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5 Scary Things About Healthcare Quality

Cheryl Clark, for HealthLeaders Media, October 31, 2013

Now there are media reports that an unidentified individual, perhaps a homeless person, was seen in the stairwell and may have seen or had some interaction with Spalding.

David Perry, a spokesman for the family, "said in a video statement, "Lynne Spalding died alone. In a stairwell. In one of the finest medical institutions in this country."

Todd May, MD, Chief Medical Officer at San Francisco General Hospital told SKY News, "What happened at our hospital is horrible… This has shaken us to our core." The hospital has reportedly made some changes to patient protocols.

4. Suspiciously Low URFO Numbers

How often do adverse events happen? Let's look at retained foreign objects.

Last week, The Joint Commission issued another in its series of Sentinel Alerts, this one on unintended retention of foreign objects (URFOs).

Consider the commission's list of items left inside surgical cavities:

Soft goods, such as sponges and towels; device components or fragments, such as broken parts of instruments, stapler components, parts of laparoscopic trocars, guide wires, catheters, and pieces of drains; needles and other sharps, and instruments such as malleable retractors.

What's particularly horrifying is that on all too many well-documented occasions, objects are not discovered until weeks, months, or even years later, such as a case in Kentucky, highlighted in the Alert:

Four years after having a hysterectomy", a woman in Kentucky began to experience severe abdominal pain. A CT scan revealed a surgical sponge left behind by the surgical team that had performed the hysterectomy.

"Upon surgical exploration, the retained sponge was found to have caused a serious infection, which required bowel resection. The patient suffered from severe health issues, anxiety, depression, disability and social isolation."

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3 comments on "5 Scary Things About Healthcare Quality"


Suresh Nirody (11/1/2013 at 2:53 PM)
He didn't actually "count" anything... He looked at four studies(covering 4,252 records reviewed, which were associated with a total of 38 deaths) and then extrapolated their rates to the total 34.4 million discharges in 2007 to get his lower boundary... Beyond the deaths he estimates a mind-boggling 2-4 million serious adverse events (not resulting in death) a year! What IS shocking is that the 1999 IOM report was based on data from studies in 1984, and this latest report is based on years old data as well. It is an indictment of the system that analysis of something so important has to rely on such old data! Also, given the magnitude of the numbers discussed, I've been completely amazed to NOT have seen any analysis of this report, either to support or to disagree with the methodology and his numbers and conclusions... Surely there are learned people who can, and should, do this!

Lisa Sams MSN, RNC (11/1/2013 at 1:27 PM)
Cheryl, thank you for highlighting the James article. The doctor consider "father" of patient safety is confident in the analysis. And you raise an important question about the level of interest in harm and death that occur during a hospital stay. Unless it happens to someone we know....or to ourselves....I believe we have learned to ignore the data because it is One Person at a time. Many attempt to tell their story and organizations like the Walking Gallery offer visual representation of lost or harmed loved ones. These are system issues, as mentioned in other comment. But calling it a system problem does not remove the provider, administrator and other staff from the analysis. As a long time advanced practice nurse, I see the value in system analysis and development of a plan that can be tracked until the culture change is truly integrated into care. If we can reach critical mass with patient communities and clinicians sharing information, collaborating and basically taking charge of the problem it will change. No clinician goes to work looking to cause harm and when it happens it is devastating. It is time to share basic information with patients and families in how to stay safe in the hospital, to push back, to question and when necessary engage the CEO through a Risk Management report...done on a scrap of paper is all it takes. Yes, these are complex system issues but if your spouse, your mom or your child is not receiving the care you think they should then push and push hard. We have a good history of patient community driving change in the 60's & 70's. It was women who changed our closed doors and drug induced hospital births to family centered care. They became educated and expected more.

stan davis (10/31/2013 at 7:15 PM)
very irresponsible to write "He says that at least 210,000 deaths a year in the U.S.[INVALID]and as many as 440,000[INVALID]can be blamed on provider mistakes". nowhere in the paper does it state this as "provider mistakes". the errors are part of a system, and requires a system approach to fix.