Articles Posted in Medical Error

Let the patient beware is an adage that may need to be extended to yet another realm of healthcare: dentistry. Kudos to a reporting team in Texas for their recently published investigation, disclosing that dentists all too frequently are involved in procedures in which their patients die and that ineffectual regulators fail to halt dodgy practices and feckless practitioners, some of whom hopscotch across the country with impunity.

The seven-part Dallas Morning News series finds that at least 1,000 dental patients have died in the last five years due to questionable oral healthcare. The report says the numbers may be greater but that regulatory laissez-faire prevents the public from understanding the severity of the issue.

Patients who go to dental practices for issues as minor as tooth decay and as significant as oral surgery all have ended up dead, often after undergoing poorly supervised anesthesia, the paper says.

The stories of patient harm prove even more chilling because those who are supposed to oversee dentists and prevent injury or death show greater concern for protecting practitioners and their reputations and privacy than for public safety. In some instances the Morning News spotlights, dangerous dentists simply packed up and moved to another state, where their credentials and records barely got blinked at before they were allowed to practice anew.

The paper provides an online checklist of ways patients can try to protect themselves and offers an interactive map so consumers can check how their states perform in dental oversight. The bad news for residents of Virginia and Maryland: The News gives the two states an F and offers harrowing incidents that have occurred in both, with little or no regulatory penalty for the dental scofflaws.

Although I join anyone who sees a dentist regularly, as I do, in hoping the profession takes its own steps to clean up its ranks across the nation, I’m not surprised by the powerful and tragic findings of some fine reporting. Back at the start of my career, I worked on an investigative reporting team that found Florida regulators blind to horrific wrongdoing by doctors and impotent in preventing them from doing more damage.

And while improvements occur because of journalistic tenacity, it’s also true that “advances” in practice and technology may make us all more vulnerable: Healthcare providers have access now to a range of powerful anesthetic drugs, and these are administered in a wider variety of settings than ever before, including in specialized centers for procedures including major surgery and colonoscopy; the results aren’t always optimal.

If the public clamor can’t get lawmakers to act, and if professions can’t assist regulators rather than hamstringing them from policing practices, it may require, as it all too often does, the intervention of lawsuits in the civil justice system.

cjdTo hear many in the health care professions and tort reform advocates tell it, malpractice litigation represents one of the great scourges of modern medicine, racking up costly and time-consuming verdicts, clogging the civil justice system, and leading caregivers to wasteful defensive practices, including over-testing and over-medicating.

Bah, humbug, to such myths, The Center for Justice & Democracy at New York Law School has replied in its fifth annual Medical Malpractice by the Numbers briefing book.

The latest work, which is available online for free (click on the previous link and follow to the end of the document for a download hyperlink) provides concise, relevant references in 128 pages of carefully footnoted citations to factual research on medical malpractice, including these salient findings:

  • Medical malpractice cases constitute just 3 percent of all tort matters, with juries deciding few of these lawsuits — an estimated 3 percent to 9 percent of them.
  • Medical errors are the third leading cause of death in the United States, claiming hundreds of thousands of lives. Even with the myriad patients treated in 2014, physicians made just slight more than 8,500 malpractice payments; just 5,288 disciplinary actions were taken “that reduced, restricted, suspended, revoked or denied physicians’ clinical privileges or membership in a health care entity.”
  • A handful of MDs, roughly 11 percent, accounted for about 25 percent of the cases that resulted in complications, and surgeons with the highest complication rates are performing operations in hospitals nationwide.

“Although hundreds of thousands of patients die each year due to medical errors, very few medical claims are paid to compensate injured patients,” says Joanne Doroshow, the CJ&D executive director who is a principal author of the briefing book with  Emily Gottlieb, CJ&D’s deputy director for law and policy.

The Centers for Disease Control and Prevention offers but one voice among many that has declared that the United States is in the midst of a prescription drug abuse epidemic. As the CDC notes: “Since 1999, the amount of prescription painkillers prescribed and sold in the U.S. has nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report. Overprescribing leads to more abuse and more overdose deaths.” Indeed, the agency says 44 Americans die daily due to prescription painkiller overdoses.

Those grim statistics provide a stark context for a startling Los Angeles case: Prosecutors have won a second-degree murder conviction against a female physician from the suburb of Rowland Heights for her role in the overdose deaths of three of her patients. The Los Angeles Times said this was one of a handful of instances in which a physician has been prosecuted on homicide charges for prescribing painkillers that led to a patient’s death.

