
- Bills would make hospitals’ data on safety issues public Source: Las Vegas Sun (Thursday March 24, 2011)
Several patient safety bills have been filed in the Nevada legislature in hopes of bringing more transparency to medical care in Nevada hospitals.
- Medical Harm: What's a consumer to do?
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.
- Legislative measure seeks medical-board transparency Source: Seattle Times (Thursday March 17, 2011)
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.
- Hospital Safety Series
An archive of Trudy Lieberman’s recurring series on hospital safety
- Keeping an Eye on Hospital Safety, Part II Source: Columbia Journalism Review (Thursday March 10, 2011)
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.
- Glenwood case led to national recall Source: Glenwood Springs Post Independent (Thursday March 10, 2011)
Local boy who’s battling leukemia contracted bacterial infection from tainted alcohol wipes recalled by the FDA two months later.
- Op Ed: Hospital acquired infection is the gorilla in the room Source: Minute Man News Service (Wednesday March 9, 2011)
“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.”
- HealthGrades study finds patients are 46% less likely to experience error in top-rated hospitals
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.
- Colo. hospital blew whistle on contaminated wipes Source: MSNBC.com (Monday March 7, 2011)
Spate of serious infections caused by rare bacteria sparked massive recall, investigation
- Do expensive buildings improve health care? Source: Concord Monitor (Thursday March 3, 2011)
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.
- Editorial: Missouri hospitals owe it to the public to admit their mistakes. Source: St. Louis Post-Dispatch (Monday February 28, 2011)
Post-Dispatch Editorial Board: Patients have a right to know a hospital’s track record.
- 9 Md. hospitals report higher-than-average rates of complications Source: Washington Post (Thursday February 24, 2011)
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.
- Hospitals leery of reporting serious errors Source: St. Louis Post-Dispatch (Sunday February 27, 2011)
Missouri hospitals don’t want people to know when and where medical mistakes happen – and no law requires them to tell.
- Patients in peril? Source: The Columbia Daily Tribune (Sunday February 27, 2011)
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.
- Study: Medical Errors in NC Indicative of Nationwide Problem Source: Public News Service (Friday December 10, 2010)
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.”
- The story of Michael Skolnik and Citizens for Patient Safety Source: Gary Schwitzer's HealthNewsReview Blog (Monday February 21, 2011)
“If you haven’t heard Michael Skolnik’s story, you should.”
- Proposed bill to require written consent from living family for autospy Source: The Katy Times (Monday February 21, 2011)
2004 death of Jerry Carswell at Katy hospital influenced introduction of HB 1009
- EMMC's nurses still fighting for adequate staffing Source: Bangor Daily News (Monday February 21, 2011)
“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?”
- Download event flyerFree Workshop in Denver March 5, 2011: Finding Your Way Through a Safe Healthcare Journey
Free Workshop by Patty Skolnik, Founder and Director, Citizens for Patient Safety. Must RSVP. For more information contact Breanna Sakis (Breanna.Sakis@HealthONEcares.com)
- Released hospital patients' many unhappy returns Source: San Francisco Chronicle (Wednesday February 16, 2011)
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.
- Study finds FDA's less stringent medical device approval process faulty
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.
- Irresponsible marketing for Lap-Bands may have deadly consequences Source: Reporting on Health (Friday February 11, 2011)
Three CA patients have died after weight-loss surgeries at one clinic alone.
- Rates of Early Elective Births 'Disturbing,' Says Watchdog Group Source: HealthLeaders Media (Friday January 28, 2011)
“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.”
- Inspection to determine if MountainView loses Medicare payments Source: Las Vegas Sun (Thursday January 20, 2011)
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.”
- Medication errors rise sharply at Minnesota hospitals Source: Star Tribune (Wednesday January 19, 2011)
Annual statewide report shows spike in medication errors during previous year.
- Minnesota Medical Mistake Report Released Source: Minnesota Fox 9 (Thursday January 9, 20)
“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.”
- Too much medical care can kill, author warns in Texas Source: American-Statesman (Saturday January 15, 2011)
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.
- Dialysis center complaints unsubstantiated Source: Merced Sun-Star (Friday January 7, 2011)
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.
- St. Luke's review finds almost 30% echocardiograms are misread Source: Journal Sentinel (Tuesday June 22, 2010)
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.
- Some patients overexposed to radiation, CoxHealth says Source: News-Leader.com (Thursday February 25, 2010)
Hospital probing any possible link to deaths.
- Patients first: Experts look at hospitals that emphasize safety Source: Las Vegas Sun (Monday January 10, 2011)
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.
- CT Advocate: Medical Errors Take a Horrendous Toll Source: Public News Service (Tuesday January 11, 2011)
“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.
- Harm in Hospitals Source: Hartford Courant (Monday January 10, 2011)
Editorial: Preventable deaths They will continue until there is a national strategy to stop them
- 'You can’t kill my mother and get away with it' Source: Las Vegas Sun (Sunday December 26, 2010)
Article by Marshall Allen after attending Consumers Union’s Safe Patient Project 2010 summit.
- How to put patients first Source: Las Vegas Sun (Sunday December 26, 2010)
Part 5 in the Las Vegas Sun series Do No Harm: Hospital Care in Las Vegas.
- Sen. Grassley Demands Information on Dialysis Clinic Conditions Source: ProPublica (Wednesday December 22, 2010)
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.
- A Pinpoint Beam Strays Invisibly, Harming Instead of Healing Source: New York Times (Tuesday December 28, 2010)
Medical radiation harm can do serious damage to patients and it is unclear what safety measures are in place to prevent future harm.
- Where We Live: Dubious Docs Source: YourPublicMedia.org (Wednesday December 22, 2010)
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.
- Why We Still Kill Patients: Invisibility, Inertia, And Income Source: Health Affairs Blog (Monday December 6, 2010)
“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.”
- Most Elderly Stroke Patients Fare Poorly After Hospital Discharge Source: National Nursing News (Monday December 20, 2010)
Nearly 60% of Medicare stroke patients die or are rehospitalized within a year of their initial discharge, according to a study by UCLA.
- Letter to the Editor: The gift of care Source: Bangor Daily News (Monday December 20, 2010)
Adequate nurse staffing can help patient safety.
