Hospital pharmacists often commit medication errors or miss doses because they are constantly interrupted or distracted. Recent studies show that interruptions, especially phone calls are increasing the risk of medication error. A recent article By Anthony J. Melanson, BS; and Marc R. Summerfield, RPh, MS published on The "Patient Safety and Quality Helthcare" website compiles the findings from recent studies covering this issue and provides recommendations to improve it.
Patient injury resulting from medication use or Adverse Drug Event (ADE) is the most common non surgical medical malpractice occuring in hospitals
Many adverse drug events are preventable and constitute Medical Malpractice. An adverse drug event occurs when a patient suffers injury resulting from medication use. Adverse drug events are the results of medication errors or of known side effects that may happen even if the medication is taken correctly.
According to a recent report from the Healthcare Cost and Utilization Project (HCUP) and led by Audrey J. Weiss, Ph.D. and Anne Elixhauser, Ph.D. , 380,000 to 450,000 hospitalized patients suffer preventable adverse drug events every year.
According to the most recent statistics, in 2011, the most common causes of ADE during hospital stays were Steroids, Antibiotics, Opiates, Narcotics and Anticoagulants with 8 out of 1000 adults over 65 experiencing one of them while hospitalized.
Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) for 32 States, 2011
The study also shows that Medicare-covered patients are the most at risk to be injured by an adverse drug event while Medicaid patients have the lowest risk.
When looking at ADEs by hospital ownership, public hospitals have a much lower rate of ADEs than private hospitals. The highest rate of ADEs was recorded in private, not for profit hospitals.
The study also show that hospitals in the Midwest have a much higher rate of adverse drug events than those in other regions of the Unites Sates.
New York Medical Malpractice - Hospital Negligence: a maternity ward worker may have exposed hundred of babies to tuberculosis
Babies recently born in St Luke's Hospital in New York may have been exposed to tuberculosis, a contagious and potentially deadly disease. The negligent hospital began notifying parents yesterday that a maternity ward worker tested positive for tuberculosis and that their babies should be tested for the disease. The hospital did not comment on how far back the exposure spans but the parents who notified NBC 4 New York about the infection gave birth more than two months ago.
Hopsital Negligence: patient missing for 17 days found dead in hospital stairwell after orderly stepped over her body a week earlier
A worker at San Francisco General Hospital reported to a nurse that he had to step over the passed out body of a woman while going up and down a fire escape stairwell. The nurse contacted the Sheriff's Department who is in charge of the security at the hospital but for some unclear reason no deputy was dispatched to check the location.
A week later, the dead body was found by another employee who had to access the locked stairwell. It was the body of Lynne Spalding, 57, who disappeared from her room on the hospital's fifth floor Sept. 21, two days after she was admitted for treatment of an infection. Her body was found Oct. 8 on the fourth-floor landing of the locked stairwell.
Medical Malpractice: To keep its Cath Lab running, a Negligent Hospital paid a high price for an unqualified surgeon who butchered multiple patients and killed one while performing unnecessary stent procedures
Medical Malpractice related to Cath Lab procedures are on the rise as overuse of Cardiac Stents lead to an increase of deaths linked to this type of procedure.
In a recent article on Bloomberg, Sydney P. Freedberg, describes the shocking extreme the administrators at Satilla Regional Medical Center in Waycross, Georgia went to in order to keep their cath lab operating and producing revenue.
Because of its remote location, the hospital was unable to attract competent cardiovascular surgeons. In order to keep their cath lab running the administrators paid an extravagant salary to a non qualified surgeon, Dr. Azmat whose only experience with cardiac stents was a two weekend course experimenting on cadavers and pigs.
When the surgeon started to operate and butcher patients, administrators completely ignored multiple complaints and warnings from nurses until the worst happened. Ruth Minter, a mother of five died after the surgeon perforated her kidney during a stent procedure that experts said was unnecessary.
After the death of Ruth Minter federal investigators found more than 30 patients who received “worthless,” poor or unnecessary care from Dr. Azmat.
Stents are metal mesh devices that have been used to prop open the arteries of 7 million Americans in the last decade at a cost of more than $110 billion. 70,000 stent procedures are being performed in the US every year. Half of them are used to restore blood flow in patients following a heart attack and their benefits are indisputable. The other half are used in elective-surgery patients in stable condition and are often linked to overuse, wrongful death, personal injury and fraud.
Most Surgical Fires result from Medical Malpractice or negligence causing serious injury, disfigurement, and even death. They occur in, on or around a patient who is undergoing a surgical procedure. An estimated 550 to 650 surgical fires occur in the United States per year. Despite the fact that the root causes of surgical fires are well-understood, surgical fires still occur.
To promote actions to reduce the risk of risk of surgical fires.The Preventing Surgical Fires Initiative is celebrating its second anniversary during National Fire Prevention Week, October 6-12, 2013.