The paper quoted experts who raised concerns as to whether the case would send a chill through the medical community, with doctors growing more sparing of powerful painkillers for patients who need them; others said that the physician involved had been reckless in her prescribing, had seen a patient overdose in her office but continued to write scripts for him, and had received multiple calls from authorities warning her that her patients had died with drugs she had prescribed in their systems.

Her attorney noted that California medical authorities had considered her wrong-doing and found her “in violation of standards” and argued that the physician should have faced civil malpractice proceedings, instead.

Perhaps. But pill addicts don’t make for the best plaintiffs and they certainly would be tarred by defense counsel as junkies deserving of little consideration. And families also typically prefer to have their loved ones alive and not have to be chasing damages after their deaths. It’s also unclear whether, after malpractice insurance payments get made, even a hefty civil win against a pill-dispensing doctor would send the requisite, widespread message to practitioners about the severity of the prescription drug abuse issue.

While the medical community has acted to address the prescribing bane — including improving pain-management regimens, supporting state laws against abuse of powerful medications, and putting in place monitoring systems so addicts can’t go, say, from emergency room to emergency room gulling harried care-givers into dispensing excess dosages — it, tragically, may take public awareness and the dual hammer of civil and criminal actions to effect change.

A recent issue of our Better Health Care newsletter focused on pain management. We interviewed Dr. Richard Ruskin, a pain management specialist who lost a relative to incompetent pill-dispensing that led to a fatal overdose.  This is an area of medicine that requires careful listening to patients, a lot of thoughtfulness, and some clear-eyed realization that people who develop chemical addictions to pain-killers are not always going to be up-front about it. That doesn’t make them bad people, and it doesn’t mean we should write them off as junkies.

The “say what?” study last month describing the disturbing frequency of errors in medical diagnoses has prompted much navel-gazing in many quarters.

One story, in KaiserHealthNews.org (KHN), quoted Leslie Michelson, who heads Private Health Management, a company that charges substantial fees for helping patients figure out what’s wrong with them, as saying he wasn’t surprised.

Too often his company has found that its clients don’t have the condition originally diagnosed; sometimes, the diagnosis is correct, but the treatment is not.

Many patients can avoid paying the steep rates Michelson charges, he said, if they would be more assertive about their medical care. His book, “The Patient’s Playbook: How to Save Your Life and the Lives of Those You Love,” directs people how to research doctors and conditions, and how to cultivate trusted family and friends as backups when you’re seriously ill. Here are excerpts of his interview with KHN about how to navigate the health system and avoid diagnostic errors.

What is diagnostic error and how common is it?

Someone being treated for the wrong cancer, for a disease they don’t have, … [for] back pain when [it’s not clear] whether the cause of the pain is a structural issue, a neurologic issue, an auto-immune condition or something else. And yet they’re going in with an intervention. It’s particularly painful with respect to cancers. When people are treated for the wrong cancer, they’re generally getting treatment that is totally ineffective. They get none of the benefit of the intervention, but all the side effects.

What are the three most important things a person can do to try to avoid a diagnostic error?

If you get a … significant diagnosis, it’s always important to see a physician with the exact expertise in what you have, particularly if it’s a rare condition.

Second is to get a second opinion. …You’re talking about determining an expensive, potentially complicated treatment program. If diagnosis is not measured twice – independently confirmed by a second pathologist – why engage in this entire potentially multi-year, multi-modality intervention unless you know exactly?

The third piece is to become an educated consumer. For all sorts of reasons, all of us are acculturated to be passive when it comes to our health, particularly when we’re sick. Figure out how to summon the courage and develop the confidence to partner with your physician. There are terrific resources online that everyone can use to understand whether their diagnosis is accurate.

Can you name some?

One of the best ones is the National Comprehensive Cancer Network. It’s a group of 26 major cancer centers that … have developed treatment protocols for all the major cancers. You can find out the symptoms, the treatments and what indices will result in a diagnosis that’s accurate. Another great resource is something called Expertscape. They’ve taken all the medical articles over the past decades, organized them by disease and identified the authors of those articles. All you need to do is put in the name of that diagnosis, put in your zip code, put in a radius of how many miles you are prepared to travel, push search and it will identify for you the physicians who have done the most prominent research on that condition.