- Top Spine Surgeons Reap Royalties, Medicare Bounty Source: The Wall Street Journal (Monday December 20, 2010)
The hospitals that collect the most Medicare dollars for spine fusion play host to many of the surgeons paid by Medtronic
- DMN Investigates: Lax supervision of residents at U.S. teaching hospitals puts patients at risk Source: The Dallas Morning News (Sunday December 19, 2010)
The public gets only glimpses of how often patients die or are injured by unsupervised residents.
- Quality ratings on coronary artery bypasses made public with surgeons' help Source: Amednews.com (Sunday September 12, 2010)
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.
- NYT Letter to the Editor: New Ways to Prevent Hospital Errors Source: New York Times (Wednesday December 1, 2010)
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.”
- Study finds room for improvement on NC patient safety Source: Asheville Citizen-Times (Tuesday November 30, 2010)
A six-year study at 10 North Carolina hospitals showed no decline in so-called patient “harms,” which included medical errors and unavoidable mistakes.
- Editorial: Danger: Hospital care ahead Source: Philadelphia Daily News (Wednesday December 1, 2010)
A study shows that many institutions lack a ‘culture of safety’
- Hospital botches operation causing healthy woman to lose both legs Source: Natural News.com (Monday November 29, 2010)
A medical error turned a routine surgury into a horror story for a New York woman.
- Plastic surgery centers that fail state standards still allowed to accept patients Source: Los Angeles Times (Tuesday November 30, 2010)
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.
- California's Cosmetic Surgery Centers Operate With Limited Oversight Source: California Healthline (Tuesday November 30, 2010)
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.
- Hospital Care in Las Vegas: Why we suffer Source: Las Vegas Sun (Sunday November 14, 2010)
Substandard hospital care has roots in a culture of seeking profits, shunning best practices, turning away from problems.
- 10 Things I Learned at the Consumers Union Safe Patient Summit - Part 2 Source: Reporting on Health (Wednesday November 24, 2010)
Bill Heisel of Reporting on Health and Antidote adds more ideas he learned at CU’s Safe Patient Project 2010 summit in Austin.
- No errors reported by nearly 90 California hospitals Source: Los Angeles Times (Saturday November 27, 2010)
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.
- Study Finds No Progress in Safety at Hospitals Source: New York Times (Wednesday November 24, 2010)
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.
- MRSA infections (video) Source: TBD.com (Friday November 19, 2010)
Activist Michael Bennett sharing his story in the wake of the Office of Inspector General report on medical errors.
- Deaths Drop After Release of Bypass Surgery Results Source: Bay Citizen (Monday October 18, 2010)
“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.”
- Study: Patients suffering harm in hospitals a national problem Source: Las Vegas Sun (Wednesday November 17, 2010)
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.
- Errors kill 15,000 aged US patients a month-study Source: Reuters (Tuesday November 16, 2010)
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.
- Mistakes Chronicled on Medicare Patients Source: New York Times (Monday November 15, 2010)
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.
- Hospital care fatal for some patients Source: USA Today (Tuesday November 16, 2010)
“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.”
- In Dialysis, Life-Saving Care at Great Risk and Cost Source: ProPublica (Tuesday November 9, 2010)
Dangerous dialysis that can harm or infect US kidney patients exposed in a ProPublica’s recent investigation.
- When Needles Dislodge, Dialysis Can Turn Deadly Source: ProPublica (Wednesday November 10, 2010)
“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.”
- Parkland knee surgery done by doctor in training leads to amputation, questions Source: Dallas Morning News (Saturday November 13, 2010)
TX woman harmed by knee surgery that leads to additional surgeries, high debt, and eventually amputation.
- State Officials Fine 12 Hospitals for Major Patient Safety Issues Source: California Healthline (Monday November 15, 2010)
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.
- Surgery error leads doc to public mea culpa Source: msnbc.com (Wednesday November 10, 2010)
Surgeon goes public with his operation mistake.
- Editorial: Reducing Medical Errors in Indiana Source: Fort Wayne Journal Gazette (Wednesday September 1, 2010)
“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.”
- Wrong-patient, wrong-site procedures persist despite safety protocol Source: American Medical News (Monday November 1, 2010)
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.
- Contemplating Safety While Lying Down Source: Prepared Patient Forum (Monday November 1, 2010)
How can patients stay safe in the hospital if they are too ill to be vigilant about their own care?
- When Errors Occur
How do hospital CEOs handle conversations with family members that occur at their hospitals?
- Senate Probes Reasons for Adverse Hospital Events Source: California Healthline (Thursday October 21, 2010)
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.
- Parents want answers after baby's death Source: thestar.com (Friday October 15, 2010)
Five years after her death, family struggling to find answers about the death of their infant at a Toronto hospital.
- The fight for medical information after patients die Source: CTV News (Saturday October 9, 2010)
Family members of medical error victim left in the dark due to hospital cover up.
- Mothers to lead free training on Staying Safe in the Hospital – Join us in San Diego on Saturday Source: MomsRising Blog (Thursday October 7, 2010)
Mothers will lead a patient safety training sponsored by Consumers Union’s Safe Patient Project.
- SC coroners investigate deaths from medical errors Source: TheSunNews.com (Saturday October 2, 2010)
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.
- Medication errors like those at Children's common, underreported Source: Hearst Newspapers (Friday October 1, 2010)
Follow up story to a Hearst investigation published on Seattlepi.com about under reporting of medical errors in Washington State.
- Despite law, medical errors likely go unreported Source: Hearst Newspapers (Sunday September 26, 2010)
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.
- Doctors Confess Their Fatal Mistakes
Read doctors’ confessions about medical errors and what has to improve to keep us safe.
- Mistakes, advances in New York's hospitals Source: Times Union (Monday September 20, 2010)
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.
- No reason to cover up mistakes Source: Boston Globe (Wednesday September 15, 2010)
Boston Globe editorial: doctors need to fess up when they harm patients.
- Doctors find 1-square-foot sponge inside patient Source: Todayshow.com (Wednesday September 15, 2010)
A huge surgical sponge is left inside a Florida man after an operation.