Fires happen during surgery because the 3 elements needed to start a fire (fire triangle) are present in an operating room:
1. the ignition source which could be a laser or an electrosurgical unit,
2. the fuel source, for example a surgical drape or or the skin of a patient that has been previously treated with alcohol
3. the oxidizer such as the supplemental oxygen or the nitrous oxide used for anesthesia
Most fires happen because of the high concentration of oxygen in the room.
To prevent these fires the FDA and partners including the ECRI Institue, the Anesthesia Patient Safety Foundation (APSF), the American Society of Anesthesiologists (ASA) and the Association of periOperative Registered Nurses have developed guideline to prevent operating rooms fire.
A fire risk assessment is now part of the the universal protocol, or the process by which a patient is confirmed to be the correct patient having the correct procedure at the correct time so the staff is also aware of the elements of the fire triangle in every single procedure.
Proper communications before and during the procedure between all members of the surgical team and specially between the anesthesia provider and the surgeon is also key in preventing these fires.
Below is a video from the FDA that explains how fire happen and what can be done to prevent them.
Medical Malpractice: alarming study estimates the number of deaths resulting from Medical Errors by Hospitals may be as high as 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm
The number of deaths resulting from Medical Errors in Hospitals have been grossly underestimated according to new estimates developed by John T. James, a toxicologist at NASA’s space center in Houston. James runs an advocacy organization called Patient Safety America that he created after his 19 year old son died as a result of medical malpractice in a Texas Hospital.
In 1999, "To Err is Human Report", estimated the number of deaths resulting from medical errors in hospitals at 98,000. In 2010, The Office of the Inspector General for Health and Human Services said that bad hospital care contributed to the deaths of 180,000 in Medicare patients alone in a given year.
According to the study published in the current issue of "Journal of Patient Safety" these numbers are too low and the true number of premature deaths associated with preventable harm to patients is estimated at more than 400,000 per year.
New data from New York DOH unveil mortality rates for cardiac surgery by hospitals and by type of procedure. Even though some procedures are by nature riskier than others, New Yorkers suffering from heart conditions should understand that not every hospital offers the same level of safety.
Based on the data provided by The New York State Health Department here are some of the findings:
Valve surgery is the riskiest type of cardiac surgery with a mortality rate of 4.59% for New York State between 2008 and 2010. PCI or Percutaneous Coronary Intervention, sometimes also called coronary angioplasty or coronary stenting is the less risky of all types of cardiac surgeries as long as it is a planned surgery. It becomes riskier when it is an emergency procedure.
The following graphs show the mortality rate by hospital for the various type of procedures. Because some hospitals may deal with riskier cases than others the graphs show 3 types of mortality rates:
New York Medical Malpractice, Surgical Errors and Complications - Mount Sinai, NYU Langone Medical Center and New York-Presbyterian Hospital are the best hospitals to have surgery in the city, St Luke's is the worst
Complications during or after surgery are happening too often at New York City, St Luke's Hospital. The Hospital scored a low overall surgery rating on the new Consumer Reports surgery safety rating. The safest hospitals in the city to have surgery are Mount Sinai, NYU Langone Medical Center and New York Presbyterian Hospital.
Consumer Reports looked at medicare claims data from 2009 through 2011 for patients undergoing 27 categories of common scheduled surgeries. For each hospital, the results for all procedures are combined into an overall surgery rating.The global ranking is based on who died in the hospital or stayed longer than expected for their procedure. More detail by type of surgery as well as a hospital ranking by state can be found on the Consumer Reports website.
Most common surgery complications are bad reaction to anesthesia, heart problems or surgeon nicking a blood vessel, leaving an instrument inside, or even operating on the wrong body part. Complications can also happen after the surgery. Nationally, 30 percent of patients suffer infections, heart attacks, strokes, or other complications after surgery and sometimes even die as a result.
Source: Consumer Reports, September 2013
Children with cancer who use a central line at home for their treatment have 3 times more risk of developing a dangerous blood infection than children who used a central line while in the hospital
Doctors should be vigilant when they decide to send home some pediatric cancer patients who still need to use a central venous catheter for their treatment. Because the central line is a tube that is placed directly into a major blood vessel, it can easily become a gateway for bacteria in the blood stream if it is not handled properly. Central line-associated bloodstream infections (CLABSIs) can lead to serious personal injury such as organ damage and sometimes death.
A recent study from Johns Hopkins Children's Center published yesterday in the journal Pediatric Blood & Cancer followed 319 children with cancer between 2009 and 2010. Most children were first treated in the hospital and then sent home to continue their treatment. 19 children developed a central line-associated bloodstream infection (CLABSI) while hospitalized and 55 while at home.
Hospitals have been fighting for a long time against bloodstream infections and they have made serious progress in reducing them. They have experienced clinicians following precise protocols.Things are different when children are treated at home by family members. More should be done in preventing development of CLABSIs at home.For example teaching family members how to handle and clean central lines should be part of the formal discharge protocol. It is not the case yet.