Despite stringent hospital protocols and watchful government agencies, preventable medical errors continue to severely harm or cause death to some 400,000 patients a year in this country.
Sometimes stories about medical harm are especially creepy and bizarre, especially when incidents that should by now have been made impossible happen anyway.
It gives me nightmares to think that despite the most diligent precautions by providers, wrong site surgeries, retained foreign objects and other tragic medical errors cause avoidable death to some 400,000 patients a year in this country. Still.
Today is Halloween, a time when we honor the dead. In Mexico, as in some parts of the U.S., November 2 is called Día de Muertos. In healthcare, it may also be a time when we think about those patients who, but for some unfortunate confluence of regrettable snafus, would still be alive.
Here are a few recent news items that I find particularly unsettling.
1. Medical Errors Account for 440,000 Deaths a Year
First on my list is a most fearsome paper by John T. James in the September issue of the Journal of Patient Safety. James, a pathologist with Patient Safety America in Houston, analyzed multiple studies to draw this eye-opening conclusion:
Providers are greatly under-reporting patient deaths that result from their medical errors. He says that at least 210,000 deaths a year in the U.S.—and as many as 440,000—can be blamed on provider mistakes, mostly occurring in hospitals. That's more than four times the amount estimated by the Institute of Medicine's 1999 report, To Err Is Human.
James counted errors not just of commission, such as the administration of an incorrect drug or dosage, but of omission, communication, diagnosis, and context (such as when physicians fail to consider a patient's limited cognitive abilities to comply with medical treatment).
He also counted not just those in-hospital deaths resulting from those errors, but deaths that occurred months after patients left the hospital.
"It should be no surprise that preventable adverse events that harm patients are frighteningly common in this highly technical, rapidly changing, and poorly integrated industry," he wrote. "The picture is further complicated by a lack of transparency and limited accountability for errors that harm patients."
And many of these deadly errors may not even be considered errors by the people who make them.
James draws these conclusions based on studies that used IHI's Global Trigger Tool to flag suspicious findings in medical records, "such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient."
He also extrapolated data from two Office of Inspector General reports and a North Carolina study that quantified these events for limited periods of time or small numbers of hospitals.
James cites the particularly disturbing survey findings of Eric Campbell, Director of Research at the Mongan Institute for Health Policy at the Harvard/Massachusetts General Hospital, published in the Annals of Internal Medicine a few years ago.
Campbell found that physicians said they "often refuse to report a serious adverse event to anyone authority." Cardiologists in particular, who as a group exhibit "the highest nonreporting group of the specialties studied," said they had "recently refused to report at least one serious medical error, of which they had first-hand knowledge."
Obviously, James says, this is "clear evidence of such unreported medical errors [that] often did not find their way into the medical records" of harmed patients.
To me, this is macabre.
2. A Cascade of Errors
It's not only deaths due to medical errors that are regrettable. Patients who survive adverse events can be harmed in ways that will haunt them for the rest of their lives.
Among the recent California immediate jeopardy fines against hospitals that harmed patients was a $100,000 penalty against Sharp Memorial Hospital in San Diego was a particularly egregious and sad incident, not just because of the harm it caused a 53-year-old man, but because of how preventable it was.
The patient was assessed at a nearby hospital, where a physician performed imaging studies that revealed a cancerous mass on his right kidney. He was referred to Sharp for surgery.
The physician erred in his notes, writing that the mass was on the left kidney.
He promptly corrected it to clarify that the lesion "is actually located within the **RIGHT** kidney." But the Sharp surgeon failed to see the second note, did not bring the patient's kidney images with him into the operating room, and neglected to remotely access them electronically, despite his team asking if the surgery should be postponed until he had those images.
The Sharp surgeon told state investigators that he "intended to access the images related to the case, but forgot the necessary log-on information needed to access the images remotely."
The patient's healthy kidney removed, a second surgery was necessary to remove the cancerous kidney, and the patient will be subjected to dialysis treatments for the rest of his life.
3. Missing Hospital Patient Found Dead In Hospital Stairwell
One medical error that would clearly make John T. James's list comes under the category of utterly unfathomable. It's the gruesome story of what happened to Lynne Spalding, 57, a patient at San Francisco General Hospital. On Sept. 19, Spalding was admitted for treatment of an infection, but two days later she could not be found.
Spalding's body was discovered in a hospital stairwell 17 days later. An autopsy is underway to determine the cause of death.
And the story gets worse. An attorney for Spalding's family told the San Francisco Chronicle that he was told by hospital officials that four requests were made to law enforcement officials to search for the patient. It's unclear whether those searches were conducted.
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."
Here's something else that's scary: The Joint Commission alert counts a total of 772 URFO incidents from all its hospitals between 2005 and 2012.
How can the number be that low?
California's annual "Fee Report" from February says that since FY year 2008, state officials have counted 1,061 incidents of "retention of a foreign object" inside patients. Just in California.
Clearly, not all URFOs are being reported to The Joint Commission.'
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The California report indicates such forgotten surgical item incidents are not in decline either. The incidence has actually been going up.
5. Dwindling Interest in Immediate Jeopardy Fines
So adverse events are causing deaths and patient harm in numbers we can't be sure of. But there's not much outrage and even media interest appears to be drifting.
Every four months or so for the last five years, the California Department of Public Health has hosted an hour-long media teleconference to publicize the latest additions to what I call its "Hospital Hall of Shame" and to announce the fines which range from $25,000 to $100,000.
These are those organizations where patients have died or been severely injured from surgical errors, falls, fires, poorly maintained medical equipment, medication errors, procedures performed by inadequately trained providers, and many other mistakes.
Last week, however, when state officials announced 10 fines totaling $775,000 to nine California hospitals, for the first time there was no teleconference, just an e-mailed news release. Debby Rogers, deputy director for the CDPH's Center for Health Care Quality, told me she thought there was no longer the media interest to warrant a teleconference.
Have we become so accustomed to these incidents that we no longer care to write about these events? Or is it that state officials only think that is the case?
I don't know what the answer is, but it's all enough to give you nightmares.
Happy Halloween.