- A Rush to Operating Rooms That Alters Men's Lives Source: New York Times (Monday August 30, 2010)
Is it necessary to rush men with prostate cancer to the operating room?
- In Wash., Adult Family Homes Draw Scrutiny Source: NPR (Tuesday September 14, 2010)
A series in the Seattle Times newspaper highlighted problems and deaths due to neglect at adult family homes in Washington State.
- For-profit hospitals performing more C-sections Source: California Watch (Saturday September 11, 2010)
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.
- Do No Harm: Hospital Care in Las Vegas
This is the summary of all of the articles the Las Vegas Sun has done on medical harm.
- Keeping an Eye on Hospital Safety Source: Columbia Journalism Review (Thursday September 2, 2010)
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.
- NH patient advocacy group becoming a nonprofit Source: AP (Monday September 6, 2010)
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.
- Caifornia healthcare workers' flu vaccination rates lagging Source: VaccineNewsDaily.com (Friday September 3, 2010)
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.
- Report: Only 50 Percent of Hospital Workers Vaccinated Against Flu Source: Capital Public Radio's "KXJZ News (Thursday September 2, 2010)
UC Davis responds to Consumers Union’s report on low flu vaccination rates at California hosppitals.
- Half of hospital workers didn’t get flu shots, Consumers Union finds Source: Healthycal.org (Thursday September 2, 2010)
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.
- U.S. Inaction Lets Look-Alike Tubes Kill Patients Source: New York Times (Friday August 20, 2010)
Feeding tube hospital errors causing serious injury or death signal problems with hospitals, medical device companies and FDA.
- A breakthrough in medical transparency Source: Las Vegas Sun (Sunday June 27, 2010)
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.
- Fire in the OR and how hospitals should report medical mistakes
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.
- After Stroke Scans, Patients Face Serious Health Risks Source: New York Times (Saturday July 31, 2010)
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.
- Girl, 16, dies during restraint at an already-troubled hospital Source: St. Louis-Post Dispatch (Sunday August 1, 2010)
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.
- Serious medical errors, little public information Source: St. Louis Post-Dispatch (Sunday August 1, 2010)
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.
- Heavy patient falls off operating room table — later dies Source: Seattle Times (Wednesday July 28, 2010)
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.
- Baby is breast-fed by wrong woman at Virginia Hospital Center Source: Washington Post (Wednesday July 28, 2010)
Hospital mix up in patient identification causes newborn to be breastfed by wrong mom.
- Screening for Sepsis Could Save Lives, Researchers Say Source: US News and World Report (Tuesday July 20, 2010)
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.
- Ob-Gyns Issue Less Restrictive VBAC Guidelines Source: HealthCanal.com (Thursday July 22, 2010)
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.
- Prone to Error: Earliest Steps to Find Cancer Source: NYT (Monday July 19, 2010)
“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.”
- Prone to Error: Earliest Steps to Find Cancer Source: New York Times (Monday July 19, 2010)
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.
- The Wrong Stuff Source: Slate (Monday June 28, 2010)
Astronaut turned patient safety expert interview on what patient safety advocates can learn from NASA.
- Are hospitals deadlier in July? Source: CNN (Thursday July 8, 2010)
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.
- July: A Deadly Time For Hospitals Source: NPR (Monday July 5, 2010)
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.
- Health care can hurt you Source: Las Vegas Sun (Sunday June 27, 2010)
Sun’s investigation of Nevada hospital data shows 969 incidents of inpatient injuries — some that can be deadly
- Back in the hospital again Source: Boston Globe (Monday June 21, 2010)
If you get admitted to a hospital, chances are way too good that you’ll be back before long — maybe more than once
- A New Survey Reveals What Most Hospitals Patients Don’t Know About the Residents Who Care For Them-- Part 1 Source: Health Beat (Wednesday June 2, 2010)
Blog post series by Maggie Mahar on resident work hours.
- July: When not to go to the hospital Source: Science News (Wednesday June 2, 2010)
A new study finds medication error rates spike 10 percent in the month of July.
- Hospitals Fined More than $1M For Failure to Report Adverse Events Source: HealthLeaders Media (Thursday June 3, 2010)
“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.”
- Avoidable mistakes rise despite hospital efforts Source: San Francisco Chronicle (Wednesday June 2, 2010)
“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 surgical fires could improve patient safety in Ohio, experts say Source: Cleveland.com (Tuesday May 11, 2010)
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 Campaign for Better Care press conference (video) Source: WCSH6.com (May 2010 (Thursday May 6, 2010)
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.
- U.S. to hospitals: Clean up your act Source: CNN (Thursday April 29, 2010)
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.”
- New Web Site Invites Patients To Report on Adverse Medical Events Source: ModernHealthcare.com (Monday April 26, 2010)
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.
- Patient Advocates Announce Website to Collect Medical Error Stories
- Report says state fails to monitor hospitals Source: San Francisco Chronicle (Thursday March 18, 2010)
“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
- California is Lagging on Patient Safety Source: California Progress Report (Thursday April 15, 2010)
Guest blog post by our Director Lisa McGiffert on the slow progress of California’s Department of Public Health to implement patient safety laws.
- Two New Health Care Quality Reports Discussed at State House Source: Health Care For All (Thursday April 15, 2010)
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).
- State Issues Fines To 7 Hospitals for Significant Lapses in Patient Safety Source: California Healthline (Wednesday April 14, 2010)
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.
- Hospital fined for sponge mistake Source: The San Diego Union-Tribune (Tuesday April 13, 2010)
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.
- California Department of Public Health (CDPH) hospital administrative penalties 4/13/2010
View California Department of Public Health (CDPH) Hospital Administrative Penalties 4/13/2010
- California Hospitals Racked Up Fines for Failing To Report Errors Source: California Healthline (Tuesday April 13, 2010)
“California regulators have fined hospitals more than $1 million for failing to report serious medical errors in a timely manner…”
- Report Says State Falling Short On Monitoring Patient Safety (audio clip) Source: KPBS (Thursday March 18, 2010)
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.
- Hospitals fined more than $1 million for failing to report errors Source: California Watch Blog (Monday April 12, 2010)
“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.”