Reading your book can make one paranoid. What if my doctor is wrong? At what level should seek a second opinion?

Americans are fabulous consumers. We’re good at harnessing information. If it’s a significant issue that is being diagnosed, get a second opinion from an expert in exactly that condition. Even if it’s not, if that little nagging gut instinct says to you “this isn’t right,” act on it.

Are there other groups that help someone who doesn’t have tens of thousands to spend on private services like your firm’s?

Yes, there are so many resources [from] disease-specific foundations. You can get tremendous pamphlets, resources and recommendations for physicians. All of them are out there awaiting an email from you, a phone call from you.

Isn’t there a risk, if patients follow your recommendations, that it would lead to additional tests and procedures that may not make a difference in their treatment or outcome, but would add costs to the patients and society?

No. Part of the reason we have overtesting or overtreatment problems in the U.S. is because of the structure of the reimbursement system. Physicians generally get paid more to do more. The second cause is patients that are too passive. When patients learn how to use the resources online to learn about their diseases and the fundamental importance of getting to experts in their precise condition, my experience is they will have the shortest line between the presentation of symptoms, the development of definitive diagnoses and the implementation of effective treatment plans. A lot of unnecessary costs – and the best estimates are that 30 percent of all health care spending is either   unnecessary or counterproductive – are because patients aren’t going to specialists they need to.

If any work places should be distraction-free, a short list would include the command post for launching nuclear arms, the control tower of a busy airport and the operating room. We have no information about the first two, but a recent study shows that the people working in the surgical suite might be monitoring their smartphones instead of monitoring you.

As KaiserHealthNews.org (KHN) and the Washington Post reported, “Cellphone use is not generally restricted in the operating room, but some experts say the time for rules has come. In interviews, many described co-workers’ texting friends and relatives from the surgical suite. Some spoke of colleagues who hide a phone in a drawer and check it when they think no one is watching.”

Sometimes a member of the surgical team might be reviewing pertinent medical data on the device, but too often, they’re being used for decidedly nonmedical purposes. As Dwight Burney, an orthopedic surgeon, told KHN/Post, “Sometimes it’s just stuff like shopping online or checking Facebook. The problem is that it does lead to distraction.”

If you’re a baseball pitcher, being distracted might lead to the runner stealing a base. If you’re a surgeon or anesthesiologist, distraction might mean leaving a sponge inside a patient. It might mean forgetting to check a drug dose. Is texting your buddy about a tee time really worth the risk of causing patient harm?

KHN/Post recalled an incident a few years ago when an anesthesiologist in Texas was accused of sending text messages and e-mails on an iPad while his patient’s oxygen levels were dropping. Supposedly, the anesthesiologist didn’t notice the problem for nearly 20 minutes, and the patient died. The woman’s family sued the doctor, and the case settled.

The American College of Surgeons, the American Academy of Orthopaedic Surgeons and doctors who published a paper a few months ago for the American Society of Anesthesiologists have raised the caution flag about phones in the OR. They want clear rules on whether and how such devices may be used. Some people were concerned about the potential for noise or distraction, and others about the possibility that they could transmit microbes and cause infection. (Who washes her iPhone?)

“No federal regulations or industry-wide quality measures address phone use in health-care settings in general or in the OR,” KHN/Post reported. “And no group tracks whether hospitals have adopted rules for cellphone use.”

Sometimes, these cunning little devices turn into tattletales. In June, we wrote about the Virginia man undergoing a colonoscopy whose phone inadvertently recorded the whole procedure when it was left in his pants pocket on a shelf under the operating table. It recorded shocking comments by the anesthesiologist that prompted the patient to file a successful defamation/malpractice lawsuit.

That event was to the patient’s benefit, but when providers are engaged in personal business, it’s more likely to cause harm. Peter Papadakos, a professor of anesthesiology, surgery, neurology and neurosurgery at the University of Rochester, told KHN/Post, “Once we get into or start using our cellphones, we separate ourselves from the reality of where we are. It’s self-evident: If you’re staring at a phone, you’re not staring at the monitors.”

Such behavior was suggested in the sad demise of comedian Joan Rivers. Her doctor supposedly was taking cellphone pictures during Rivers’ procedure, and although the investigation didn’t directly link Rivers’ death to the doctor’s phone use, it was a serious breach of clinical practice and ethics.

