DC Medical Malpractice & Patient Safety Blog

A new survey of hospital risk managers finds that malpractice lawsuits can give them important clues to holes in their hospitals' patient safety nets that need patching.

The study by UCLA law professor Joanna Schwartz was excerpted in the New York Times op-ed page. Professor Schwartz writes:

New evidence ... contradicts the conventional wisdom that malpractice litigation compromises the patient safety movement’s call for transparency. In fact, the opposite appears to be occurring: the openness and transparency promoted by patient safety advocates appear to be influencing hospitals’ responses to litigation risk. ...

My study also shows that malpractice suits are playing an unexpected role in patient safety efforts, as a source of valuable information about medical error. Over 95 percent of the hospitals in my study integrate information from lawsuits into patient safety efforts. And risk managers and patient-safety personnel overwhelmingly report that lawsuit data have proved useful in efforts to identify and address error.

One might think that hospitals would have little to learn from lawsuits, given other requirements that hospitals report, investigate and analyze medical error. But participants in my study said that lawsuits can reveal previously unknown incidents of medical errors — particularly diagnostic and treatment errors with delayed manifestations that other reporting systems are not designed to collect.

Lawsuits can also reveal errors that should have been reported but were not — medical providers notoriously underreport errors (although studies have shown that the threat of litigation is not responsible for this underreporting) and lawsuits may fill these gaps.

Professor Schwartz's findings, which readers can also read about here, should help the pushback against misguided "reforms" that purport to make hospitals safer by making it harder for patients to sue for accountability when they have suffered serious harm from medical errors. As she reports, even hospital risk managers are finding that lawsuits are valuable sources of information about what really goes in inside hospitals. And is that any surprise?

Although we’ve addressed the difficulty of knowing the cost of medical care before the bill arrives, few recent stories have illustrated the problem as well as one widely covered last week, including by the New York Times.

A hospital in Livingston, N.J., for one example, charged an average $70,712 to implant a cardiac pacemaker, while another in nearby Rahway, N.J., charged $101,945. One hospital in Saint Augustine, Fla., charged an average $40,000 to remove a gallbladder via minimally invasive surgery, while one not far away in Orange Park, Fla., charged more than double that--$91,000. A hospital in Dallas charged $14,610 to treat pneumonia while another in that city charged more than $38,000 for the same treatment.

As summarized by The Times, “Data being released for the first time by the government on Wednesday [show] that hospitals charge Medicare wildly differing amounts — sometimes 10 to 20 times what Medicare typically reimburses — for the same procedure, raising questions about how hospitals determine prices and why they differ so widely.”

The Center for Medicare and Medicaid Services (Medicare) released cost data for 3,300 hospitals around the country, and costs were divergent not only regionally, but sometimes practically across the street. The data cover bills submitted in 2011 for the 100 most common treatments and procedures performed in hospitals.

Federal officials ascribed the variation, in some cases, to varying degrees of sickness and to some patients requiring longer stays in the hospital.

Still. This is not a new issue and people continue to be stung by costs they had no way of anticipating.

As The Times notes, how hospitals price medical services remains a mystery, and at a time when America is gearing up for the Affordable Care Act’s broader health-care coverage, you’d think it would be in everyone’s interest to solve it.

Medicare and insurance companies that contract with providers don’t pay the “rack rate”—a term commonly used in the hotel and other industries to indicate the suggested retail price of a service or product; that is, the rate paid by the ignorant, the uninsured and schlubs who lack the power of an economy of scale.

Because these large entities pay reduced amounts for certain services for certain conditions (Medicare standardizes costs, insurers negotiate them), their patients generally don’t see the bills and aren’t as affected by the charges as people outside of this coverage. And as The Times says, “Experts say it is likely that the people who can afford it least — those with little or no insurance — are getting hit with extremely high hospitals bills that may bear little connection to the cost of treatment.”

After the report was released, The Times contacted some of the hospitals whose charges were examined. Some of their representatives said that the higher bills they submitted reflected their status as either teaching hospitals, which tend to see patients who are sicker and/or have more complicated issues, or that their patient base was older and sicker, and cost more to treat.

Some hospital said that if their charge was more than what Medicare would pay, they would write off the difference instead of trying to collect it from the patients.

Those are valid points, but in big-picture terms, there are still too many people paying far more for the same care that someone else gets. And if costs are written off when people can’t pay, ultimately we all pay when insurance premiums rise in response.

The data, The Times says, do not explain “why one hospital charges significantly more for a procedure than another one. And Medicare does pay slightly higher treatment rates to certain hospitals — like teaching facilities or hospitals in areas with high labor costs.”

One Medicare official interviewed by The Times said he would have anticipated, at the most, two to three times the difference among hospital charges. But bills submitted to Medicare were, on average, about three to five times what it typically pays to treat a condition, according to The Times’ analysis. And some variations could be even greater.

The data also show that significant cost variations occur even for procedures that are standardized and not susceptible to patient complications.

Bills submitted by for-profit hospitals to Medicare are higher than those submitted by nonprofit facilities, and public hospitals generally bill Medicare less than both.

One hospital finance expert told The Times, “If you’re charging 10 % more or 20% more than what it costs to deliver the service, that’s an acceptable profit margin. Charging 400% more than what it costs has no rational basis in it at all.”

The Medicare official had no explanation for the wide cost swings, but a representative from the American Hospital Association ascribed them to what we’ll call “business as usual”—as insurers demand bigger discounts from a hospital, it might raise its rack rates to protect its bottom line.

A representative of America’s Health Insurance Plans said some of its members (insurance companies) were reporting price increases of 20% to 30% for some services. No one is surprised that many of those underwriters impose premium increases to compensate.

Give Medicare credit for releasing the report in the interests of transparency. We’ll withhold any additional applause until providers and insurers take more responsibility for making the medical care market fair to all payors.