- Patient Safety Report Shows Medical Errors Continuing in NJ Hospitals Source: Atlantic Hightland Herarld (Thursday April 1, 2010)
AARP: Older Adults Still the Most Affected by Dangerous Medical Errors
- Public Citizen Releases Annual Ranking of State Medical Boards Source: Public Citizen (Monday April 5, 2010)
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.
- Reform Promotes Patient Safety By Creating Payment Incentives, Making Mistakes Public Source: Kaiser Health News' Daily Report (Thursday April 1, 2010)
Consumers Union’s Safe Patient Project mentioned in Kaiser Health News.
- Billings Gazette Opinion: All Americans will benefit from care delivery reforms Source: Billing Gazette (Sunday April 4, 2010)
Editorial on the patient safety provisions of the health reform bill.
- Viewpoints: Fine print on Rx labels spells danger Source: Sacramento Bee (Saturday April 3, 2010)
Betsy Imholz of Consumers Union challenges the decision the California Pharmacy Board has signaled it will adopt regarding presription drug labeling standards.
- Health System Bears Cost of Implants With No Warranties Source: NYT (Friday April 2, 2010)
“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. “
- UK: Hospital checklists for common conditions 'cut deaths' Source: BBC (Thursday April 1, 2010)
Checklists that spell out exactly how to care for patients with common conditions have dramatically reduced hospital deaths, say doctors.
- Health reform can cut errors Source: Times Union (Thursday April 1, 2010)
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.
- This Won't Hurt a Bit Source: Newsweek (Friday March 5, 2010)
How we can save billions by cutting out unnecessary procedures that kill tens of thousands a year.
- California patient safety changes slow in coming, despite 13,500 deaths each year Source: Protect Consumer Justice (Thursday March 18, 2010)
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.
- You wouldn't fly with a dead-tired pilot. So why let a wiped-out physician work on you? Source: Dead By Mistake Blog (Thursday February 11, 2010)
Patient Safety Advocates Launch Campaign to Reduce Resident Physician Fatigue, Boost Patient Safety
- Seattle hospital a safe haven Source: Hearst Newspapers (Monday March 22, 2010)
Hearst Newspapers (March 22, 2010)
- N.Y. hospitals on the "watch list" Source: Hearst Newspapers (Monday 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.”
- Detective work required to uncover errors Source: Hearst Newspapers (Sunday March 21, 2010)
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.
- Transparency and the health-care reform bill Source: Washington Post (Sunday March 21, 2010)
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.”
- Hospital safety info shielded from public Source: Seattle Pi (Monday March 22, 2010)
Americans have more information about the safety of their cars than about the hospitals that treat them at their most vulnerable moments.
- The Worst Time for a Hospital Visit Source: NYT Health blog (Thursday March 18, 2010)
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.
- Video: The Faces of Medical Errors...From Tears to Transparency
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.
- Consumer group: state lags in enforcement of laws on hospital infections, errors Source: HealthyCal.org (Wednesday March 17, 2010)
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.
- Transparency and Public Reporting Are Essential for a Safe Health Care System Source: Commonwealth Prespectives on Health Reform Brief (Wednesday March 17, 2010)
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.
- New Resource for Those Dissatisfied with a Health Care Experience Source: A Healthy Blog (Thursday March 11, 2010)
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.
- Taking care with treatment Source: Boston Globe (Monday March 8, 2010)
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.
- Intriguing people for March 1, 2010: Patty Skolnik Source: CNN (Monday March 1, 2010)
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.
- Concerns Over 'Metal on Metal' Hip Implants Source: New York Times (Wednesday March 3, 2010)
“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.”
- Attorney General Richard Blumenthal promotes bill to require hospital-specific medical error reporting Source: Newstime.com (Monday March 1, 2010)
“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.
- Book Review: Safe Patients, Smart Hospitals Source: Wall Street Journal (Tuesday February 16, 2010)
Review of Dr. Peter Pronovost’s new book on challenging a “toxic” medical culture that doesn’t crack down on medical errors.
- Hospital panel should focus on quality of care Source: Concord Monitor (Saturday February 27, 2010)
Preventing harm will save money
- Hospital recycling on increase Source: The Baltimore Sun (Thursday February 25, 2010)
Reusing one-time-use tools cuts waste, stirs some concern
- Public deserves a voice on health quality commission Source: Concord Monitor (Thursday February 25, 2010)
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.
- Study: Costly Health Care Not Necessarily Best Source: NPR; WBUR (Thursday February 25, 2010)
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.
- How a checklist can reduce hospital infections Source: Baltimore Sun (Thursday February 18, 2010)
“Hospitals can reduce medical errors and cut unnecessary hospital-related infections with the use of a checklist.”
- Hospital reviews care of Murtha Source: Tribune Democrat (Wednesday February 17, 2010)
“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.”
- Navy opens review of care Murtha received in surgery Source: CNN (Wednesday February 17, 2010)
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 women dying from pregnancy complications; state holds on to report Source: California Watch (Tuesday February 2, 2010)
More California women dying from pregnancy complications; state holds on to report
- Stop Running Red Lights AND Pay for Health Care Reform Source: Rosemary Gibson, The Treatment Trap (Tuesday February 2, 2010)
“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.”
- Editorial: Murtha death raises questions over preventable medical errors Source: Politico.com (Wednesday February 10, 2010)
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.
- Study: Two Methodist Health System hospitals have high ICU infection rates Source: Dallas Morning News (Wednesday February 3, 2010)
Dallas-based Methodist Health System had two hospitals with bloodstream infection rates double the national average, according to a Consumer Reports study.
- Hospitals Rated on Post-Surgery Infections Source: CBS News (Wednesday February 3, 2010)
Consumer Reports has made an online system available which gives consumers access to hospital infection rates.
- Mercy Medical Center Merced gets low rating in patient survey results Source: Merced Sun-Star (Wednesday February 3, 2010)
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.
- ICU patients at Harlem's North General Hospital 4 times more likely to get deadly infection: report Source: New York Daily News (Tuesday February 2, 2010)
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.
- Malpractice reports are easier to find Source: NewsObserver.com (Tuesday December 8, 2009)
NC makes it easier to find malpractice reports.
- Radiation Offers New Cures, and Ways to Do Harm Source: New York TImes (Saturday January 23, 2010)
Radiation errors can cause severe harm or death for cancer patients.
