Feeding tube hospital errors causing serious injury or death signal problems with hospitals, medical device companies and FDA.
As part of a two-year investigation, Sun reporters have uncovered some of the dangers patients have unknowingly encountered as they enter delivery rooms, surgical suites and intensive care units, including thousands of cases of injury, death and deadly infection associated with stays in Las Vegas hospitals.
Blog post by Maggie Mahar, author of Money-Driven Medicine, on the need for hospitals to report medical errors so that they can be prevented.
New York Times investigation on radiation overdoses during CT brain perfusion scans, and the long-term risks radiation overdoses can have on patient health. The FDA began an investigation but has yet to provide a final report on what it found.
Tragic story of a young girl who was suffocated in a bean bag chair at a hospital that had been warned by state and federal regulators that patients weren't safe.
Hear from a journalist about how difficult it is to find information about a serious medical error. No matter what source you turn to, you are left with few answers.
A 300-pound sedated patient who was awaiting a routine procedure fell off an operating table and later died. Accidents like these should be prevented before it's too late.
Hospital mix up in patient identification causes newborn to be breastfed by wrong mom.
A recent study in the July issue of Archives of Surgery found that surgery patients are more likely to suffer sepsis or septic shock than blood clots or heart attack.
The American College of Obstetricians and Gynecologists released guidelines that state it is safe to have a vaginal delivery after a previous delivery by cesarean delivery.
"Diagnosing the earliest stage of breast cancer can be surprisingly difficult, prone to both outright error and case-by-case disagreement over whether a cluster of cells is benign or malignant, according to an examination of breast cancer cases by The New York Times."
The New York Times finds that early diagnosis of breast cancer can be prone to error on whether the cells are benign or malignant, leading to unnecessary treatment and psychological distress.
Astronaut turned patient safety expert interview on what patient safety advocates can learn from NASA.
A recent study finds that deaths from medication errors increase by 10 percent during July, a so-called July effect as students graduate from medical school and enter residency programs.
Is the "July Effect" a myth. A study shows that deaths due to medication errors spike in July at teaching hospitals where new residents are just starting their residency. Medical records from 1979-2006 were analyzed.
Sun’s investigation of Nevada hospital data shows 969 incidents of inpatient injuries — some that can be deadly
If you get admitted to a hospital, chances are way too good that you’ll be back before long — maybe more than once
Blog post series by Maggie Mahar on resident work hours.
A new study finds medication error rates spike 10 percent in the month of July.
"One-fourth of California's 450 acute care hospitals have been fined a total of more than $1 million so far—one hospital received five fines totaling more than $130,000—for failing to promptly report adverse events."
"In the latest fiscal year, California hospitals reported 197 cases of "retained foreign objects" for a total of 350 incidents over the past two years. They accounted for 14 percent of all preventable errors reported during those two years. That's out of 2,446 adverse events reported in California from July 1, 2007, through Dec. 31, 2009, according to the state Department of Public Health."
Reporting medical errors, such as surgical fires, to outside agencies can help prevent them, medical safety experts say. But Ohio doesn't require it.
Maine health care advocates held a press conference to make sure health reform is implemented properly, including improving the quality and safety of health care.
The article highlights quality and safety provisions in healthcare reform. "The legislation contains dozens of provisions, including fining hospitals, to reduce medical errors, hospital-borne infections and costly preventable readmissions."
The Empowered Patient Project has created a patient oriented survey on adverse medical events. Aggregate information from the surveys will be posted on their website.
"The California Department of Public Health has consistently failed to enforce new laws designed to reduce medical errors and infections at California hospitals."
View the report here: http://www.safepatientproject.org/CAPatientSafetyReportFinal_2.pdf
Guest blog post by our Director Lisa McGiffert on the slow progress of California's Department of Public Health to implement patient safety laws.
Health Care For All hosts event to publicize the release of the Massachusetts Department of Public Health first hospital-specific report about Health-care associated infections (HAIs) and the second report on Serious Reportable Events (SREs).
On Tuesday, the California Department of Public Health announced its latest round of fines, charging seven state hospitals for serious patient safety violations, the Los Angeles Times reports.
State health regulators Tuesday cited staffers at Scripps Mercy Hospital in San Diego for leaving a surgical sponge in the abdomen of a cervical cancer patient, who required two additional surgeries to remove it.
View California Department of Public Health (CDPH) Hospital Administrative Penalties 4/13/2010
"California regulators have fined hospitals more than $1 million for failing to report serious medical errors in a timely manner..."
CU's Betsy Imholz interviewed by KPBS about the state of California falling short on monitoring patient safety. Our recent report found that the California Department of Public Health has been slow to implement a number of key provisions of new patient safety laws.
"California regulators have fined hospitals just over $1 million for failing to report incidents such as leaving a foreign object in a patient after a surgery or operating on the wrong person, according to data released to California Watch by the California Department of Public Health."
AARP: Older Adults Still the Most Affected by Dangerous Medical Errors
Public Citizen’s 2010 annual ranking of state medical boards shows that most states, including one of the largest, are not living up to their obligations to protect patients from doctors who are practicing substandard medicine, according to the report released today.
Consumers Union's Safe Patient Project mentioned in Kaiser Health News.
Editorial on the patient safety provisions of the health reform bill.