If no good deed goes unpunished, does it follow that no bad deed goes punished?

It does, apparently, if you’re a hospital. As widely reported earlier this month, including by the New York Times, a new study published in the Journal of the American Medical Association [JAMA], says that errors committed by hospitals can be lucrative because insurers compensate them for patients who must remain hospitalized longer than they should as a result of preventable surgical mistakes.

According to The Times, “Changing the payment system, to stop rewarding poor care, may help to bring down surgical complication rates, the researchers say. If the system does not change, hospitals have little incentive to improve: in fact, some will wind up losing money if they take better care of patients.”

What is this, Opposite Day in Health Care?

Researchers analyzed records of 34,256 people who had surgery in 2010 at one of 12 hospitals run by Texas Health Resources, a large, nonprofit hospital system. Of those patients, 1,820 suffered at least one complication, such as blood clots, pneumonia or infected incisions that could have been prevented.

Without such complications, these patients would have been hospitalized three or four days; with them, they averaged 14 days in the hospital. The average tab was $30,500 more than for patients without complications ($49,400 versus $18,900). Private insurers paid far more for complications than did Medicare, Medicaid or patients who paid for their own care.

The researchers made clear to The Times that they weren’t suggesting that hospitals make deliberate errors in order to boost their bottom lines, nor were they refusing to address the problem. But they did say, the paper reported, “that the current payment system makes it difficult for hospitals to perform better because improvements can wind up costing them money.”

You’d think that insurers would be motivated to heal this sick financial scenario, and a spokeswoman for an insurance trade group said all the right things about moving American health care away from the fee-for-service model to one that emphasizes quality over quantity, one that rewards better care. She did note that Medicare and private insurers now use a “never list” of things they will not pay for, including leaving a sponge or instrument inside a patient, or operating on the wrong organ or wrong limb.

Still, given that, for example, Wellpoint, the corporate parent of Anthem Blue Cross Blue Shield and others, made a profit last year of more than $2.6 billion, how much farther will insurers go to fix a system that, for them, isn’t broken?

Reducing complications, said the researchers, means that insurers not only should not pay for substandard care, but should financially reward excellent care. Also, hospitals should be required to disclose their complication rates so that patients who have options can avoid those with high rates. Such facilities could either improve, or close.

To its credit, Texas Health Resources was trying to figure out how to reduce its hospitals’ surgical complication rates, which prompted the study. The outfit’s complication rate was 5.3%, about the same as those reported by similar hospitals. A Texas Health Resources consultant, according to The Times, said the they were stunned to learn that lowering the complication rates would cost the hospital money.

Dr. Mark C. Lester was one of the study’s authors and also is an executive with THR. He told The Times that its hospitals used a checklist system to help prevent complications. Harvard’s Dr. Atul A. Gawande is a pioneer of the checklist approach, and he also participated in the study. Surgical checklists, as we’ve described before, involve routine procedures, some of them quite simple, to ensure such things as the right patient is on the table, the right body part is being addressed, drug allergies are known and the right medications are being given in the right doses.

When asked if the hospital would lose money if more patients required less care, Lester said, “To us that doesn’t have an impact.”

“Reducing complications and increasing safety is why we’re there,” he told The Times. “If in doing that, some payments don’t come our way, it’s not of consequence. What’s of consequence is that people who come to us are in a safer environment.”

To learn more about hospital errors, read our backgrounder. For information about how to protect yourself and your loved ones while hospitalized, read our two-part newsletter, “Protecting a Loved One in the Hospital,” and “A Safer, Healthier Hospital Stay.”

Intensive care in hospitals includes extreme measures that can induce delirium in many patients, and that, doctors are now discovering, don't necessarily go away when the patient leaves the ICU.

About 3 in 4 ICU patients develop delirium, according to a story in the Philadelphia Inquirer, and delirium is associated with poorer survival rates and worse long-term outcomes.

It has long been known that ICU delirium sometimes includes delusions and hallucinations. Some ICU patients have believed that that they were being assaulted or imprisoned; that their nurses were plotting to kill them; that the walls were covered in blood; that huge spiders were riding bicycles in the room.

Medical professionals used to think patients left these disturbing adventures in the ICU, but now they acknowledge that sometimes they take their terrifying false memories home with them. A recent Johns Hopkins study found that 1 in 4 patients had post-traumatic stress symptoms two years after going home.

Many former ICU patients struggle with physical weakness, thinking problems, anxiety, depression and post-traumatic stress disorder (PTSD); you might be more familiar with that disorder as associated with soldiers returning from a war zone, or victims of sexual assault.

What’s unusual among hospital PTSD victims, the study said, is that their flashbacks are of delusions or hallucinations they had in the hospital, not events that actually occurred. “Having a life-threatening illness is itself frightening,” according to the Cambridge Journal blog, “but delirium in these patients — who are attached to breathing machines and being given sedatives and narcotics — may lead to ‘memories’ of horrible things that didn’t happen.”

Last year, the Society of Critical Care Medicine gave ICU PSTD its own name—post-intensive care syndrome (PICS). The society says that as many as 1 in 5 ICU patients might suffer from it. With a diagnosis, generally, comes a refocusing of professional resources on how not only to save lives in the ICU, but to address its effects after hospital care.

PICS can be tricky to fix because patients often look OK after they've been home for a while; their family and friends might not understand why they’re aren’t bouncing back. It’s also difficult to address, says The Inquirer, because it can take ICU doctors so long to notice the problem they often don’t see patients who recover enough to be moved to another floor.

So, critical care docs are learning how to educate their primary-care colleagues and others who manage a patient’s discharge and follow-up care.

Savvy ICU staff hope to minimize PICS with changes in how they care for their patients. The key is to reduce the delirium by administering less sedation, ensure 24-hour visitation, starting physical therapy sooner and making sure rooms are dark night to promote sleep.