In 2012, the ECRI Institute, a nonprofit enterprise devoted to health-care quality, included cellphone distraction among the top 10 risks that technology could pose to patient safety.

Some hospitals are trying to address the situation. The University of Rochester Medical Center, according to the KHN/Post story, requires staff to keep phones silenced when working with patients, and forbids employees to use phones for personal matters when they’re at any “clinical work stations,” not just operating rooms.

Cardiologist Chandan Devireddy at Emory University oversees a catheterization laboratory where patients undergo cardiac procedures. He forbids staffers from checking e-mail or browsing the Internet when patients are present. At least once a year, his department discusses social media and appropriate cellphone use.

“Appropriate,” in many instances might be the assistance a smartphone offers in bringing up patient information, or consulting with colleagues who aren’t present during a surgery.

But how do supervisors know if their teammates are buying books on Amazon or reviewing lab results “unless you’re videotaping or monitoring all persons at any time of the day?” Devireddy said. So how do you retain the utility of the devices without compromising patient safety?

“Our ability to address patient-care issues is much faster,” Devireddy acknowledged. “The idea of eliminating mobile phones is, I think, a very restrictive one.” He believes that hospitals must find a way to cultivate the benefits while keeping staffers from getting distracted.

Life is full of distractions, and whether it’s a cellphone in the OR or a cute kid in the convertible next to your car, it’s up to the person wielding the tool to make sure it’s used properly. If not, in some cases the consequences are life or death.

Patients who suspect malpractice after they’ve had an unforeseen injury from a surgical procedure quickly learn that the operating room works on a basic “honor system” for reporting errors. If something goes wrong, the surgeon is required to describe the event in his or her dictated report of the operation. Of course, that lets the surgeon control what gets put on paper.

Now there is a budding movement to have cameras in operating rooms record what happens and save the recordings for possible use later — both to educate professionals and as potential legal evidence.

The Washington Post has an article describing a bill introduced in the Wisconsin legislature to require such recordings. The man behind the move is the brother of a patient who died from too much propofol, the same anesthetic drug that killed Michael Jackson.

Reporter Tom Jackman’s article quotes a Toronto surgeon who has invented a device that synchronizes the vital signs recordings of a patient’s pulse etc. with video and audio recordings of what is going on in the OR. Teodor P. Grantcharov, a professor of surgery at the University of Toronto, told the Post:

If we don’t know what we’re doing wrong, we’ll never improve. This is what many other ­high-performance industries have been using for decades.

Lawyers for the medical industry complain that such recordings would “invade the privacy” of surgeons, nurses and others in the OR. But if it could educate surgeons on how to avoid errors and save lives, that seems like a minor quibble that could be worked around. Other practical issues also need to be addressed. But many surgical procedures are already video-recorded, because they are done with tiny cameras inside the body in so-called “minimally invasive” techniques.

So why not just save the recording?

Of all the medical mistakes that could be made in the first hours of a newborn’s life, few lay people would think to attribute any of them to a delay in naming the infant. But neonatologists (doctors who treat ill or premature newborns) know that the unnamed wee ones under their care are more likely to be on the receiving end of a medical error.

When a baby is born and the parents are still dithering about what to call him or her, hospitals use a generic gender descriptor on the patient bracelet – Babygirl Smith, for example. Once the kid is entered into hospital records with that ID, it’s often there until the baby is discharged, even if he or she gets a real name in the meantime.

A study in Pediatrics conducted by researchers aware that such anonymity can invite problems tested a new naming method to see if it reduced potential errors.

As reported on NPR, it’s believed that generic baby names increase the risk of the wrong treatment being given to the wrong patient, especially if the baby is in the neonatal intensive care unit, where about 12 in 100 newborns land.

The neonatal ICU, or NICU, is filled with tiny, often fragile beings requiring complicated care. According to the study’s lead author, Dr. Jason Adelman, an internist and patient safety officer at Montefiore Health System in New York, “All neonatologists know [generic naming] is a problem, but weren’t able to quantify it.”

His team changed naming convention by using a real first name – the mother’s. Instead of Babygirl Smith, that baby would get the ID Donnasgirl Smith. Twins would be 1Donnasgirl Smith and 2Donnasgirl Smith instead of the standard BabygirlA and BabygirlB.