- Insurer Anthem invests in hospital initiative to improve safety, cut costs Source: LA Time (Wednesday January 20, 2010)
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.
- Hospitals Required To Start Reporting Mistakes
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.
- An Empowered Patient Source: The Patient Factor (Tuesday January 12, 2010)
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.”
- Calif. Board Reinstates Doctor's License With Fatal Results Source: ProPublica (Thursday January 7, 2010)
According to the California Medical Board, half of the doctors seeking to get lost licenses reinstated this past fiscal year were successful.
- Patient safety improving slightly, 10 years after IOM report on errors Source: American Medical News (Monday December 28, 2009)
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.
- Annual Hope Award Winner-Patty Skolnik
Medically Injured Trauma Support Services (MITSS) honors Patty Skolnik for her work on patients safety through the organization she founded- Colorado Citizens for Accountability.
- Inept nurses free to work in new locales Source: Los Angeles Times (Sunday December 27, 2009)
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.
- Oklahoma caregivers fight patient wounds Source: NewsOK (Monday December 14, 2009)
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 releases 2009 list of best hospitals for patient safety Source: Hearst; Dead By Mistake Blog (Wednesday December 9, 2009)
Leapfrog sites only five of U.S. News’ 21 best hospitals. View Leapfrogs press release on the top hospitals list.
- Kent Hospital settles suit with Woods family Source: The Providence Journal (Wednesday December 2, 2009)
The Providence Journal (December 2, 2009)
- Temp Firms a Magnet for Unfit Nurses Source: Propublica and LA Times (Saturday December 5, 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.
- Warning: Going to the hospital may be hazardous to your health Source: Los Angeles Times health blog (Wednesday December 2, 2009)
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.
- 10 years, 5 Voices, 1 Challenge
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.
- Dead by Mistake reporter speaks at Consumers Union paitent safety forum
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.”
- Hidden Mistakes In Hospitals Source: Hartford Courant (Monday November 16, 2009)
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.
- Dr. Donald Berwick: We Need To Have More Consequences In The Health Care System Source: Kaiser Health News (Thursday November 12, 2009)
Interview with Don Berwick, President of the Institute for Healthcare Improvement on the quality of care and patient safety.
- How to avoid falling victim to a hospital mistake Source: CNN (Friday November 13, 2009)
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. Braley (IA) stands up for patients
Rep. Bruce Braley highlighted the importance of improving patient safety in order to reduce medical malpractice.
- Rhode Island hospital ordered to have camera's in operating room. Source: The Today Show; NBC (Tuesday November 3, 2009)
Consumers Union Safe Patient Project Director Lisa McGiffert comments on wrong site surgery.
- Film explores broken health care system Source: Dead By Mistake (Saturday October 31, 2009)
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 Watch-In!
“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.
- Making Hospitals Pay For Own Mistakes Source: CBS Evening News (Tuesday March 18, 2008)
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.
- Florida Hospital Confirms Patients Infected by Reused IV Bags Source: Newsinferno.com (Friday October 16, 2009)
Broward General Medical Center patients received reused IV bags and have tested positive for some infectious diseases.
- Health care bills sidestep medical errors issue Source: Connecticut Post (Friday October 16, 2009)
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.
- MRI die can lead to fatal disease for some Source: Business Week (Friday October 16, 2009)
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.
- Report finds 9,400 serious errors at N.J. hospitals Source: New Jersey Star Ledger (Thursday October 15, 2009)
The New Jersey Health Department has released the 2009 Hospital Performance Report.
- Physician misconduct often tolerated by state medical board, analysis finds Source: The Dallas Morning News (Sunday October 11, 2009)
The Dallas Morning News investigates the many holes in the Texas Medical Board review process over the past seven years, leaving patients at risk.
- California hospitals fined for errors Source: Los Angeles Times (Friday September 25, 2009)
Of 11 facilities cited by the state, about half were penalized for leaving objects in patients after surgery.
- PA: Hospital report: Mixed ratings
Readmission rates were lower, but some death rates were up
- What Josie King's story should teach us Source: New Jersey Star Ledger (Monday September 21, 2009)
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.
- Patients at UPMC hospital may have been exposed to viruses Source: Pittsburgh Gazette (Wednesday September 16, 2009)
“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. “
- East of Eden: Why Health Care Got Hijacked Read more at: http://www.huffingtonpost.com/caryl-rivers/east-of-eden-why-health-c_b_291303.html Source: The Huffington Post (Friday September 18, 2009)
“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.
- From tragedy to advocacy Source: Modern Healthcare (Monday September 7, 2009)
A determined breed of patient-safety advocates have forged their personal pain into a dedication to improving medical safety.
- November 12 event: MITSS annual dinner Source: Health Care For All (Wednesday September 9, 2009)
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.
- Jersey forces hospitals to disclose medical errors Source: The Star-Ledger (Tuesday September 1, 2009)
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.
- When a Hospital Let Families Call for Rapid-Response Help Source: The Wall Street Journal (Monday August 31, 2009)
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.
- Patients Get Power of Fast Response Source: The Wall Street Journal (Monday August 31, 2009)
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.
- Op-Ed: The Unintended Consequences of "No Pay for Errors" Source: The Health Care Blog (Tuesday July 21, 2009)
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.”
- Doctors' woes don't compare to patients' Source: Concord Monitor (Thursday August 27, 2009)
Letter to the editor on health care reform by patient safety activist Michael Bennett, President of the Coalition for Patients’ Rights.
- Pitching Patient Safety and Hospital Transparency on YouTube Source: Wall Street Journal Health Blog (Monday August 24, 2009)
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.
- Adverse Event Reporting System (AERS) Statistics Source: FDA, as of (Tuesday March 31, 2009)
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.
- New Jersey Doctors Getting Paid Extra To Save Hospitals Money Source: AP (Wednesday August 19, 2009)
A dozen New Jersey hospitals are paying doctors as an incentive to save the hospitals money.
- Crucial medical records 'concealed' after deaths at local hospital Source: KHOU.com (Tuesday May 12, 2009)
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.
- Americans Continue to Die from Preventable Injuries
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 Source: Source: Hearst Newspapers (Friday July 31, 2009)
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.