An awareness of PICS, it’s thought, also can improve other ICU problems. Every year, approximately 1 million Americans are hooked to a ventilator in an ICU. That can lead to lung problems or sepsis, a serious infection. The PICS findings might translate to a broader group of delirious patients who were not in ICUs.

It’s estimated that at least half of ICU survivors have trouble with basic living activities a year after discharge. Of those with severe lung problems, 55 in 100 had cognitive impairment, according to one study, and 36 in 100 had depression.

But even if there’s no such diagnosis, former ICU patients still might be weak and tired long after they go home. They have trouble concentrating, making decisions and remembering; they might be emotionally fragile, and are plagued with upsetting memories.

Some of their delusions seem related to the patients’ legitimate care, such as placing catheters and breathing tubes. One patient who had gotten an MRI thought he was on a conveyor belt feeding into an oven.

If you have a breathing tube down your throat, you can’t even tell anyone what you believe is happening to you. Doctors have learned to suspect a trauma disorder if patients are particularly combative once the tubes are removed. And some ICUs now screen patients daily for delirium by asking questions such as: Can a stone float on water? Patients with delirium will say yes.

If your loved one is in ICU, make sure the staff knows you’re familiar with PICS, and ask what they know about the syndrome.

Also, visit as often as you can, and bring familiar objects from home. Hearing a familiar voice, said one expert interviewed by The Inquirer, is not only "vocal anesthesia," but helps to anchor the patients in reality. Make sure the room is as dark and quiet as possible during normal nighttime sleeping hours. Find out how much sedation the patient is being given, and ask if it’s the lowest dose possible.

And when it’s time for discharge, ask transition care team members how to recognize and address the effects of delirium. Make sure they have a plan for treating its long-lasting effects.

In a contest in which patient safety could hang in the balance, hospital administrators are facing off against nursing unions over a bill requiring hospitals in Washington, D.C., to maintain a minimum nurse-to-patient ratio.

As reported by KaiserHealthNews.org (KHN), the bill is modeled on a California law that took effect in 2004. That state is the only one that requires minimum staffing ratios in its hospitals.

Hospitals claim the cost of additional nurses would put them out of business. Nurses claim that the proposed Patient Protection Act acknowledges that minimum staffing levels are needed to maintain patient safety.

So far, says KHN, the staffing ratio requirement seems to have a mixed effect in California hospitals. National Nurses United says it has improved patient safety, added 130,000 nursing jobs and helped to retain experienced nurses.

The proposed staffing ratios in D.C. are different depending on the department. In a pediatrics unit, the bill requires at least a 1-to-4 nurse-to-patient ratio. In the operating room, it would be 1-to-1—one nurse for every patient at all times.

KHN interviewed a nurse who has worked at MedStar Washington Hospital Center for more than 20 years. She said understaffing has forced her to take care of five or six patients at a time.

"There are times when I have to do the dressing on patients and I can’t get to it," she said. "I have to put antibiotics on patients and they're late. You have to turn patients every two hours and you can’t get to it. It infringes on their care."

A hospital executive said that staffing levels are managed in conjunction with its nurses, and that levels fluctuate depending on the number of patients it has, and how sick they are.

One study showed that that the California law led to an increase in hiring and another showed a decrease in nurse turnover from burnout. But researchers also found that the law exerted financial pressure on some hospitals.

So we have to ask: At what price is it acceptable to risk patient safety? If you can’t run a sufficiently staffed facility without jeopardizing your financial well-being, aren’t you in the wrong business?

Trying to determine if the California law actually reduced patient mortality is tricky. Nursing professor Teresa Serratt from the University of Nevada, Reno, studied the effects of the California law, and told KHN that the data are inconclusive.

Nurses in D.C. certainly aren’t inconclusive about their work situation. In a union survey of them:

• 57 in 100 said staffing is inadequate always or almost always;


• 64 in 100 said they have less time to care for patients;


• 60 in 100 said changes in their workload have led to worse outcomes for patients;


• 88 in 100 said they have had to work through meal and rest breaks because of inadequate staffing;


• 87 in 100 said that mandatory nurse-to-patient ratios, such as those in California, are needed in D.C.

And patients can only suffer when there’s strife in the halls of a hospital.

The honor system is a fine thing when people are honorable. Not so much if they’re not. A medical example of the latter unfolded recently in Kentucky, where unnecessary heart procedures failed to help the patients, but certainly boosted the bank accounts of the hospital and the surgeons.

As reported last month by the Courier-Journal, a former meat cutter, Edward Marshall had undergone at least two-dozen heart procedures over two decades. They were disabling, and he finally decided in September 2010 to seek treatment by people other than the cardiologists at St. Joseph London hospital.

After consulting a specialist in Lexington, Ky., he was told that an artery in which Dr. Sandesh Patil at St. Joseph had implanted a stent was barely blocked. In other words, there had been no need for the balloon angioplasty procedure, which opens blocked arteries and keeps them that way with the use of a stent, a tiny tube that prevents surrounding tissue from collapsing.

“I would have not carried out this procedure,” the Lexington cardiologist told Marshall in a letter that is included in the court record. Marshall became the first of nearly 400 people to sue the London hospital and 11 cardiologists. The claim is conspiracy to perform unnecessary, risky and often painful heart procedures that served only the purpose of enriching the providers.

The problem in Kentucky is old, sad news. In “Hospital Profit Soars on Wings of Unnecessary Heart Procedures," we wrote about HCA, the largest for-profit hospital chain in the U.S. When the doctor there was performing heart procedures on patients who didn’t need them, the hospital slapped his wrist, fired the nurse who blew the whistle on him and pocketed enough money to run a small country.

Our blog a few years ago, “Baltimore Malpractice Cases Raise Broad Questions About Heart Stents,” concerned a case when a Maryland cardiologist performed more than 1,000 surgeries to implant heart stents. Except that the arteries weren’t blocked, and didn’t require the dangerous, expensive procedure.