Researchers compared the rate of so-called retract-and-reorder (RAR) events in the years before and after implementing the new ID system. “Retract-and-reorder,” NPR explained, “is a tool that uses the hospital’s computer system to flag medical orders retracted by a health-care worker and then placed by the same worker on a different patient within a short time period.”

The study showed that RAR events declined by more than one-third in the year after the intervention compared with the earlier period.

That doesn’t prove that the new ID system is superior to the old one, but it’s food for hospital thought to consider revising clinical practice.

Keep in mind that the RAR tool does not track medical errors, just close calls. As Dr. Gautham Suresh, a neonatologist not involved in the study explained to NPR, “Say I’m driving down the highway and I almost take the wrong exit but then swing back into the right lane and take the correct exit later. RAR is catching those times when I almost took the wrong exit.”

The researchers also noted that RAR slightly over-reports wrong-patient errors because it includes some false positives. That’s when a test indicates something amiss that leads to more tests and the possibility of complications (such as infection) when, if nothing had been done in the first place, no harm would have occurred.

Although his study analyzed only computerized orders, Adelman said the new naming system has the potential to lower the rate of other kinds of errors, some as simple as taking the wrong container of pumped breast milk from the refrigerator.

Suresh said the study advanced the body of knowledge, but he didn’t go as far as to advise that the new ID system be widely implemented. But he did advocate for further attention to the traditional way babies are named in the hospital, and noted that other factors contribute to wrong-patient mistakes, such as human distraction or poor lighting. “Patient identification errors are complex, and the name is only part of the puzzle,” he says.

The simplest way to avoid them, of course, is to figure out what to call your kid before he or she arrives. Come on, mom and dad … it’s not as if Baby has a vote.

A newly launched website tracks the complication rates of about 17,000 surgeons across the country. The idea is to help patients choose the person who’s going to operate on them based on his or her safety and performance records in comparison with their peers.

The database, Surgeon Scorecard, was established by ProPublica, the nonprofit investigative news site. It analyzed 2.3 million hip and knee replacements, spinal fusions, gallbladder removals, prostate resections and prostate removals done between 2009 and 2013 on patients in Medicare, which pays for two out of every five U.S. hospital stays.

Complications directly related to the operations included infections, blood clots, misaligned orthopedic devices and uncontrolled bleeding. ProPublica counted only cases in which the patient died in the hospital or had a complication requiring readmission within 30 days.

The analysis factored in patients’ health and age. To qualify for comparison, surgeons had to have performed a certain number of the given procedure within five years, so that apples could be compared with apples, so to speak. The team analyzed only elective surgeries because they typically involve healthier patients with the best odds of a smooth recovery.

About 11 in 100 doctors accounted for about 1 in 4 complications, but the rates for hundreds of surgeons were double or triple the national average. About 63,000 Medicare patients suffered serious harm, and 3,405 died after they had procedures generally considered low risk.

The cost of complications was considerable: Taxpayers paid hospitals $645 million solely for readmissions (inpatients who had to be readmitted within 30 days of discharge due to complications).

Another important finding was that even when hospitals identify problems with doctors’ competency or practices, significant barriers impair disciplining the poor performers. Their rights of due process prolong what ProPublica deemed even clear-cut cases.

ProPublica’s analysis has some limitations,” it acknowledged. “Patients covered by private insurance were not included, which in some instances omits a substantial portion of a surgeon’s practice. And our definition of complications does not cover other types of patient harm, such as diagnostic errors or readmissions more than 30 days after an operation.”

Among the site reviewers who considered Surgeon Scorecard’s limitations as problematic was the writer of the Skeptical Scalpel blog He or she is a retired surgeon who said that “big data is not enough” to make sweeping comparisons about surgeon competence and safety.

“It took me less than a minute to discover some interesting omissions from the application,” the anonymous blogger wrote. He/she said that one procedure, laparoscopic cholecystectomy (minimally invasive removal of the gall bladder), was the only general surgery procedure listed, and that approximately one-third of the hospitals in his/her state were not surveyed.

“It looks like the problem is that using Medicare fee-for-service data does not yield enough surgeons performing 20 or more cases in some categories such as laparoscopic cholecystectomy for the five years included in the database.”

At one of the biggest hospitals in his/her state, “apparently only one surgeon performed 20 laparoscopic cholecystectomies on fee-for-service Medicare patients in the five years studied; 23 other surgeons were listed as having performed fewer than 20 laparoscopic cholecystectomies on patients in the target population. I don’t see how patients who want to use that hospital for their gallbladder surgery will benefit from the Surgeon Scorecard.”

