Medical Errors and Patient Safety: Protecting Your Family

Medical errors are one of the Nation's leading causes of death and injury, according to the Agency for Healthcare Research and Quality.

The rate for medication errors and potential adverse drug events was three times higher in children than adults, and substantially higher still for babies in neonatal intensive care units, in a 2001 study in the Journal of the American Medical Association.

According to Dr. Allen Vaida, executive vice president of the Institute of Safe Medication Practices (ISMP), acknowledging medication errors and reporting them is the most important step toward prevention. Vaida claims children are especially vulnerable to drug overdoses in hospitals because of calculation errors that can occur with medications. Nurses must administer the medication dosages according to a child's body weight and other necessary factors, that can lead to medication mistakes. Drug naming and labeling is also an issue.

Surgical errors like wrong-site surgeries garner headlines, but more often surgical mistakes involve objects left in the patient.

For kids, instruments or sponges are rarely left inside after procedures, but a new report in the journal  Archives of Surgery  shows specifically girls under 18 undergoing gynecological surgeries appear to be at a particularly high risk.  Girls who underwent the removal of ovarian cysts had four times the risk of coming out of surgery with a foreign object inside them as other children who'd had surgery, researchers said.

Children who had objects left inside them spent, on average, eight days longer in the hospital and accumulated more than $35,000 extra in hospital charges related to follow up surgery or infection, as compared to surgical patients who did not experience object accidents.  The results are based on nearly 2  million hospital records from childhood surgeries in the United States from 1988 to 2005 in two national databases.

The US Department of Health and Human Services has  20 tips to help prevent medical errors in children.

Today, more new research by the Office of the Inspector General (OIG) is highlighting the overall problem of medical errors.

The OIG found one in seven Medicare patients is harmed by their hospital care - that's higher than previously estimated.

This points to the need for mandatory validated public reporting of medical errors, according to Consumers Union, the nonprofit publisher of Consumer Reports.

“When mistakes are made in hospitals, the consequences can be serious and too often deadly,” said Lisa McGiffert, Director of Consumers Union’s Safe Patient Project. “This 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.”

The new OIG study found 134,000 hospitalized Medicare patients experienced medical harm in the month evaluated. 

An estimated 15,000 Medicare patients died due to the errors. That's potentially 180,000 people killed annually by the help they sought.

The financial toll, an additional $324 million monthly in hospital care. The study estimated the annual cost for additional care at $4.4 billion.

Last year, Consumers Union detailed the lack of progress since the Institute of Medicine first sounded the alarm in 1999 that as many as 98,000 Americans were dying every year from preventable medical errors.

"One decade later, we can’t say whether we are any better off today than when the IOM first sounded the alarm...,” said Arthur Levin, Director of the Center for Medical Consumers and member of the IOM’s Committee on the Quality of Health Care in America, which issued the landmark To Err is Human CU report. “We can’t wait another decade to take the steps needed to protect patients from deadly and costly medical errors. The time to act is now. Too many lives and health care dollars are at stake.”

The Solution?

At least half a million worldwide deaths could be prevented annually with effective implementation of the World Health Organization Surgical Safety Checklist, according to a just released study in the New England Journal of Medicine.

With the use of a checklist, surgery complications were reduced by more than one-third and deaths reduced by almost half in test hospitals compared to control hospitals.

27 states and the District of Columbia have adopted laws in recent years that require hospital-specific reporting of patient infection rates to the public. The State Hospital Infection Disclosure Laws are available at SafePatientProject.org.

In Rhode Island, two bills (S2382 and HB7962), passed and signed into law in 2008, require the Department of Health to issue public reports comparing infection rates among RI hospitals.

An advisory committee will help to develop the infection reporting system and will serve as a permanent subcommittee to an already existing steering committee on health care quality. The majority of the advisory committee members must come from the infection control community, but representatives of consumers, labor and employers who purchase health care are also included.

Through regulations based on the advisory committee’s recommendations, the department will establish which types of infections  rates are to be reported. The law allows for reporting on the four major types of hospital-acquired infections -- surgical site infections, ventilator associated pneumonia, central line blood stream infections, and urinary tract infections -- and allows for the advisory committee to recommend additional reporting. Surgical infection reporting must include post-discharge surveillance.

So far, 21 states have issued reports detailing infection rates by hospital to the public. The Rhode Island Department of Health Performance Measurement and Reporting has Ocean State information.

While many hospitals around the country reported  they followed the recommended surgical infection prevention measures for a high proportion of patients, Consumers Union found that a significant number of hospitals reported low levels of compliance.

How does Rhode Island Hospital measure up? Check out their statistics at  Stop Hospital Infections.org.

According to a study in the Archives of Internal Medicine earlier this year, sepsis and pneumonia, two common conditions caused by hospital-aquired infections like MRSA, killed 48,000 Americans in 2006, and cost the nation over 8 billion dollars to treat.

Earlier this month, the Agency for Healthcare Research and Quality announced the award of $34 million for projects focused on preventing healthcare-associated infection, or hospital-acquired infections, know as HAIs.

The new funding will help improve the quality of care delivered to patients and expand the fight against HAIs in hospitals, ambulatory care settings, end-stage renal disease facilities and long-term care facilities.

Based on estimates from the Centers for Disease Control and Prevention (CDC), there are nearly 2 million HAIs in hospitals annually, which contribute to almost 100,000 deaths.

Pat Mastors, former TV news anchor and medical reporter, who began patient safety advocacy following the loss of her father to a HAI, has worked to pass the above mentioned RI state laws improving patient safety and continues to advocate for change on a national level. 

Mastors, a member of the Consumer's Union Safe Patient Project,  has also pioneered an infection defense kit known as The Patient Pod to protect your family during any hospitalization.

Mastors tells Examiner she most recently began a new blog to help survivors and family members cope with medical mishaps and heal as community.

"Light A Candle and reject the darkness that can drag us down, keeping us stuck in a grim and hopeless place. This blog is for sharing the uplifting things you learn see, or strive for, that help you and might help others get to a better place. It costs a candle nothing to light another", added Mastors.

Additional Resources:

Staying Safe in the Hospital.

PatientSafety.gov

MedlinePlus - A service of the U.S. National Library of Medicine and National Institutes of Health

National Patient Safety Foundation

Agency For Healthcare Research and Quality Patient Safety Network

World Health Organization Patient Safety

2010 National Patient Safety Goals, The Joint Commission

Infection Control Today

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