The problem common to all of these unfortunate events is that the medical honor system monetarily rewards cardiologists for breaking the rules if they're willing to gamble on not getting caught. These surgeries happen only because one guy says they should. No peer or institutional review. It’s the honor system, and too often, it’s not working.

The Kentucky lawsuits also name the hospital’s parent company, Catholic Health Initiatives (CHI). Two patients died from the alleged unnecessary procedures, and the others must take blood-thinning medications for life. Not only do such drugs carry risks of dangerous side effects, the procedures leave these people at risk of potentially fatal complications.

The hospital’s defense? Exactly as you might imagine. “These were very sick people who needed the interventions, and got them,” its attorney told the Courier-Journal. He called the conspiracy allegations “Alice in Wonderland stuff.”

As the newspaper notes, however, it isn’t only the plaintiffs who are troubled by St. Joseph’s practices:

• The U.S. attorney’s office in Lexington is investigating the medical necessity of its cardiac procedures, and the financial relationship between the St. Joseph system and Patil’s cardiology group.


• A federal criminal health-care fraud investigation focusing on Patil has been launched. The doctor refused to answer 109 questions at a deposition in Marshall’s suit, declining even to confirm that he is a doctor.


• Earlier this year, the Kentucky Medical Licensure Board found that Patil provided substandard care to 4 of 5 patients whose records it examined. It said he used stents without justification in three of them.

Remarkably, however, the board allowed Patil to continue to practice, with monitoring and remedial education. (That’s not oversight, that’s sending someone to bed without dinner.)


• In 2011, the Centers for Medicare & Medicaid Services cited St. Joseph for failing to review the medical necessity of 3,367 cardiac catheterizations performed there in 2010. (That procedure, in which a wire is moved through an artery into the heart, was a problem as well in the HCA case.) This citation noted that one of the hospital’s patients had annual heart procedures (20 in all), never mind that he had no symptoms of heart disease.

Patil has not had privileges at St. Joseph London since December 2010, but he’s not the only problem at CHI—it paid $22 million in 2010 to settle allegations in a federal case that its hospital in Towson, Md., made improper payments to a cardiology group, and that doctors regularly performed unnecessary procedures.

Marshall’s case is moving slowly through the legal paces. Over the years he claims Patil and others unnecessarily implanted a pacemaker and stents and performed unneeded angioplasties and catheterizations. Unlike many such patients, Marshall said he did question Patil about the need for the procedures, but the doctor would change the subject.

Then, in August 2010, Patil was doing an angioplasty, said that he’d found no blockage in the artery but was going to insert a stent anyway. That’s when Marshall went to the Lexington cardiologist. His report, Marshall told the Courier-Journal, destroyed his faith in doctors.

“It is serious business when someone is fooling with your heart,” he said. “It is just not right what they put people through.”

In a good news/bad news scenario about end-of-life care, more people older than 65 are dying in hospice care and fewer are dying in hospitals, but patients also are hospitalized more frequently in the last three months of their lives. They’re also more likely to spend time in intensive care units, and frequently receive hospice care for only a matter of days before they die.

The study was published recently in the Journal of the American Medical Association (JAMA), and widely interpreted throughout the media, including on Forbes.com. Although the increasing use of hospice is a welcome development in health care, the problem is that where somebody dies doesn’t say much about how he or she was cared for in the final weeks of life.

This study paints a far more disappointing picture of that—nearly 30 in 100 hospice users were enrolled for three days or fewer.

A patient might spend the last couple of days under hospice care, whose mission isn’t to test or treat, but simply make the patient the most comfortable he or she can be. But right before being moved to that welcoming environment, many patients were subjected to invasive hospital care, often in the intensive care unit. Sometimes in the last days or weeks of life, patients were shuttled among home, hospital, nursing home and back to the hospital.

That situation is seldom good for anybody. As one of our blogs last year discussed, our culture extends the lives of the elderly and the terminal by taking extreme measures often beyond what patients desire or families understand. That essay contrasts those common practices with what doctors themselves generally choose for their end-of-life experience.

As reported by Forbes, the Centers for Disease Control and Prevention (CDC) recently found that more people are dying at home. And Medicare is considering that where somebody dies might be a quality measure for end-of-life care on the theory that it’s less stressful than dying in an institution.

The JAMA study showed that about 1 in 3 Medicare beneficiaries died at home in 2009, 10 percent more than in 2000. Only about 1 in 4 died in the hospital in 2009, down 25 percent from 2000. The ratio of people who died in nursing homes remained about the same. But about 42 in 100 people died in hospice care in 2009, nearly double the numbers in 2000.

But moving from one care setting to another in the last 90 days of life increased by half—from about two moves in 2000 to three in 2009. One in 10 patients was moved (known as a “care transition”) in his or her last three days in 2000, but 14 in 100 were moved in 2009. About 1 in 4 people who died used the ICU in 2000, and nearly 30 in 100 did in 2009. More than 1 in 10 had three or more hospitalizations in the last 90 days of their life.

These patients spent slightly less time in the hospital, but they spent more time in the ICU, where treatment is most invasive and intense. Dementia patients spent more time in the intensive care in 2009 than in 2000.

To learn more about how to protect your interests when you’re hospitalized and unable to communicate, see my newsletter, “Talking to Your Doctor When You Can’t Speak.”

As Forbes explains, the JAMA study isn’t conclusive—it involved only patients in traditional fee-for-service Medicare, not Medicare Advantage plans, which are provided by private insurers and offer broader coverage. And the study looks retrospectively at all patients who have died, even those who would not have been expected to receive end-of-life care; for example, an otherwise healthy senior who has an accident with fatal complications. It might have been appropriate for that person to have been transitioned through several levels of care, unlike other patients whose situations led them to be overtreated.