- Death by Mistake: Advocates call for mandatory reporting of medical errors Source: San Antonio Express-News (Sunday August 16, 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.
- Editorial: Why so many needless deaths? Source: Albany Times (Tuesday August 11, 2009)
“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.”
- Washington law lacks both money and teeth Source: Hearst Newspapers (Thursday July 30, 2009)
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.
- Medication errors harm millions each year Source: St. Louis Today (Sunday August 2, 2009)
Despite efforts to prevent medication errors, mix-ups like this are occurring across the country with alarming frequency.
- Basic Patient Safety Reforms Would Save 85,000 Lives and $35 Billion a Year, Public Citizen Report Says Source: Public Citizen (Thursday August 6, 2009)
The report, “Back to Basics,” analyzed the results of scientific studies of treatment protocols for chronically recurring, avoidable medical errors.
- Did NUMC pass the test? Source: Newsday.com (Saturday August 1, 2009)
The hospital accreditation experience of a Long Island hospital.
- Simulation center to test new nurses Source: Arizona Republic (Monday August 3, 2009)
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.
- First, Make No Mistakes Source: The New York Times (Tuesday July 28, 2009)
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.
- Reps should be commended for fighting for patient rights Source: Nashua Telegraph (Thursday July 23, 2009)
Letter to Editor from Lori Nerbonne thanking lawmakers for passing hospital infection and error reporting legislation.
- Ranking hospitals now done by many organizations, not just U.S. News & World Report Source: Cleveland Plain Dealer (Monday July 27, 2009)
There’s a movement to make hard numbers the basis for rankings among hospitals, instead of reputation or word-of-mouth.
- Daily News investigates faked records and fatal blunders at city-run hospitals Source: Daily News (Sunday July 26, 2009)
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.
- Medication errors harm millions of Americans each year Source: Kansas City Star (Saturday July 11, 2009)
Kansas City Star (July 11, 2009)
- Is Angioplasty Worth The Risk? Source: CBS (Tuesday June 9, 2009)
Though A Common Medical Procedure, Many Are Performed At Hospitals Unprepared If Something Goes Wrong
- Blaming the Hospital, A Widow Turns Activist Source: The Washington Post (Tuesday July 21, 2009)
The Washington Post (July 21, 2009)
- Hospitals Tally Their Avoidable Mistakes Source: The Washington Post (Tuesday 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.
- When Caregivers Harm: Problem Nurses Stay on the Job as Patients Suffer Source: ProPublica and Los Angeles Times (Saturday July 11, 2009)
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.
- Op-ed: Stop hospital-borne infections Source: The Courier-Journal (Thursday July 9, 2009)
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.
- New Ratings for America's Hospitals Now Available on Hospital Compare Website Source: Centers for Medicare & Medicaid Services (Thursday July 9, 2009)
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.
- Double failure' at USA's hospitals Source: USA Today (Wednesday July 8, 2009)
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.
- As health data becomes available, patients can demand better care Source: Dallas Morning News (Tuesday July 7, 2009)
This increased transparency is one of the great hopes among health care reformers for tackling the high cost of American medicine.
- Editorial: Health Care’s Infectious Losses Source: New York Times (Sunday July 5, 2009)
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.”
- Medical Malpractice Payments Fall to Record Low, Public Citizen Study Shows
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
- Springs surgery tech suspected of exposing 5,700 to hepatitis C Source: Colorado Springs Gazette (Thursday July 2, 2009)
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.
- Nearly 90 major medical mistakes logged at Utah hospitals in 2008 Source: The Salt Lake Tribune (Monday June 29, 2009)
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.
- Video: Problem Doctors Practice Bad Medicine Source: ABC News (Sunday June 21, 2009)
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.
- At V.A. Hospital, a Rogue Cancer Unit Source: New York Times (Saturday June 20, 2009)
NYT story about a Philadelphia VA hospital where many patients received botched cancer treatments.
- MD: State links billing rates to hospital performances Source: HometownAnnapolis.com (Tuesday June 16, 2009)
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.
- VA inspections show continued flaws Source: AP (Monday June 15, 2009)
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.
- Editorial: Mandatory reporting makes hospitals safer Source: Concord Monitor (Thursday May 14, 2009)
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.
- MD hospital fined for not reporting errors Source: Washington Post (Monday June 15, 2009)
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.
- Health Outcomes Driving New Hospital Design Source: New York Times (Monday May 18, 2009)
Single-patient rooms are now viewed as an important element of high-quality health care.
- U.S. Health Care System Fails to Protect Patients From Deadly Medical Errors
Consumers Union Assesses Lack of Progress Ten Years After Institute of Medicine Found Up To 98,000 Die From Preventable Errors
- Report: about 98,000 Americans still die annually from medical errors Source: China View (Friday May 22, 2009)
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.
- Top medical mistakes in orthopedics include equipment, communication errors
53% of orthopedic surgeons reported medical errors in the past 6 months!
- Preventable Medical Errors Still Kill Thousands, Cost Billions as Employers Foot Bill Source: Workforce Management (Wednesday May 20, 2009)
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.
- Deadly Medical Errors Still Plague U.S.
Report Shows 10-Year Effort to Curb Medical Errors Yields Few Results
- U.S. group sees little progress on medical errors Source: Rueters (Tuesday May 19, 2009)
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.
- Historic Initiatives for Consumer Information and Patient/Provider Partnerships Approved
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.
- Government Reports Criticize Health Care System Source: New York Times (Wednesday May 6, 2009)
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.
- Preventable hospital errors / No patient should pay Source: Press of Atlantic City (Wednesday May 6, 2009)
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.
- The Devil Inside Wired Medicine Source: Forbes Magazine (Monday May 11, 2009)
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.
- New Jersey bill would require reporting of "never" events Source: AARP Bulletin Today (Wednesday April 1, 2009)
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.
- Legislature passes MRSA-prevention hospital guidelines Source: Nisqually Valley News (Monday April 13, 2009)
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.
- Wrong baby given to nursing mom at NH hospital Source: Concord Monitor (Monday April 6, 2009)
A couple whose day-old baby was given to the wrong mother to nurse in a hospital is demanding answers about how it happened.