Betsy Imholz of Consumers Union challenges the decision the California Pharmacy Board has signaled it will adopt regarding presription drug labeling standards.
"When a car breaks, a computer fails or a toaster flames out, the manufacturer is often liable under the product warranty. But that is not how the multibillion-dollar orthopedics industry tends to work, according to doctors, industry experts and three of the biggest device makers. "
Checklists that spell out exactly how to care for patients with common conditions have dramatically reduced hospital deaths, say doctors.
More reforms are needed to protect patients from preventable medical harm, but the new health reform law creates a solid foundation that will help ensure that the health care we are paying for is safe.
How we can save billions by cutting out unnecessary procedures that kill tens of thousands a year.
What’s taking the California Department of Public Health (CDPH) so long to implement a program to prevent hospital acquired infections? That’s what Consumers Union has been trying to find out since December, but the watchdog group isn’t getting answers.
Patient Safety Advocates Launch Campaign to Reduce Resident Physician Fatigue, Boost Patient Safety
Safety problems at Albany Medical Center Hospital and Glens Falls Hospital landed the two Capital Region facilities on the Hearst Newspapers investigation's "watch list."
The federal government can't thoroughly detect medical errors in hospitals without employing physicians or other clinicians like gumshoes, according to a recent federal study.
Merrill Goozner points out another little-noticed provision in the bill: "Drug and device companies will soon have to report payments to physicians in a national database, thanks to a little noted section of the health care reform bill called the Physician Payments Sunshine Act."
Americans have more information about the safety of their cars than about the hospitals that treat them at their most vulnerable moments.
According to a study published this month in the journal Medical Care hospital occupancy, weekend admissions, nurse staffing and the seasonal flu are major factors that increase the risk of dying in a hospital.
The following films from Transparent Learning are the first in a series of educational stories that feature patient safety advocates including Helen Haskell, Rosemary Gibson and Dr. Lucian Leape.
Consumers Union’s has been reviewing hospital infection and medical error laws passed in recent years to determine if the state has begun implementing and enforcing these laws and concluded that California has not done it's job. The state estmates 240,000 Californians a year get a hospital infection and 13,500 die.
Leading patient safey advocate Dr. Lucian Leape released report. He makes a strong statement on public reporting: "Transparency is an idea whose time has come and both hospitals and the public will be better off because of it." His statement and report are online now.
This survey was created for patients who have experienced medical harm, their loved ones and their advocates. This survey was created by the Empowered Patient Coalition and we have jointly published this survey on our websites. This survey is designed to answer questions that are important to patients. This is a way for patients to report their experience as they have lived it, and to know that their report will be counted.The Empowered Patient Coalition will be entering the events annonymously on a map so you can see your error and others in your state by clciking on the map.
Health Care For All has created an informative website, www.assertivepatient.org, to assist patients on how to navigate the complaint process when something goes wrong at the hospital.
Author Rosemary Gibson says when medical care is overused, it can cost patients their health and their savings. To attend Rosemary's March 9th talk at Health Care for All, 30 Winter St., e-mail Deb Wachenheim: dwachenheim@hcfama.org.
Patty Skolnik, Founder of Citizens for Patient Safety, makes CNN's "Intriguing people" feature. Patty was a speaker on CU's consumer panel on medical harm at our "To Err Is Human, To Delay Is Deadly" forum in DC. She is a lead advocate in Colorado and nationally on patient safety and doctor accountability issues.
"Some of the nation’s leading orthopedic surgeons have reduced or stopped use of a popular category of artificial hips amid concerns that the devices are causing severe tissue and bone damage in some patients, often requiring replacement surgery within a year or two."
"Since 2004, 116 people in Connecticut have died as a result of medical errors in hospitals -- most of which were kept secret because of a "gaping legal loophole," according to the Connecticut Attorney General Richard Blumenthal.
Review of Dr. Peter Pronovost's new book on challenging a "toxic" medical culture that doesn't crack down on medical errors.
Preventing harm will save money
Reusing one-time-use tools cuts waste, stirs some concern
If the New Hampshire Hospital Association has its way, the euphemistically named New Hampshire Health Care Quality Assurance Commission will continue operating without accountability to the public, in closed and secretive sessions and with only hospital and human services representation. That's a dangerous problem for consumers of health care and for patient safety.
For some medical conditions, the cost of care does not directly correlate to the quality of care according to a study in the Archives of Internal Medicine.
"Hospitals can reduce medical errors and cut unnecessary hospital-related infections with the use of a checklist."
"The Naval Medical Center in Bethesda, Md., confirmed Thursday that it is conducting an inquiry into Rep. John P. Murtha’s gallbladder surgery and his medical care there in late January."
The National Naval Medical Center has opened a review of the surgical care provided to the late Congressman John Murtha after the Pennsylvania Democrat died following surgery, a senior U.S. military official told CNN Wednesday.
More California women dying from pregnancy complications; state holds on to report
"With all the hand wringing about health care costs, it is possible to cut costs without harming patients. Even better, costs can be reduced while making patients better off. Here’s how."
The death Monday of Rep. John Murtha (D-Pa.) after complications from gallbladder surgery raises questions about whether the lawmaker was among the nearly 100,000 people who die in U.S. hospitals annually due to preventable medical errors.