But most people don’t die in those unforeseen ways. They suffer from chronic diseases or dementia, and death often is not a surprise. The study, says Forbes, “tells us there is still a lot more we need to learn about how to deliver care at the end of life.”

The magazine also describes a new study by AARP that ranks the 50 states and the District of Columbia on the quality and accessibility of their long-term care supports and services. The ratings were determined by affordability and access; choice of setting and providers; quality of life and care; and support for family caregivers.

By those criteria, these regions are the top 10:

Minnesota
Washington
Oregon
Hawaii
Wisconsin
Iowa
Colorado
Maine
Kansas
Washington, D.C.

These states are the bottom 10:

Georgia
Louisiana
Florida
Tennessee
Kentucky
Indiana
Oklahoma
West Virginia
Alabama
Mississippi

You might remember a blog we wrote last year about safe injection practices, and how hepatitis, HIV and infections can be spread when hygiene is not a priority.

Nothing is stupider than reusing invasive medical equipment, but a couple of hospitals in New York don’t seem to have a very high safe-injection IQ. As reported on AboutLawsuits.com last month, Buffalo Veterans Administration Center and Olean General Hospital have both been found to have reused insulin pens on different patients.

Such devices are designed to be reusable, but only for the same patient, and only when the needles are changed after each injection. Although the hospitals used new needles for each patient, blood can still back up into the pen, which makes them safe only for one user. But the New York hospitals apparently allowed multiple patients to use a single pen. All of them are now at risk of hepatitis C and HIV.

Olean General warned 1,915 patients that they might have been exposed between November 2009 and Jan. 16, 2013, and Buffalo Veterans warned more than 700 patients who might have been exposed between October 2010 and November 2012. So far, there are no reports of disease transmission caused by the improper use of the insulin pens, but the incubation period for HIV can be two years. Hepatitis C can incubate for six months.

If you or a loved one received an insulin pen injection at either of these facilities, contact them immediately to receive free blood tests. In addition, Olean has a call center for anyone with questions—(888) 980-1220.

For everyone else, the lesson is always to watch the preparation of an injection. If you don’t see how the medication was prepared, whether it involves a pen, syringe or IV tube, ask the doctor, nurse or other health-care aide who is giving it to you if the both the dispenser and the needle are fresh. If you have any question that they aren’t, decline the medication until you are allowed to see its preparation.

Worrisome findings about the work load of doctors who work fulltime in hospitals comes from a recent survey of hospitalists published in JAMA Internal Medicine.

Hospitalists are physicians who treat patients only while they are in the hospital. As their plight was described by MedPageToday.com, many hospital physicians feel overburdened to the extent that it negatively affects patient care, satisfaction and maybe even safety.

In the JAMA survey, nearly 1 in 4 respondents said that their excess workload prevented them from fully exploring and discussing treatment options for some patients, and from fully answering their questions. More than 1 in 5 said they had delayed admitting or discharging patients until a subsequent shift.

Four in 10 of more than 500 hospitalists surveyed said their heavy workload was unsafe for patients at least once a month; nearly that many said that it was unsafe at least weekly.

So, what’s “unsafe” about having more work to do than you think is reasonable?

More than 1 in 5 doctors reported ordering potentially unnecessary tests or procedures because they did not have the time to exam a patient thoroughly enough to assess his or her exact medical need or range of options. In other words, overwork caused them to default into a “do something, anything” treatment plan.

That’s not good for the patient, it’s a waste of resources and an abuse of the system. And, according the doctors surveyed, it “likely contributed” to patients being transferred, to increased morbidity (higher incidence of a disease or disorder) or mortality.

As the researchers noted, as many as 98,000 hospital patients die every year because of preventable medical errors. (See our blogs on preventable surgical and diagnostic errors.) “[F]or resident physicians,” they wrote, “workload so heavy as to result in physician fatigue is associated with increased medical errors and has led to the implementation of work-hour restrictions."

The survey also showed that:

• Nearly 1 in 5 respondents said they'd seen too many patients to the point where it adversely affected the quality of their hand-offs (communicating about patient status with the new doctors when one shift ends and another begins).


• One in 10 failed to note or act on critical lab results because of high patient volume.


• One in 10 failed to transfer a patient to a higher level of care.


• Nearly 1 in 5 said they thought their workload worsened patient satisfaction.


• Fourteen in 100 said their workload increased readmission rates (patients who are readmitted to the hospital within 30 days of being discharged).


• More than 1 in 10 said their workload worsened overall quality of care.

The researchers have a couple of suggestions for improving the situation: regularly evaluating workloads for attending physicians, and cutting health-care costs without increasing workloads to compensate for payment reductions.

In our opinion, the first is wish-list, perfect-world irony (who’s got the time to monitor people who don’t have the time not to need monitoring?), and the latter is an evergreen problem the system has long recognized and been unable to address.

The survey isn’t a conclusive diagnosis of the overworked doctor problem because its respondents chose to participate (it wasn’t a random sample), and, potentially, there are differences between someone’s perceived workload as it relates to a patient’s outcome versus an actual workload with actual outcomes.

Still. There’s a problem with doctors being able to do the best job they can with hospitalized patients. And at least for now, the best way to protect yourself and your loved ones is to monitor the care. Learn how by reading out two-part newsletter here and here.

If the staff of any particular work site should be required to get a flu shot, it’s the people working in a hospital. Guarding against the flu in the hospital isn’t just a matter of personal protection; it’s a matter of patient protection and safety.

So why do so many doctors, nurses, technicians, service workers and clerks go unvaccinated?

It’s a question Dr. Bob Wachter addresses on his blog, Wachter’s World. He’s professor and associate chairman of the department of medicine at the University of California, San Francisco, and a renowned hospitalist. That medical specialty is dedicated to the delivery of comprehensive medical care to hospitalized patients.