But he/she understands why ProPublica chose that procedure to review. “They needed to select a procedure that was done frequently enough to yield a sufficient number of cases for analysis. Unfortunately, because of the limitations of the Medicare fee-for-service data and the low complication rate of the procedure, the Surgeon Scorecard is useless for anyone looking to compare general surgeons.”

He/she finds similar shortcomings with prostate surgery, a procedure also chosen because it’s done a lot. But many surgeons of the blogger’s acquaintance also didn’t perform 20 cases on fee-for-service Medicare patients, so they escaped review.

“Perhaps the next iteration of the scorecard will utilize a data set that contains enough patient and surgeon records to make a meaningful comparison.”

Those are valid points. But that doesn’t mean Surgeon Scorecard lacks value for people who want to know about potentially dangerous surgeons before they commit to their care.

Like the surgeon at Baltimore’s Johns Hopkins Hospital, which is renowned for excellence and a commitment to patient safety. He had more complications from prostate removal surgery than all 10 of his colleagues combined even though they performed nine times as many of them.

Like the Florida surgeon who performed spinal fusions at Citrus Memorial, which was rated among the top 100 nationally for spinal procedures, but he had one of the highest rates of complications in the country for spinal fusions. His two colleagues had rates among the lowest for postoperative problems such as infections and internal bleeding.

Like the chairman of surgery and medical director for orthopedics at Chicago’s Weiss Memorial Hospital who had among the nation’s highest complication rates for knee replacement operations.

“It’s conventional wisdom that there are ‘good’ and ‘bad’ hospitals,” according to the ProPublica story, “and that selecting a good one can protect patients from the kinds of medical errors that injure or kill hundreds of thousands of Americans each year.

“But … when it comes to elective operations, it is much more important to pick the right surgeon.”

Many hospitals don’t track the complication rates of individual surgeons, so they can’t exercise any quality control over those who don’t measure up. The government doesn’t track doctors either.

The database reflects the fact that some subpar performers work at elite medical centers considered among the nation’s best, and that some surgeons with impressively low complication rates work at small-town clinics.

ProPublica found that overall complication rates were relatively low, ranging from 2 in 100 to 4 in 100 procedures, depending on the type of surgery. “But experts who reviewed ProPublica’s results say they strongly suggest that the typical surgeon’s rate can and should be significantly lower,” according to the story.

For example, more than 750 surgeons who did at least 50 operations did not record a single complication in the five years covered by the analysis. And more than 1,400 had only one.

Rating sites other than Surgeon Scorecard do exist, but without a report as thorough as ProPublica’s it’s difficult to know exactly how the databases were developed and their shortcomings. One new one was established by Consumers’ Checkbook, a nonprofit whose site enables consumers to type in a Zip code and search for the top-performing surgeons in 14 types of major surgery.

Its ratings also rely on Medicare claims data from more than 4 million surgeries performed by more than 50,000 doctors. Its criteria include death rates, other bad outcomes, such as infections, falls or other complications and recommendations by other doctors
It’s worth a patient’s time to learn about their surgeon’s track record. Certainly George Lynch thinks so. He nearly died from complications after a 2013 knee replacement performed by a surgeon at New York Methodist Hospital who had one of the highest complication rates on knee replacements in New York State.

Lynch contracted multiple postsurgical infections, went into septic shock and almost died. Now, he needs another knee replacement and, as ProPublica reported, “This time, he’s peppering his doctors with questions and said performance data will help guide his choice of a surgeon and a hospital.”

“I’d rather be a difficult live patient,” he said, “than a compliant dead patient.”

Hospitals love new technology and new treatment initiatives because using them can result in better outcomes for patients. But hospitals also like them because they can charge more for an expensive or complicated surgical tool or protocol, and leverage that use for promotional purposes.

Unfortunately, as we’ve often pointed out, new and complicated treatments sometimes don’t work right. Sometimes they’re used by people insufficiently trained. Sometimes they cause grievous harm to patients and qualify as malpractice. So, many policy experts are calling for hospitals to prove they’re capable before they engage in certain surgical practices.