Dallas-based Methodist Health System had two hospitals with bloodstream infection rates double the national average, according to a Consumer Reports study.
Consumer Reports has made an online system available which gives consumers access to hospital infection rates.
A comparison by Consumer Reports of Mercy with hospitals in Turlock and Modesto shows Mercy lags in all areas, including the average cost of a hospital stay.
The Consumer Reports Hospital Ratings study, released Tuesday, says North General Hospital's so-called central line infection rate was 394% worse than the national average - and the worst in the city.
NC makes it easier to find malpractice reports.
Radiation errors can cause severe harm or death for cancer patients.
California's largest health insurer is teaming with hospitals and doctors throughout the state to better share ways to improve patient safety and cut costs, leaders of the initiative said Tuesday.
NH plans to make medical errors and hospital infection information available to the public but does not have a date that they will be available. A very compelling video of medical error victim is also on this page.
Canandian medical error survivor Rhonda Nixon organized “The Empowered Patient Conference: Including the Patient in Patient Safety” conference. Speakers included Helen Haskell and Julia Hallisey, authors of "The Empowered Patient."
According to the California Medical Board, half of the doctors seeking to get lost licenses reinstated this past fiscal year were successful.
A December 2008 report by Health Affairs does find "unmistakable progress," despite setbacks. Critics say mandatory disclosure of medical errors is the key to breakthrough safety improvement.
Medically Injured Trauma Support Services (MITSS) honors Patty Skolnik for her work on patients safety through the organization she founded- Colorado Citizens for Accountability.
An LA Times/ProPublica investigation on nurses who were disciplined for medical errors in one state who hold nursing licenses and may continue to practice (and harm patients) in other states. Using public databases and state disciplinary reports, reporters found hundreds of cases in which registered nurses held clear licenses in some states after they'd been sanctioned in others, often for serious misdeeds. In California alone, a months-long review of its 350,000 active nurses found at least 177 whose licenses had been revoked, surrendered, suspended or denied elsewhere.
The Centers for Medicare and Medicaid Services estimate 7 percent of the state’s nursing home residents developed bed sores from 2007 to 2008. During the same time period, the state had the third-highest ranking for pressure ulcers in the country.
Leapfrog sites only five of U.S. News' 21 best hospitals. View Leapfrogs press release on the top hospitals list.
Firms that supply temporary nurses to the nation's hospitals are taking perilous shortcuts in their screening and supervision, sometimes putting seriously ill patients in the hands of incompetent or impaired caregivers.
A study published in the December 2nd Journal of the American Medical Assn. by an international group of researchers examined data on 13,796 adult patients from 1,265 hospitals in 75 countries who were unlucky enough to be in an intensive care unit on May 8, 2007. Here’s a summary of what they found: Fifty-one percent of ICU patients had some sort of infection, the longer you’re in the hospital, the more likely you are to become infected. The mortality rate for ICU patients with an infection was 25%, compared with 11% for patients without an infection. Infection rates in North America were slightly below average, at 48%, but the lowest rate was in Africa, at 46%. The highest infection rate was 60%, found in Central and South America.
To Err Is Human jump-started a movement to improve patient safety. How far have we come? Where do we go from here? Five patient safety "stakeholders" were interviewed for this article, including the Director of Consumers Union Safe Patient Project, Lisa McGiffert.
The forum was called "To Err is Human, to Delay is Deadly" in order to highlight the lack of progress the U.S. health care system has made since the Institute of Medicine's report "To Err is Human."
A state law intended to protect patients by making them aware of hospitals' errors has ended up making it easier for hospitals to avoid scrutiny. That's because when hospitals notify the state, the health department keeps most of those reports secret from the public.
Interview with Don Berwick, President of the Institute for Healthcare Improvement on the quality of care and patient safety.
The Joint Commission, which accredits hospitals, reports that wrong-site, wrong-side and wrong-patient procedures occur more than 40 times each week in the United States.
Rep. Bruce Braley highlighted the importance of improving patient safety in order to reduce medical malpractice.
Consumers Union Safe Patient Project Director Lisa McGiffert comments on wrong site surgery.
A new documentary film, "Money-Driven Medicine", tackles the economic underpinnings of an American healthcare system that kills four times as many people through medical error and preventable infections as die in highway accident. Consumers Union has encouraged activists to view this film and take action to make our health care system safer.
“Money-Driven Medicine” examines the medical industrial complex, and what’s wrong with our healthcare system. Watch the movie for free here until November 10 and sign our petition for reform.
For decades, the U.S. health care system has paid doctors and hospitals by the services performed, even if those services harmed the patient. Beginning in October 2008, Medicare will no longer pay for some major hospital mistakes.
Broward General Medical Center patients received reused IV bags and have tested positive for some infectious diseases.
Health care legislation now before Congress takes only modest steps to address a problem that is far more deadly than inadequate medical insuance -- medical error.
Many MRI patients are injected with a GE dye to enhance images. If they have weak kidneys, they might develop a rare and sometimes fatal disease.
The New Jersey Health Department has released the 2009 Hospital Performance Report.
The Dallas Morning News investigates the many holes in the Texas Medical Board review process over the past seven years, leaving patients at risk.
Of 11 facilities cited by the state, about half were penalized for leaving objects in patients after surgery.