Wachter believes getting a flu shot shouldn’t be optional for hospital workers. Hospital patients are more vulnerable to infection because they’re already sick, because many are older (which is an added risk factor) and because they’re at higher risk for contracting other infections, so they need to be protected from the introduction of any additional microbes.

As Wachter writes, “[I]nfluenza can be an unpleasant inconvenience for a healthy person, but, for older and immunosuppressed patients, it can be a killer. … While one would hope that the professionalism of clinicians would drive them to vaccinate on behalf of their patients’ welfare (and most do – CDC data shows that about two-thirds of hospital workers get the vaccine), it’s not enough.

“Sorry folks, but this one should not be a choice. It should be a mandate.”

At his hospital, clinicians who refuse the vaccine must wear masks during the flu season. More than 9 in 10 people there are vaccinated, and as a result, he reports, there have been no recent cases of clinician-to-patient (or vice versa) transmission, unlike in the days before the vaccine (or mask) was required.

Wachter refers to a Centers of Disease Control and Prevention (CDC) survey from 2011 that found that more than 400 U.S. hospitals (about 1 in 10) now require flu vaccine for employees; 29 of them fire unvaccinated employees.

The Joint Commission, an independent, nonprofit organization that accredits and certifies health-care organizations, now requires accredited hospitals to have a program for promoting staff vaccinations.

Still, Wachter says, some health-care personnel object to the vaccines because they are worried about side effects (which are rare) or about how well they work (this year’s vaccine is 62 percent protective). These objections are surprisingly strong among a population of people who should know better. A recent article refutes them in the Journal of the American Medical Association.

But some people object to being forced to get the shot purely as a breach of their rights. “One nurse in Indiana who was fired for refusing the vaccine,” Wachter reports, “spoke of ‘the injustice of being forced to put something in my body.’”

OK, then don’t be a health-care worker. It’s that simple. Your rights shouldn’t override those of patients who are in no position to protect themselves from you.

As Wachter says, “The average hospitalized patient … will see up to 50 different healthcare workers each day. Any one of them with the flu can put their patients at risk, and not all of them will have full-blown symptoms to warn them to stay away. Patients giving their trust to healthcare professionals have a right to know that we have done everything within reason not to compromise their health further.”

For Wachter, it’s not just a single practice for patient safety; it’s a matter of changing a paternalistic culture. “[L]et’s require flu shots, not just to prevent flu but also to begin to shift our culture to one in which we actually require people to do things when they are the unambiguously right things to do.”

It’s a little late—although not too late—to improve the odds for this season that hospital workers won’t give you the flu along with your treatment. You should advocate for vaccination.

Ask your caretakers if they’ve been vaccinated, and if not, request that they wear masks when treating you. Ask the hospital’s patient advocate what is the facility’s flu vaccination policy. Make sure that person knows of your concern. And let your health insurer know if unvaccinated staffers are treating you or your loved ones.

Dr. Elaine Goodman had just finished her first year at Harvard Medical School when she became intimate with the consumer side of medical care. Her story, recounted on ProPublica.org, is a cautionary tale for everyone, professional or patient, and sheds yet more checkered light on patient safety in the hospital.

Goodman learned firsthand, while her mother was being treated for breast cancer, that plenty of errors and mishaps occur in the hospital, not so much from glaring medical malpractice, but from the "swiss cheese" holes everywhere in the system that too often lined up to hurt a patient.

When the daughter visited her mother one morning, she found her bloodied, hallucinating and disoriented. Mom had pulled out the staples from a recent procedure on her head. Another time, mom got a black eye from being banged in the face with a stethoscope. She fell frequently, experienced unnecessary side effects from drugs, almost had unnecessary brain surgery and was nearly given the wrong drug.

Remember, this is a person whose family member was part of the medical community. What in the world was going on?

“It was really eye opening for me to see the reality of how difficult it was to keep her safe in the hospital,” Goodman told ProPublica, the public interest investigative news outfit. “It’s not enough just to have caring, qualified people to keep the patient safe.”

Goodman’s mother died in 2008 after spending six months in the hospital. Her daughter believes the inpatient misfortune she suffered hastened her decline.

Goodman, now a second-year resident in internal medicine and primary care at Brigham and Women’s Hospital in Boston, participated in ProPublica’s coverage of patient safety by completing its Provider Questionnaire. ProPublica reporters confirmed the details of her mother’s story.

In her extended interview with ProPublica, Goodman addressed several issues about patient safety she hopes will contribute to the public good. Following are excerpts.

What did you your experience with your mom teach you about medicine?

“I hadn’t realized how hard it is to keep a complicated patient safe in the hospital. The harm is rarely caused by actual negligence. The vast majority of cases involve a lot of people doing fairly reasonable things, and somehow something just falls through the cracks.”

“One day my mom fell out of bed in the middle of the night. They had bed alarms to notify nurse if a patient starts to fall out of bed. But there’s also a chair alarm, and the nurses showed us that there were only enough electric outlets for one alarm at a time, and the alarms had identical cords – making it hard for the nurses to tell which alarm was plugged in. The day my mom fell, the wrong alarm was plugged in.”

Medication errors were frequent. My mom was on a seizure medication that needed the dose adjusted according to her nutritional status. The physicians probably knew this, but with all the handoffs, [see our recent blog about hospital shift changes] a new doctor would come in, see the drug level was low in her blood – and without carefully observing her nutrition – and then up the dose. She was being accidentally overdosed on the medication which caused her to sleep for days.”

“The biggest error related to her chemotherapy, which was administered by a device straight into the fluid of her brain. They’d give her the chemo about once a week, and it was supposed to last an entire week. One weekend … [a different] physician administered the chemo. About a week later her normal oncologist came to us in tears. …[H]er colleague had not administered the right chemotherapy drug, and the type she’d received had only lasted a day, not a week. My mom had effectively gone for a week without getting any treatment.”

How did the hospital doctors and officials respond?