“As the U.S. health-care landscape advances toward rewarding quality rather than quantity, just buying a new high-tech surgical tool or hiring skilled surgeons may not be enough to support offering the new service,” according to a recent story in Modern Healthcare. “Facilities should more frequently be asked to prove not only the ability to achieve good clinical outcomes, but that there is a community demand for the service in the first place, [health quality and policy leaders] say.”

Implementing new surgical programs sometimes is the result of misguided priorities (see our blog about proton beam technology). Devon Herrick, senior fellow at the National Center for Health Policy Analysis, told Modern Healthcare, “They don’t establish [such programs] because they have a competitive advantage or are especially skilled in the area. [They do so] because there are patients who have insurance that will reimburse for these lucrative services.”

He also said that if hospitals don’t compete on price, they probably don’t compete on quality either.

According to the Centers for Disease Control, congenital heart defects affect about 1 in 100 (about 40,000) births per year in the U.S. About 1 in 4 of those babies are sick enough to require surgery. One medical center that performed them for four years suspended elective pediatric congenital heart surgeries earlier this month because of too many poor outcomes.

In those four years, St. Mary’s Medical Center in West Palm Beach, Fla., performed only 132 separate heart procedures on a total of 90 patients after receiving approval by Florida’s Agency for Healthcare Administration in 2011. Florida, Modern Healthcare explained, requires a Certificate of Need (CON) before a facility may expand, offer a new service or purchase certain kinds of equipment.

When St. Mary’s got the approval, it made sure people knew: “No other hospital in Florida has received such approval in more than 15 years,” it announced, claiming that congenital heart defects are fairly common and that local folks could now access the “unique minimally invasive treatment option right here in the local community.”

But given the CDC data, was there ever a demand for this service in this community? As we’ve noted, the more often a provider performs a certain procedure, the likelier it is that its patients will get the best outcomes. “Families and insurers could have sent patients to already established facilities that have specialized pediatric cardiovascular care teams and in some cases average more than 800 of the procedures each year,” Modern Healthcare noted.

“Ask a parent if they would prefer a place that does that many, or one that does one every other week. I don’t think it takes a genius to figure that out,” Dr. Edward Bove told Modern Healthcare. He’s head of the divisions of pediatric and adult cardiac surgery at the University of Michigan Health System, and collaborates with Joe DiMaggio Children’s Hospital, where a few patients from St. Mary’s had been transferred for additional care.

St. Mary’s wanted the cachet and the revenue from pediatric heart surgery, but it appears that it didn’t have the chops, regardless of what the state decided.

In places where hospitals must receive a CON before a new service can be offered, some industry experts believe they should be required to prove that they have the resources to establish a program as well as a sufficiently high volume of such cases in order to remain proficient.

It’s not as if St. Mary’s was surprised that its reach exceeded its grasp. Concerns over its suitability to perform pediatric heart surgeries were raised during public hearings for its CON process. At the time, reported Modern Healthcare, the hospital’s open heart surgery program was expected to generate 64 cases in the first year and 66 cases in the second, both of which are low numbers. Still, the hospital managed only 46 and 44 respectively in those years.

Cardiac surgeons told Modern Healthcare that hospitals doing these procedures must provide specialized cardiac teams around the clock. “You really need an entire city of people, it’s an enormous technical undertaking,” Bove said. “You don’t just go out and hire a surgeon.”

It’s not clear whether St. Mary’s had that expertise. Documents in support of its CON said its on-call policies would enable the rapid mobilization of surgical and medical support for emergency cases, and that the hospital would recruit staff with appropriate experience and training in pediatric open heart surgery.

Legal claims filed last year by at least four families whose infants underwent cardiac care at St. Mary’s accused the hospital of not being able to quickly recognize and treat the complications during and after their surgeries. They alluded to “systematic failures.”

According to Modern Healthcare, The Joint Commission, the nonprofit that accredits U.S. hospitals and conducts unannounced onsite surveys, said the situation at St. Mary’s is something it “will likely take a look at.”

Conventional wisdom would deem that sort of review necessary before a facility performs the surgery. The view from hindsight is much more likely to reveal collateral damage that never should have been inflicted in the first place.

If Google maps has made you less able to find your way around a printed version, consider that some people believe that advanced medical technology has led to some epically stupid human medical errors.

Megan McArdle, a columnist for Bloomberg, has looked into the advanced technology = retarded thinking scenario in health care. She recalled the story of a 16-year-old who was hospitalized in 2013 for a routine colonoscopy to check on his congenital gastrointestinal condition.