Readmission rates were lower, but some death rates were up
Josie King, an 18 month old went to the hospital for burns from hot bath water and later died in the hospital from dehydration and medical error.
"The Derrick newspaper in nearby Oil City reported yesterday that "a failure to follow equipment sterilization guidelines" at the hospital resulted in "the notification of more than 100 surgical patients. "
"The American hospital, the center of health care, is a cottage industry in the post-industrial world, and we can save billions of dollars by bringing them into the modern world."- Clare Crawford Mason.
A determined breed of patient-safety advocates have forged their personal pain into a dedication to improving medical safety.
Mark your calendars for the MITSS (Medically Induced Trauma Support Services) annual dinner on Thursday, November 12, 5:30-9:30pm, at the Boston Marriott Copley Place. This is an opportunity to support an organization that does unique and important work supporting patients, families and medical providers impacted by adverse medical events. Learn more on the MITSS website.
Gov. Jon Corzine signed legislation yesterday giving residents more information about major preventable medical errors that occur in New Jersey hospitals. The law requires the state to release data identifying the hospitals responsible for making certain mistakes -- such as surgery performed on the wrong body part, the wrong person, or a sponge or medical tool left inside a patient following a procedure -- and the frequency they occur. It also prohibits hospitals from charging for some preventable medical errors.
A closer look at how families are calling for hospital rapid-response teams directly or at least to demand immediate medical attention from a senior physician if they feel a patient is in trouble and their concerns aren’t being met.
Tragic loss and patient advocacy has moved some hospitals to explore family-activated rapid-response teams. Patient advocates, Helen Haskell and Julia Hallisy, will launch a website later this month--empoweredpatientcoalition.org--that will help patients navigate the hospital system and encourage them to alert hospital staff if they sense something has gone wrong.
Bob Wachter writes: "I remain enthusiastic about 'no pay for preventable adverse events' as a clever way to use payment policy to goose the system into focusing on patient safety prevention practices. But for 'no pay...' to make a difference, there must be evidence-based prevention strategies to implement."
Letter to the editor on health care reform by patient safety activist Michael Bennett, President of the Coalition for Patients' Rights.
Features film trailer for “The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman” (son of patient safety activist Helen Haskell). This is the first in a new patient safety film series that addresses several critical health care issues: prevention of medical errors; how providers and institutions respond when care has caused harm; the important role patients and families can take in their care.
The Adverse Event Reporting System (AERS) contains over four million reports of adverse events and reflects data from 1969 to the present. Data from AERS are presented here as summary statistics. These summary statistics cover data received over the last ten years.
A dozen New Jersey hospitals are paying doctors as an incentive to save the hospitals money.
Medical records were concealed at a Texas hospital involving the medical error death of Linda Carswell's husband. There was no follow up by the Texas Health Department on any complaints related to concealing or tampering with medical records at any hospital in the state, according to this KHOU investigation.
Despite an authoritative federal report 10 years ago that laid out the scope of the problem and urged the federal and state governments and the medical community to take clear and tangible steps to reduce the number of fatal medical errors, a staggering 98,000 Americans die from preventable medical errors each year and just as many from hospital-acquired infections.
Dead by mistake was researched and written by a team of journalists from across Hearst newspapers and television stations. Hearst describes medical errors as "a critical and neglected health care issue." Consumers Union's Safe Patient Project published a report on medical harm, "To Err is Human, To Delay is Deadly" in May 2009.
Consumers Union supports nationwide “MVP” reporting: mandatory, validated (meaning hospital data is audited) and public disclosure at a facility-specific level. Most state reporting systems now divulge only statewide information, which isn't much help to consumers.
"You can't say we weren't warned. And you can't say we've done enough to address those warnings about the degree of avoidable deaths in hospitals in New York and across the country."
Six years after the “To Err is Human” report, the Washington state Legislature responded with a law mandating medical error reports. State Rep. Tom Campbell, a bill sponsor, envisioned a day when patients could click on a Web site and compare hospitals' safety records.
Despite efforts to prevent medication errors, mix-ups like this are occurring across the country with alarming frequency.
The report, "Back to Basics," analyzed the results of scientific studies of treatment protocols for chronically recurring, avoidable medical errors.
The hospital accreditation experience of a Long Island hospital.
It's part of a nationwide trend spawned by a patient-safety movement after studies a decade ago found that errors in hospitals account for an estimated 40,000 to 90,000 deaths per year.
Op-ed by Jim Hall, former chairman of the National Transportation Safety Board. The Obama administration should take a lesson from the transportation safety board’s successes and establish an independent agency charged with identifying and eliminating the causes of medical error.
Letter to Editor from Lori Nerbonne thanking lawmakers for passing hospital infection and error reporting legislation.
There's a movement to make hard numbers the basis for rankings among hospitals, instead of reputation or word-of-mouth.
City-run hospitals faked records and covered up dozens of botched operations, deadly accidents, malpractice and other medical screwups, a Daily News investigation has found.
Though A Common Medical Procedure, Many Are Performed At Hospitals Unprepared If Something Goes Wrong
Under laws that took effect last year in Virginia and a few years earlier in the District and Maryland, hospitals must report to health regulators many serious injuries that patients suffer in the course of treatment.