- Editorial: Medical Mistakes Source: The Philadelphia Inquirer (Tuesday March 10, 2009)
New Jersey legislation would give public hospital-specific information on medical errors.
- Victims of medical errors testify Source: Concord Monitor (Wednesday February 18, 2009)
NH bill will require public reporting of adverse events.
- Medical community collaborates to cut medication errors and infections Source: Cleveland Plain Dealer (Tuesday January 20, 2009)
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.
- KY Health Care Transparency Conference
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.
- Conference will address MRSA and 'never events' Source: Lexington Herold Leader (Friday November 14, 2008)
Issues surrounding hospital-acquired infections and other medical events “that should never happen” will highlight a health care conference in Lexington next week.
- NH hospitals not required to publicize mistakes Source: Union Leader (Monday October 13, 2008)
Legislators are considering passing a law requiring New Hampshire’s 26 hospitals to publicly report their “never events” to the state.
- In-hospital errors go unreported in NH Source: Union Leader (Sunday October 12, 2008)
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.
- Editorial: Medicare to Slash Payments for Medical Errors Source: Washington Post (Wednesday October 1, 2008)
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.
- Editorial: First, do no harm Source: Houston Chronicle (Wednesday October 1, 2008)
Medicare is right to stop paying hospitals for treating reasonably preventable medical errors
- Medicare Won’t Pay for Medical Errors Source: New York Times (Wednesday October 1, 2008)
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.
- Medicare won't pay for hospital mistakes anymore Source: New Jersey Star Ledger (Wednesday October 1, 2008)
New federal regulations target 11 hospital-acquired conditions that are considered reasonably preventable.
- Errors don’t warrant pay, insurers say Source: Chattonooga Times Free Press (Monday April 7, 2008)
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.
- Many in NJ are medical errors victims Source: The Record (Thursday March 6, 2008)
More than a third of New Jersey residents surveyed say they or a family member have been a victim of a medical error, and 90 percent would like the state to publicly report the number of errors at each hospital.
- Patients still stuck with bill for medical errors Source: MSNBC.com (Friday February 29, 2008)
11 states waive fees for worst mistakes, but most will charge you or insurer
- Medicare won’t pay hospitals for medical errors Source: Associated Press (Tuesday February 19, 2008)
Medicare will start hitting hospitals where it hurts in October, and other insurers are hot on the trail.
- Medicare Will Not Pay For Hospital Mistakes And Infections, New Rule Source: Medical News Today (Monday August 20, 2007)
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.
- US Hospital Errors Continue to Rise Source: Washington Post (Monday April 2, 2007)
HealthGrades shows rise in post-operative sepsis
- Making hospitals safer Source: CBS Evening News (Tuesday February 6, 2007)
Katie Couric interviews Dr. Donald Berwick about the Institute for Healthcare Improvement’s campaign to reduce medical errors, including hospital infections.
- Hospitals' dirty secret Source: Modern Healthcare (Monday November 27, 2006)
New reports reveal pattern of deadly and expensive, yet preventable, medical errors.
- $21 million grant to fight medical mistakes, hospital infections in South Carolina Source: WLTX-TV (Tuesday August 15, 2006)
A $21 million grant coming to South Carolina aims to improve patient care and prevent unnecessary hospital deaths.
- Over 250,000 die from potentially preventable medical errors under Medicare Source: Health Sentinel (Monday April 17, 2006)
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.
- Medical errors still claiming many lives Source: USA Today (Wednesday May 18, 2005)
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 80 pct of US doctors witness mistakes Source: Silence Kills (Wednesday January 26, 2005)
Report finds that most nurses and doctors witness medical errors, but few speak up when they see them. Requires a short registration.
- Why do so many still die needlessly in hospitals? Source: USA Today (Thursday August 5, 2004)
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.
- EDITORIAL -- Ill-advised secrecy: Open records, competition helped health care under some states' laws Source: Omaha World-Herald (Thursday December 11, 2003)
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.
- Editorial: The Right to Know / Information on hospital performance needs to remain accessible to public Source: The Buffalo News (Friday October 3, 2003)
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.
Research and Reports
- Trends in Pregnancy-Associated Maternal Death in Virginia, 1999-2008
Maternal mortality is increasing in VA
- Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events
Medicare hospital oversight failed to address serious medical errors such as medication and surgical errors, physical abuse by hospital staff, and patient suicide.
- The Joint Comission responds to coalition of patient safety consumer groups regarding The Joint Comission's complaint process
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.
- Too Little? Too Much? Primary Care Physicians' Views on US Health Care
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.
- Consumer groups seek Senator Harkin to help in making Medicare accreditation surveys public
Patient safety consumer groups, including Consumers Union, seek Senator Harkin to help in making Medicare accreditation surveys public.
- Consumer groups call on The Joint Commission to improve responsiveness to patient complaints
A coalition of patient safety consumer groups, including Consumers Union, wrote a letter to the Joint Commission to improve responsiveness to patient complaints.
- 2010 State Snapshots
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.
- The Empowered Patient Video
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.
- Patient Safety Webinars
Past and future webinars on patient safety.
- Testimony on Healthcare Acquired Infections and Public Reporting
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.
- What To Do If You Have a Concern About Quality in a Pennsylvania Nursing Home
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.
- What to Do if You Have a Concern about Quality in a Pennsylvania Hospital
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.
- NJ Ambulatory Surgery Centers: Quality and Safety Information
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.
- Consumers' Priorities for Hospital Quality Improvement and Implications for Public Reporting
Report by the Center for Healthcare Decisions describes consumer perceptions of health care quality and provides new insights for those involved in public reporting.
- AHRQ: Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008
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.
- Partnership for Patients: Better Care, Lower Costs
U.S. Department of Health & Human Services description of its new patient safety initiative.
- Nurse Staffing and Inpatient Hospital Mortality
When nurse staffing levels fell below target levels in a large hospital, more patients died, a new study discovered.
- Reducing Hospital Readmissions--Lessons from Top-Performing Hospitals
Report of four case studies of hospitals with low readmission rates.
- Medicare releases hospital specific data
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.
- Patient Experience of Overtreatment
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.