First he experienced numbness and tingling all over his body, and soon he was having seizures. Why? Because he had been given 39 times too much antibiotic. The teenager’s tale was told on the website Medium in its story “How Medical Tech Gave a Patient a Massive Overdose.”

“[I]f I had to condense its five parts’ worth of fascinating insights into one sentence,” McArdle wrote, “here’s how it would read: ‘Machines make us stupid.'”

McArdle noted that after having spent three months traveling recently, with only a cellphone, she had forgotten the telephone number of her landline. “To be sure, we don’t use it very often,” she wrote. “Still. We’ve had that number for five years. I forgot it in less than one football season.”

And just as cellphones keep wonderful records of the phone numbers we use, our computers are swift researchers with an excellent memory. Although that capability provides us with more knowledge faster, McArdle accepted that “[I]f I’m cut off from these tools, I am suddenly a moron. And if something gets entered into the computer wrong, I’m totally helpless. A few months back, people gently emailed to inquire where I was, as the panel I was on was about to begin. Turned out I’d put it into the calendar on the wrong day, …”

But that’s a common, human mistake with few real consequences. McArdle’s point was that techno errors can have serious consequences in health care, such as when software that was supposed to prevent a medical error instead contributed to a teenager receiving nearly 40 times the desired dose of his medication.

That horrific occurrence brought to light two contributing human factors: alert blindness and excessive trust in the automated system. In fact, the software did issue a warning to both the doctor and the pharmacist that something was wrong with the prescription. But it also had tried to warn them that something was wrong with a whole lot of the drug orders that were entered into the computer. Most of them were minor, so hospital staffers felt less alerted than annoyed by the serious mistake – they’d glance at the alerts and dismiss them.

If they hadn’t, McArdle wrote, “the hospital would have ground to a halt as everyone devoted their days to reading software alerts. So when a message came along that wasn’t trivial, they didn’t read it. Or didn’t even truly see it.”

The second human failure was creepier. When the system delivered the huge number of pills to the nurse on the floor where the teenager was to receive his procedure, she thought something was wrong. But she administered them anyway, because the system’s bar code system confirmed that they were what the doctor prescribed.

McArdle said that although what the nurse did was idiotic, we’re all prone to that kind of idiocy. “There’s an eerie authority to an automated system,” she wrote. …After all, computers are smarter than we are … It’s easy to turn off our judgment and hand the decision over to the machine.”

But computers are machines, and machines aren’t perfect either. They’re superior performers for certain tasks they’ve been programmed to handle, but humans are more successful performers within an unfamiliar environment because we have the capability to judge; we have common sense.

“So when a computer tells us to do something obviously wacky, where is our common sense?” McArdle wondered.

What happened to the part of our brain that used to “get it” when our mother demonstrated the idiocy of peer group pressure by asking “If Johnny also told you to jump off a bridge, would you do it?”

When medical records were keep strictly on paper, errors were also fairly common. But we knew that, so we were more vigilant, McArdle suggested. Automated systems make fewer mistakes, so we’re less likely to be watching out for them. Which means that when one occurs, it’s more likely to be a whopper. “The old system gave a lot of people the wrong medication, in the wrong dose, but it probably never gave anyone a 39-fold overdose of antibiotics,” McArdle said. “Unfortunately judgment atrophies just like a muscle.”

Use it or lose it.

The author of the Medium article and a related book, Dr. Robert Wachter, a patient safety advocate whose name is familiar to regular readers of this blog, noted how the aviation industry has refined how pilots get the alerts they need without overwhelming them with insignificant information. So why not the medical industry?

But Wachter also observed that pilot training experts are worried about a higher accident incidence when automated systems fail, and that pilots who spend a lot less time actually flying the plane than they used to might lack the judgment to assume control.

“This is a problem that is also bound to afflict driverless cars,” McArdle noted, “… so let’s hope that the experts crack it [before they become commonplace].”

If we don’t have a solution to the machines-make-us-dumb proposition, we do have the ability to design better machines that make fewer of these big errors. But, McArdle concluded, we also need never to forget that “human brains are better than computers at a lot of things – so when the computer’s instructions seem crazy, you should trust your judgment, not the monomaniacal machine.”

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
Washingtonian Top Lawyer 2011
Avvo Rating 10.0 Superb Top Attorney Best Lawyers Firm

Contact Information