The board charged with overseeing California's 350,000 registered nurses often takes years to act on complaints of egregious misconduct, leaving nurses accused of wrongdoing free to practice without restrictions, an investigation by The Times and the nonprofit news organization ProPublica found.
Our state needs to take an active and aggressive policy of mandatory public reporting and tracking of HAI. Kentucky should become a leader in health care, but if Kentucky always waits for the majority of other states to act, we will be relegated to being below average.
Important new information was added today to the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Web site that reports how frequently patients return to a hospital after being discharged, a possible indicator of how well the facility did the first time around.
Too many people die needlessly at U.S. hospitals, according to a sweeping new Medicare analysis showing wide variation in death rates between the best hospitals and the worst.
This increased transparency is one of the great hopes among health care reformers for tackling the high cost of American medicine.
Former Treasury Secretary Paul O'Neil comments on reducing health care costs: "The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years."
The only economically feasible and, indeed, humane way to improve the system is to reduce the number of senseless and tragic medical errors in our hospitals. In its report, Public Citizen calls on Congress to put safety measures in place that would set the nation on course to meet the IOM’s goal of cutting the number of avoidable deaths in half in five years.
READ the report: http://www.citizen.org/documents/NPDB_Report_200907.pdf
Federal officials Thursday warned that about 5,700 surgery patients, including 1,000 at a Colorado Springs surgery center, are at risk of having been infected by an operating room technician with hepatitis C.
There were at least 89 serious medical errors last year in Utah hospitals and surgical centers, up 56 percent from the 57 logged in 2007, according to a Utah Department of Health report requested by The Salt Lake Tribune. These errors may include surgery on the wrong body part or leaving foreign objects like sponges in the body.
Public Citizen's report on ineffective hospital peer review (and under-reporting bad doctors to the National Practitioner Data Bank) made ABC World News on Sunday evening, June 21st. Doctors who perform medical errors are not always reported, and hospitals are not penalized for failing to report bad doctors.
NYT story about a Philadelphia VA hospital where many patients received botched cancer treatments.
On July 1, the state's hospitals will receive financial incentives based on the steps taken to prevent complications, including collapsed lungs and infections of the urinary tract and in the blood.
The VA started a nationwide safety campaign at it's 153 medical centers calling attention to potential infection risks from improperly operating and sterilizing the equipment.
Lori Nerbonne of New Hampshire Patient Voices writes in support of a bill for funding hospital infection rate reporting and an adverse event reporting bill, which will require hospitals to report serious, completely preventable errors to the state.
The hospital failed to notify the Department of Health that a patient had died and that at least seven others suffered serious harm last year as a result of mistakes by the medical staff.
Single-patient rooms are now viewed as an important element of high-quality health care.
Consumers Union Assesses Lack of Progress Ten Years After Institute of Medicine Found Up To 98,000 Die From Preventable Errors
The Consumers Union report said lawmakers largely have failed to enact patient safety reforms recommended by a 1999 report by the Institute of Medicine that found that medical errors cost the U.S. as much as 29 billion U.S. dollars a year.
53% of orthopedic surgeons reported medical errors in the past 6 months!
Despite a landmark report a decade ago detailing the deadly nature of the U.S. health care system, a consumer group finds that little has been done to prevent errors that cost the nation $17 billion to $29 billion and kill as many as 100,000 patients annually.
Report Shows 10-Year Effort to Curb Medical Errors Yields Few Results
Despite a decade of promises, little has been done to fix the problem of preventable medical errors that kill nearly 98,000 people in the United States each year, a consumer group said on Tuesday.
The Massachusetts Public Health Council approved regulations to implement major patient safety reforms passed last year, including public reporting of hospital infections and serious medical errors, no-pay policies for certain preventable medical errors, and requiring every hospital in the state to have a Patient and Family Advisory Council and a rapid response system that can be activated by patients and their families.
Two annual government reports released Wednesday show that progress in improving the quality of health care and narrowing health disparities among ethnic groups remains agonizingly slow, and that patient safety may actually be declining.
Billing patients or their private insurance company for the cost of medical mistakes would change under a bill that's cleared the state Senate and is now before the Assembly. The bill would prevent hospitals from charging anyone for serious medical errors. The legislation would also require the state to make public individual hospitals' errors.
Electronic records might make medicine safer and cheaper. But it might just digitize the worst flaws of today's system, where errors are rampant and basic recommended treatments often fall through the cracks.
From February 2005 through December 2008, New Jersey hospitals reported 1,817 medical errors to the state’s Department of Health and Senior Services. Of that number, 251 resulted in deaths. But consumers have no way of knowing where these errors occurred; the law keeps hospital-specific information secret. A bill making its way through the legislature would lift that veil.
The state Senate today concurred unanimously with the House in passing tough new procedures to help prevent the spread of infections acquired in hospitals and other health facilities.
A couple whose day-old baby was given to the wrong mother to nurse in a hospital is demanding answers about how it happened.
New Jersey legislation would give public hospital-specific information on medical errors.
NH bill will require public reporting of adverse events.
A group of Ohio business leaders and 24 hospitals has launched what it hopes will become a statewide effort to reduce hospital medication errors and infections. Solutions for Patient Safety, as the effort is called, takes place as the state is preparing to publish hospital quality data, including some infection rates, on the Web for consumers.