“[The family] had a lot of conversations with the hospital administrators about what they were going to do about such a big medication error. We arranged to become members of the hospital’s patient safety committee. That got us involved in a way that made us feel they were addressing it.”

“... It turned out the drug that had been incorrectly administered had a name that was almost identical to the name of the correct drug, and the labels were almost identical. Plus, the hospital did not have a pharmacist who had specific expertise in chemotherapeutics. It was a case that illustrated what they call the “Swiss cheese model” for how errors occur. All the holes just line up and then the mistake is made. …”

“The hospital ended up hiring a new chemotherapy pharmacist, training the nurses and changing how the chemotherapy drugs were ordered and labeled.”

What do you see as the causes of ongoing patient safety problems?

“Complexity. There are exponentially more treatments, medications and technologies now compared to a few decades ago. We also have so many different ways patients are insured, different facilities they’re staying in and various aspects to their care. There are so many layers to manage.”

There’s also a huge problem with overbooking our physicians and medical staff. The patient volume is high, and they’re in and out of the hospital more quickly. … Physicians are constantly multitasking — being paged all the time, distracted, working long hours — with no time to sleep. …”

“And yet the emphasis is on the individual doctor taking care of all the issues. … Frankly there aren’t enough hours in the day to make sure you do all of that. You also don’t have the mental bandwidth to do it.”

How did your experience change the way you practice medicine?

“… When I was first in the hospital with my mom I tried not to ask too many questions. I didn’t want to be labeled ‘difficult,’ or as the daughter in med school who thinks she can dictate decisions. As a result, my mom’s care got worse. I realized that we family members had a lot to offer, especially in terms of handoffs between physicians. … In one case with my mom, a radiologist had picked a chemo drug he thought was best and later I saw a nurse begin to administer a different chemotherapy drug in response to his order. I questioned the nurse. The nurse was kind of annoyed, but she called the radiologist and then administered the correct drug.”

What did you learn about patient safety as a medical student?

“We had some lectures peppered throughout the curriculum. No patient safety course, but we had talks here and there. I went to med school because I was passionate about science and care, so the patient safety topics weren’t the most exciting. …”

“I would have been more attuned to this problem if the instruction had been tied to individual patients. When I came back to medical school [after caring for her mother], I did a patient safety elective – which was a new thing at the time – where students sit in on committees that are reviewing adverse events. Reviewing those cases made it easy for me to imagine myself as a physician who missed something important while caring for a patient.”

What’s one way medical providers can reduce the number of patients who suffer harm?

“Sometimes errors are not even tracked. When I returned to medical school after my mom’s death, I found that there was no way for medical students to report an error. There was an error reporting system, but the medical students did not have a login for it. …”

“And when errors are reported, the response is not always constructive. I filed an error report a few days ago about a medication event. Most people responded well, but a few emails I got showed some people were not happy being involved in an error report. … People are still prone to taking these things as personal failings instead of thinking about the system. …”

“We need to build a culture of patient safety. That means removing the stigma from patient safety and error reporting so we can collect data about errors and learn how we can fix things. That’s better than not knowing the scope of the problem because people are afraid to talk about it.”

To see the article Goodman wrote about patient safety for the American Medical Association, link here. To learn more about how to protect patients in the hospital, see my two-part newsletter on preventing common hospital errors, here and here.

Earlier in 2012, we wrote about the sad, unnecessary death of Rory Staunton, a 12-year-old New Yorker who died of septic shock because he was misdiagnosed with a stomach bug. A good thing has come of that tragic event.

As the New York Times reported, New York will be the first state to require hospitals to look aggressively for sepsis, a life-threatening bacterial infection of the bloodstream or body tissues, in order to initiate treatment sooner. (See our backgrounder on sepsis and malpractice.)

The regulations currently being drafted demand that hospitals also must publicly report the results of their efforts to control and treat sepsis.New York’s action, which the governor hopes to implement in 2013, reflects the interest of a national panel that recommended the adoption of similar standards on a federal level.

Sepsis is a leading cause of death in hospitals. Dr. Mitchell M. Levy, author of a forthcoming paper on sepsis treatment, told The Times that sepsis is “the most common killer in intensive care units. It kills more people than breast cancer, lung cancer and stroke combined.”

Recent efforts by the Surviving Sepsis Campaign, a global community of medical professionals, have established guidelines on identifying and treating sepsis, and mortality rates have declined by 40 percent as a result. But because the early signs of sepsis—high pulse rate, fever—are similar to those of many other illnesses, it’s difficult to diagnose it conclusively in its early stage.

But the key is to catch it early, when it can be treated effectively with antibiotics and fluids. The problem is that many hospitals don’t follow the guidelines. One sepsis research program involves some 300 hospitals, but the global consortium would like to have 10,000 participants.

As The Times reports, in April 2012, Staunton died of severe septic shock after he became infected, apparently through a cut. He was treated in the emergency room of NYU Langone Medical Center, where the severity of his illness was not recognized as soon as it should have been, nor were the indications communicated effectively when they were known. Staunton was sent home with a diagnosis of stomach pain. When his laboratory results came back after he checked out, showing cause for alarm, his parents were not contacted. The publicity following his death prompted the medical community to pay attention.

New York’s health commissioner, Dr. Nirav R. Shah, convened a symposium on sepsis that included presentations from Staunton’s parents. Shah said the new regulations requiring hospitals to use best practices in identifying and treating sepsis were actions taken “in honor of Rory Staunton.”

Everyone remembers a classroom where the students were assigned seats alphabetically by last name. Often, the kids with the W, Y and Z names got stuck at the back of the class. (Some, of course, relished this less visible position; others preferred to be closer to the teaching action.)

Generally, such seating charts helped the teacher connect faces to names, and keep better track of who’s where. But what if the kid named Zimmerman needed extra attention, what if that kid didn’t see well?

