Hospital Errors and Patient Safety Issues

In safe hands

The recent news about a Central New York hospital penalty of $22,000 for two critical errors committed by the hospital staff has brought the patient safety and medical errors issue into focus again.

Last month, California Department of Public Health (CDPH) issued penalties to ten California hospitals amounting to $625,000, following investigations on the facilities’ licensing and medical records compliance issues.

California Pacific Medical Center – Pacific Campus Hospital and Palomar Health Downtown Campus in San Francisco had the highest penalty of $100,000 each. In the first case, the patient had to undergo surgery twice due to medical errors, while the second hospital was charged for failing to frame policies and procedures to ensure patient safety.

In October 2009, Doctors at St. Joseph’s Hospital Health Center erroneously declared a 41-year-old woman, Colleen S. Burns, brain dead without performing the necessary tests. Neither had they treated the patient properly for the drug overdose, for which she had been admitted.

A nurse had observed that the patient responded to a reflex test and was breathing without the support of a ventilator. However, the doctors choose to ignore the warning signs and prepared to harvest her organs after getting the family’s consent.

In a dramatic event, the woman opened her eyes on the operating table, and the organ-harvesting process was called-off. The doctors mistook the deep coma for a cardiac death.

It is noted that the hospital made no investigation into the matter, which could have been a catastrophic event.

The state health department had started the investigation in 2010, and in 2012, imposed a fine of $6000 for the Burns case and another $16,000 for negligence and leaving a patient unattended, which resulted in a fall and head injury in 2011.

More than a decade ago the Institute of Medicine in its attempt to build a safer health system, had outlined strategies to decrease the incidence of preventable medical errors by 50%, at a time when 98,000 people were estimated to have died due to hospital errors. However, since then, various studies and reports have found that even with the advancement of IT in the healthcare sector, there has been a rise in hospital errors and a drastic increase in the number of patients becoming victims of these mistakes.

In articles titled “It’s time to Account for Medical Error” and the “Top Ten Causes of Death,” published in the Journal of Participatory Medicine, Bart Windrum, discussed how these errors are underestimated and not acknowledged. He also explained that these were the top ten causes of deaths in hospitals. Both his parents were victims of medical errors in their final stages of life.

Earlier this month, Royal Devon and Exeter Hospital were reported to have investigated two incidents, which according to the state health department are considered “never events” due to the criticality of the mistakes.  In one case, the patient had received a transfusion of the wrong blood type, while in the other incident an unnecessary tube was inserted into the patient’s heart.

Patients often depend on the reputation of the hospital and surgeons rather than choosing a health care provider they can trust. However, there is no way of knowing the medical errors performed by doctors and the hospitals.

According to Lisa McGiffert, director of Consumers Union Safe Patient Project, there are currently no systems to collect information on hospital medical errors and patient safety issues.

Most of the hospital errors are unreported and left uninvestigated. A proper system to track medical errors has not yet been discovered.

There are special groups like the Society of Thoracic Surgeons who aim to track the outcomes of surgeries and medical procedures. Many hospitals have also started taking initiatives to record events and improve patient safety at their centers.

Written by: Janet Grace Ortigas