The main topics of the conference were healthcare acquired infections, never events and healthcare transparency. Lisa McGiffert (Director of Stop Hospital Infections.org) is a featured speaker.
Issues surrounding hospital-acquired infections and other medical events "that should never happen" will highlight a health care conference in Lexington next week.
Legislators are considering passing a law requiring New Hampshire's 26 hospitals to publicly report their "never events" to the state.
Unlike 27 other states, New Hampshire does not require hospitals to report serious, preventable medical errors to the state, to the patient or to the family left behind if the patient dies as a result of the mistake.
And in another development, federal officials late last week approved a new company to begin inspections as part of its often criticized hospital accreditation program.
Medicare is right to stop paying hospitals for treating reasonably preventable medical errors
On Wednesday, Medicare will start applying that logic to American medicine on a broad scale when it stops paying hospitals for the added cost of treating patients who are injured in their care.
New federal regulations target 11 hospital-acquired conditions that are considered reasonably preventable.
As the federal Centers for Medicare and Medicaid Services moves to deny Medicare payments for conditions caused by hospital mistakes, hospital executives here are watching private insurers in Tennessee and nationwide follow suit.
More than a third of New Jersey residents surveyed say they or a family member have been a victim of a medical error, and 90 percent would like the state to publicly report the number of errors at each hospital.
11 states waive fees for worst mistakes, but most will charge you or insurer
Medicare will start hitting hospitals where it hurts in October, and other insurers are hot on the trail.
CMS said that the new rules will not only improve the quality of care for Medicare benificiaries, but will save millions of taxpayer dollars every year.
HealthGrades shows rise in post-operative sepsis
Katie Couric interviews Dr. Donald Berwick about the Institute for Healthcare Improvement’s campaign to reduce medical errors, including hospital infections.
New reports reveal pattern of deadly and expensive, yet preventable, medical errors.
A $21 million grant coming to South Carolina aims to improve patient care and prevent unnecessary hospital deaths.
A new report by HealthGrades concludes that as many as 950 preventable deaths occur each day from medical errors and other patient safety incidents, including hospital infections.
A new article in the Journal of the American Medical Association reports that little progress has been made in the past five years to reduce deaths caused by medical errors in U.S. hospitals.
Report finds that most nurses and doctors witness medical errors, but few speak up when they see them. Requires a short registration.
When a report came out last week from a private group claiming that nearly 200,000 hospital patients die each year from preventable medical errors, it promptly sparked a fierce controversy.
Voluntary reporting systems to track and improve hospital error and infection rates don't work well. Only public disclosure and reporting laws passed in some states have been successful. "Americans concerned about their health care should urge their senators to kill the misnamed Patient Safety and Quality Improvement Act," states the editorial.
The United States Senate is on the verge of approving legislation that could decrease the quality of hospital care in New York and elsewhere around the country. It needs to take a moment to be sure it doesn't. The Patient Safety and Quality Improvement Act allows hospitals to shield medical error data from public scrutiny. It adopts a popular and plausible theory that holds that doctors will own up to mistakes, thereby improving the practice of medicine, if they feel they are not sacrificing their careers. But the bill may have other, more insidious effects, if critics such as Consumers Union are correct.
The magnetic field of the MRI scanner may exert forces on certain implanted objects that are susceptible to the effects of the magnetic field, potentially causing the object to move within the body, which could result in serious harm. Learn how you can help protect yourself.
Know what steps you can take to prevent a wrong-site surgery from happening to you or a loved one.
Patient injury reports indicate that it is important to use radiopaque sponges during any IR procedure in order to prevent the retention of foreign objects following IR procedures.
In 2008, the Pennsylvania Patient Safety Authority received approximately 150 reports describing events in which the magnetic resonance (MR) clinical screening process was inadequate and, in some cases, erroneously permitted patients with implanted pacemakers and other ferromagnetic objects into the MRI scanner room.
Nearly 1,000 event reports submitted to the Pennsylvania Patient Safety Authority specifically mentioned medication errors that occurred in care areas providing radiologic services.
PA annual report on state activities relating to hospital infections and medical errors.
Steps you can take if you are concerned about the quality of care in a CA nursing home.
This brief provides answers questions about what to do if you are concerned about your hospital's quality of care and links to resources that can help. It addresses steps you can take within a hospital or with organizations that regulate or oversee hospitals.
The Hearst Newspapers have created a color coded map of state reporting systems for medical errors. States collect a variety of data in different ways. The amount of information available to the public also differs from state to state.
OIG report on the sad state of medical error reporting.
When our health care system remains silent about preventable medical harm it only creates more problems.
In 2008, there were 57,852 readmissions in Pennsylvania, amounting to approximately $2.5 billion in charges. In reported events involving the use of insulin products, 52% of the events led to situations in which a patient may have or actually received the wrong dose or no dose of insulin.
Des Moines hospital posts rates of hospital infection and patient falls, two common medical harm events.
Between June 2004 and October 2008, the Pennsylvania Patient Safety Authority received 316 reports involving shoulder dystocia. Neonatal injuries were identified in 124 (39%) of these reports and included fractures, brachial plexus injuries, and death.