- What To Do If You Have a Concern About Quality in a Maine Nursing Home
Advice and resources for dealing with quality concerns
- What to Do if You Have a Concern about Quality in a Maine Hospital
Advice and resources for dealing with quality concerns
- First Do No Harm
“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.”
- What To Do If You Have a Concern About Quality in a New York Nursing Home
Steps you can take if you are concerned about the quality of care in a NY nursing home.
- Study on rates of patient harm in medical care
Study finds one in four hospital patients are harmed.
- Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries
An estimated 134,000 Medicare beneficiaries (13.5 percent) experienced at least 1 adverse event in hospitals during the 1-month study period.
- CDPH ISSUES ADMINISTRATIVE PENALTIES TO 12 HOSPITALS
“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.”
- Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era
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.
- Dangerous Dialysis
Article about the common errors (including infection) that occur in dialysis units.
- Events that are never supposed to happen in state hospitals (graphic)
Graphic of some of the adverse events reported by California hospitals over the past two fiscal years.
- One in four patients experiences revolving-door hospitalizations
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.
- Eliminating Mistakes To Improve Patient Safety
“Nearly one in five adverse events is due to erroneous diagnoses made by physicians.”
- Medical Malpractice & Errors
A series of articles on medical malpractice in Health Affairs outlines the real cost of malpractice in the U.S.
- What You Need to Know Before Having an MRI Scan
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.
- What You Can Do to Prevent Wrong-Site Surgery
Know what steps you can take to prevent a wrong-site surgery from happening to you or a loved one.
- Preventing the Retention of Foreign Objects during Interventional Radiology Procedures
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.
- Safety in the MR Environment: MR Screening Practices
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.
- Medication Errors Occurring in the Radiologic Services Department
Nearly 1,000 event reports submitted to the Pennsylvania Patient Safety Authority specifically mentioned medication errors that occurred in care areas providing radiologic services.
- Pennsylvania Patient Safety Authority 2009 Annual Report
PA annual report on state activities relating to hospital infections and medical errors.
- What To Do If You Have Concern About Quality in a California Nursing Home
Steps you can take if you are concerned about the quality of care in a CA nursing home.
- What to Do if You Have a Concern about Quality in a California Hospital
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.
- Medical Errors State Reporting (Map)
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.
- Adverse Events in Hospitals: Methods for Identifying Events (pdf)
OIG report on the sad state of medical error reporting.
- The Silence
When our health care system remains silent about preventable medical harm it only creates more problems.
- March 2010 Pennsylvania Patient Safety Advisory
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.
- Iowa Infection Rates
Des Moines hospital posts rates of hospital infection and patient falls, two common medical harm events.
- Neonatal Complications: Recognition and Prompt Treatment of Shoulder Dystocia
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.
- Quarterly Update on the Preventing Wrong-Site Surgery Project: Improving, But Still Room for Perfection
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.
- Maryland: All-Payer Approach to Nonpayment
Learn about Maryland’s efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
- Minnesota: Comprehensive Quality Improvement and Payment Reform
Learn about Minnesota’s efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
- Kansas: Medicaid Mirrors Medicare Policy on Adverse Events
Learn about Kansas efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
- Missouri: Focus on Nonpayment for Adverse Events
Learn about Missouri’s efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
- Nonpayment for Preventable Events and Conditions: Aligning State and Federal Policies To Drive Health System Improvement
A new report on state and federal nonpayment policies for preventable hospital acquired conditions and events that harm patients.
- State Patient Safety Initiatives and Nonpayment for Preventable Events and Conditions
A new report on state and federal nonpayment policies for preventable hospital acquired conditions and events that harm patients.
- US Office of Inspector General on public reporting of medical harm (PDF)
U.S. Department of Health and Human Services (Jan 2010)
- Nevada Sentinel "Never Events" list
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.
- Department of Health Issues Compliance Order to Rhode Island Hospital
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
- PA: Hospital Mortality Rates Decline; Reducing Readmissions Represents Cost and Quality Opportunities
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.
- CA: List of hospital fines by county
See if hospitals in your county have had administrative penalties issued by the California Department of Public Health.
- State report of enforcement actions against Texas hospitals July 2008--July 2009
Texas Department of State Health Services
- Beyond the Count: Preventing the Retention of Foreign Objects
Analysis on how to prevent “retained foreign objects” or “RFOs” from the PA Patient Safety Authority.
- IOM Vision for Reducing Medical Errors Not Yet Realized
Has the U.S. made any progress on patient safety since the Institute of Medicine (IOM) released To Err is Human in 1999?
- IN: Medical error reporting system ( 2007)
Report date: August 25, 2008
- Rehospitalizations Among Patients in the Medicare Fee-for-Service Program
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.
- Report: The Direct Medical Costs of Health Care Associated Infections in US Hospitals and the Benefits of Prevention
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.
- Adverse events in hospitals: Overview of key issues
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.
- AHRQ's Patient Safety Organization Web site
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.
- NY Comptroller finds many hospitals underreport medical errors
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).
- Adverse Events amoung Medicare patients
This GAO study found that 15% of hospitalized Medicare beneficiaries in two selected counties experienced an adverse event during their hospital stay.
- Adverse Events in Hospitals: State Reporting Systems
Department of Health and Human Services Office of Inspector General Report
- ADVERSE EVENTS IN HOSPITALS: OVERVIEW OF KEY ISSUES
Department of Health and Human Services Office Of Inspecter General Report
- Like Night and Day - Shedding Light on Off-Hours Care
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”?
- New Medicare rules on non-payment for hospital infections and other medical errors
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 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
- Patient Safety
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.
- Suicidality in pediatric clinical trials
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.
Stories about Medical Errors
My wife’s life was shortened by hepatitis C which she contracted at a clinic in Minnesota. I can give you proof. When my wife arrived at the clinic, after multiple tests, it was determined that she had no physical problem, but needed psychiatric treatment. (NOTE: No elevated liver enzymes.) As we were awaiting a taxi to depart a month later, three doctors suddenly appeared (why THREE doctors?). They said her liver enzymes were “slightly elevated”, and when we got back home to Clearwater, FL, we should have them checked. A week later she was diagnosed with hepatitis C, and later died of liver failure as a result.
William of Asheville, MinnesotaNorth Carolina
To Delay is Deadly
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.