Wrong site surgery incidents are decreasing, but analysis of anesthesia related errors indicates that “time out” should be done prior to administration of anesthesia, instead of prior to incision.
Learn about Maryland's efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
Learn about Minnesota's efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
Learn about Kansas efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
Learn about Missouri's efforts to alter its payment system for preventable hospital acquired conditions and events that harm patients.
A new report on state and federal nonpayment policies for preventable hospital acquired conditions and events that harm patients.
A new report on state and federal nonpayment policies for preventable hospital acquired conditions and events that harm patients.
The Nevada Hospital Association has a list of all sentinel events for 2005, 2006, 2007, 2008 by hospital type; sentinel event type and sentinel event outcome.
The Rhode Island Department of Health cites Rhode Island Hospital for surgical errors; the full deficiency report, indicating failure to follow standard safety procedures, and compliance order can be found at: http://www.health.ri.gov/discipline/hospitals/RhodeIsland200911.pdf
A report shows that PA hospitals had a significant decrease mortality rates associated with hospital readmissions compared to the previous year. Readmissions often are due to complications or infections – in this case, the cause of 22,094 of PA readmissions, which accounted for almost $1.1 billion in charges and 157,000 hospital days. The report found that readmissions for complication or infection comprise 38.2% of all readmissions in PA.
See if hospitals in your county have had administrative penalties issued by the California Department of Public Health.
Analysis on how to prevent “retained foreign objects” or “RFOs” from the PA Patient Safety Authority.
Has the U.S. made any progress on patient safety since the Institute of Medicine (IOM) released To Err is Human in 1999?
Report date: August 25, 2008
A study of Medicare hospital records from 2003 and 2004 found that 1 in 5 patients was readmitted within 30 days, and half of non-surgical patients were rehospitalized without having seen an outpatient doctor in follow-up. In 2004 Medicare paid $17.4 billion to hospital for these readmissions. Readmissions are often avoidable and connected with problems in the hospital (like an infection) or with aftercare.
According to the CDC, the overall annual direct medical costs of hospital acquired infections to U.S. hospitals ranges from $28.4 to $33.8 billion.
Department of Health and Human Services, Office of Inspector General report on issues ranging from public and confidential reporting of adverse events, variations in estimates of adverse events, underreporting, measurements and nonpayment policyies for adverse events.
Agency for Healthcare Quality and Research (AHRQ) website for Patient Safety Organizations. The concept of PSOs is to collect data on medical harm while shielding the information from the public in order to encourage reporting by hospitals and doctors. All information obtained by the PSO's is confidential and voluntary, which fails to inform consumers about how well their health care providers are doing on patient safety.
A comprehensive study issued today by the Office of the Comptroller William C. Thompson Jr., found that many New York City hospitals substantially underreport “adverse events” to the New York State Department of Health (DOH).
This GAO study found that 15% of hospitalized Medicare beneficiaries in two selected counties experienced an adverse event during their hospital stay.
Department of Health and Human Services Office of Inspector General Report
Department of Health and Human Services Office Of Inspecter General Report
The consequences of service deficiencies during off-hours include higher mortality and readmission rates, more surgical complications, and more medical errors. Given the health care industry's renewed focus on ensuring patient safety and providing high-quality medical care, why hasn't the situation changed at the "other hospital"?
Rules go into effect October 1, 2008.
Minnesota releases adverse events report released. The report identifies 27 different “medical errors” (such as operating on the wrong part of the body or wrong patient) and “adverse events” (such as patient falls, suicide, and abduction), it does not include hospital-acquired infections. A new bill filed in the MN legislature (HF 87) will require inclusion of hospital infections in the future.
GlaxoSmithKline (GSK) performed an analysis of suicidal behaviors in their paroxetine pediatric clinical trial database, and found that there was a statistically significant increase in suicide-related adverse events for paroxetine-treated subjects compared to placebo.
http://www.patientsafetyamerica.com/
Paient Safety America seeks to educate the public on the dangers and excess cost of medical care in America. Our ultimate goal is a substantive, enforced, national patient bill of rights that fosters transparency for all who seek healthcare. Transparency creates informed consumers of healthcare and safer patients.
Contact: John T. James, Ph.D. john.t.james@earthlink.net
Voice4Patients.com has been designed to educate patients and consumers (potential users of the healthcare system) on the national epidemic of healthcare error. The site offers informative on-line resources for consumers; including an extensive list of disease specific organizations offering support and education for patients and their families, as well as resources that enable consumers to research medical conditions and browse on-line medical dictionaries. These resources are not a substitute for the expertise of trained clinicians.
Voice4Patients.Com
PO Box 273
Warren, ME. 04864
(207) 975-3475
www.voice4patients.com
voice4patients@aol.com
The Empowered Patient Coalition is a consumer and advocate-led effort to inform, engage and empower the public to assume a greater role in their own medical treatment and in becoming a driving force for meaningful health care reform.
The coalition was formed by advocates Helen Haskell and Julia Hallisy who share the same great loss of a child, similar patient safety goals and a clear vision of a health care system that is safe, effective, transparent and patient-centered.
Our goal is to partner with individuals, other advocates and consumer organizations to give the public a stronger voice in all health decisions. We strive to enable a new level of collaboration by facilitating the sharing of ideas and resources among all coalition members and participants and encourage the formation of powerful partnerships within the group that will lead to policy changes and quality health care for all.
http://www.empoweredpatientcoalition.org/home
Contact: info@EmpoweredPatientCoalition.org
Mission Statement:
The Maryland Coalition for Patients’ Rights is a grassroots alliance of parents, children, siblings, friends, patients and concerned citizens dedicated to promoting, protecting and preserving the civil rights of all patients. Through education, public awareness and political action, CPR is fighting to preserve the right to safe, honest and professional healthcare for all Marylanders and, in cases of injury suffered as a result of negligence and mal-practice, the right to legal redress and fair and just compensation.
http://www.coalitionforpatientsrights.org/
The Consumer Health Quality Council (a coalition of Health Care for All) empowers those impacted by health care quality issues to have a voice in our health care system, to engage fellow consumers to be active partners in their health care, and to advocate for high quality, safe, and accessible health care for all Massachusetts residents.
http://hcfa.org/index.cfm?fuseaction=Page.viewPage&pageId=546&grandparentID=531&parentID=544
Mothers Against Medical Error (MAME) is a South Carolina-based group that works with medical error victims, healthcare professionals, and legislators to promote its mission of providing support to victims of medical harm; educating policymakers and the public about patient safety issues; and advocating for improvements in healthcare policy. Areas in which MAME has been active include medical education reform, hospital infection reporting, in-hospital patient support systems, and disclosure of medical error.
Contact: Helen Haskell mamemoms@gmail.com
http://www.mamemomsonline.org/
The Empowered Patient
595 Buckingham Way # 305
San Francisco, CA 94132
Contact: Dr. Julia Hallisy
Hallisy@TheEmpoweredPatient.com
(415) 681-1011
Our goal is to help empowered patients claim their right to safe, effective health care. Patients are beginning to grasp the importance of taking a proactive role in their health care and are coming to the realization that they are a powerful, yet untapped safety resource.
Our mission is to raise public awareness about patient safety issues including adverse events, medication errors, hospital-acquired infections and communication challenges. Help us stand and bear witness to the fact that we can and must do more to keep patients safe.
http://www.TheEmpoweredPatient.com/NH Patient Voices
6 Fieldstone Drive
Bow, NH 03304
contact: Lori Nerbonne
nhpatientvoices@comcast.net
603-491-4563
(website under construction)
Mission: To advocate for urgent improvements in patient safety and in gaining access to hospital quality data that will allow NH health care consumers to make informed decisions when selecting hospitals and treatment providers. We also raise awareness for and educate healthcare consumers about patient safety, infection & error prevention, and patients' rights.
CT Center for Patient Safety works in our communities, within our healthcare systems, and with elected officials to improve the quality of healthcare and to protect the rights of injured patients through education, accountability and advocacy. We believe that quality healthcare is a right.
read and watch what the Cleveland clinic does to their patients
http://www.kidneytransplantkiller.com
More than 290,000 surgical site infections occur in U.S. hospitals each year. Patients who acquire infections from surgery spend, on average, an additional 6.5 days in the hospital, are five times more likely to be readmitted after discharge, and twice as likely to die.
Surgery patients are at risk for infection because surgical incisions create a pathway for germs to enter the body. Maintaining a sterile environment in the operating room is therefore critical to protect patients from being contaminated with bacteria, which can lead to infection.
How well is your hospital, state and the nation as a whole are performing on three key practices that help prevent infections during surgery? Find out here »
On June 9, 2008, my brother, Kenneth Novak died due to the terrible mistake of two anesthesiologists at a hospital in Fort Lauderdale, FL. While central lines were being placed into his internal jugular vein to prepare for a liver transplant, the catheter/needle was advanced too far, perforating both the jugular and right subclavian artery. My brother bled to death.
Read More »
On September 30 of 1991, a simple forceps biopsy was performed (in my chest of a massive 13cm tumor) to diagnose, and/or grade and stage Non-Hodgkin's lymphoma. A surgical accident occured during this biopsy
Read More »
The surgeon was not prepared for my sedative needs, did not listen to my request of what to give me, and because I was holding up the Endoscopic Unit, he called for an anesthesiologist I had never met. He never asked a single question, nor did he check out my charts. He simply injected me with Propofol, without the Lidocaine to ease the pain. I was in hell, and then out for a quick intubation. As a heart patient with all the symptoms from that, I should not have had Propofol. I woke up coughing my guts and lungs up as they extubated me. I was on the other side of the hospital in the main recovery area. Neither doctor came to tell me what happened and what might happen later.
Read More »
In 2001, Patty and David Skolnik spent nearly three years watching their only child, Michael, play victim to a broken system as a result of unnecessary brain surgery. Due to medical error caused by negligence and incompetence, routine expectations of our healthcare system proved ineffective in providing quality medical care and patient safety for 22 year old Michael Skolnik.
Read More »
Helen Haskell, founder of Mothers Against Medical Error (MAME), was another key advocate for the Stop Hospital Infection Campaign in South Carolina where she worked with a coalition of other activists (individuals with hospital infection experiences) and organizations (John Ruoff, SC Fair Share; Theresa Arnold, SC AARP; and other) to get the hospital infection public disclosure bill passed into law.
Read More »
Stay informed about Medical Errors activity with