In health care, like classroom management, implementing a certain process just to make life easier for the people conducting it can mean that the people you’re trying to help fall through the cracks. A story published recently by Kaiser Health News (KHN) looked at how this happens during hospital shift changes.

Called the “handoff,” it’s the drill doctors use to inform the incoming shift about the status of the patients the previous shift has attended. As described in a research letter published in the Archives of Internal Medicine, “Handoffs in hospitals have been widely recognized by both regulators and researchers as a locus of potential communication failure, with substantial risks to patient safety and quality of care. By conservative estimate, there are over half a billion patient handoff discussions annually in U.S. hospitals.”

Dr. Michael Cohen of the University of Michigan conducted a handoff study of 262 patients at a hospital in Ontario, Canada. The sampling, of course, is limited, but in an interview with KHN, Cohen called the process he observed “a very common practice” in American hospitals.

In handing off treatment in the intensive care unit (ICU) at the Canadian hospital, doctors didn’t organize their discussions based on how ill patients were, but by their bed numbers. Is anyone surprised that the docs spent more time talking about patients at the beginning of the list than those at the end?

As Cohen described it to KHN, “We call it the ‘portfolio effect.’ It’s the effect that people tend to spend excess time on the early cases on the list. … Because the total time is limited, that means less time [to discuss the cases] at the end.”

What if the guy “at the end” experienced complications during the last shift, what if he presented with some really odd symptoms, what if a bunch of doctors were called to consult? Such patients might get shortchanged—Cohen’s study alluded to previous research that indicated miscommunication during handoffs threatens patient safety and might contribute to medical errors that otherwise could have been prevented.

Improving handoffs is pretty simple, Cohen said. “Physicians and nurses have to pay attention at the start of the handoff session to which cases require the most discussion time. Under the [federal] health care act and the stimulus package, hospitals are being encouraged to adopt electronic health records. [They] can be adopted to support a better picture of which patients need the most discussion.”

In better allocating handoff time, doctors and nurses should be aware not only of issues arising in the outgoing shift, but also the in the ones that preceded it—patients don’t always heal or worsen predictably.

If you or a loved one is an inpatient, ask your attending doctors and the hospital’s patient representative (also called patient service representative or patient advocate) about their handoff procedure. Be specific:

• How is my care transferred from one shift to the next?


• How do I know all relevant information will be communicated and understood?


• How do I know all of the information the previous shift entered into the digital records is reviewed by the new shift?

The Washington Hospital Center has agreed to change the way that patients are admitted for brain imaging procedures, in response to a lawsuit by a brain-injured patient whose family says she was left without a doctor for several hours while she was having an undetected stroke after a procedure in the hospital's radiology department.

The patient was represented by Patrick Malone & Associates in both a medical malpractice lawsuit for her brain injury and another lawsuit to enforce the policy change agreement .

When Lyn Gross underwent a procedure in June 2003 to treat an aneurysm in her brain, the radiologist who conducted the procedure listed her in the hospital record as being the patient of a neurosurgeon who had no idea who the patient was. When she showed signs of developing a stroke after the procedure, treatment for the stroke was delayed for several hours because of confusion over who was supposed to be her main doctor. Mrs. Gross ended up with severe brain damage. She lives with her husband at their home in Fairfax County, Virginia.

In settling the lawsuit brought on her behalf by her husband Paul Gross, the family asked the hospital as a condition of the settlement to agree that the interventional radiologists who do procedures on patients would not have authority to list another doctor as the "attending physician," unless that doctor knew about the patient in advance and consented to be the patient's doctor. The hospital agreed to implement a new policy.

Mr. Gross filed a new lawsuit against the hospital this year because the hospital had never confirmed its new policy, and he asked the Superior Court to enforce the settlement. That prompted confirmation from the hospital that the policy has been implemented.

Patrick Malone, the Gross family's attorney, said:

"This is good news for patients in the District of Columbia who undergo intricate and dangerous brain interventional procedures performed by radiologists. These radiologists aren't qualified to direct the care of patients after the procedure when something goes wrong. So it's important to have a clear understanding up front about who is going to be the treating doctor after the procedure."

More details about Mrs. Gross's lawsuit against Washington Hospital Center can be found on the Patrick Malone firm website, under the "True Stories" section.

Anyone who has spent time in a hospital—as a patient, visitor, family member or medical professional—knows that they can be noisy, frantic places. Contributing to the cacophony is what’s known as “alarm fatigue,” or the deadening effect on medical personnel of the myriad sounds issuing from monitoring devices, particularly in critical care units. We first wrote about alarm fatigue last year. If you’re exposed to these beeps and whines long enough, you become desensitized to them.

They're the electronic Boy Who Cried Wolf.

That’s a hazard for patients who rely on the optimal operation of these machines to remain alive. As noted in a story on MedCityNews.com, many monitor alerts don’t necessarily communicate a specific, urgent condition; they communicate an abundance of information, some of it much more important than the rest. So their sheer volume—in number and sound—that health-care professionals are supposed to interpret and respond to can increase the risk that an important alert will be missed until it’s too late.

MedCity refers to a report from last year by the ECRI Institute that called alarm fatigue a top health technology hazard for hospitals. ECRI is an independent, nonprofit research organization devoted to improving the safety, quality and cost-effectiveness of patient care. The FDA as well has begun to study the problem of alarm fatigue in an effort to improve training for alarm safety and standards.

MedCity interviewed Dr. Joseph Frassica, chief medical officer of Philips Healthcare (manufacturers of medical devices and consumer health products), who serves on an alarm steering committee with other members representing the Joint Commission (which accredits hospitals), the FDA, device manufacturers and medical professionals. The committee is developing recommendations for resolving alarm fatigue, and a timeline to implement them.

Frassica said the risks of alarm fatigue have been around since the invention of the EKG machine, which studies and records the electrical activity of the heart. Now that the FDA has boosted the profile of alarm fatigue, the medical community is looking at the amount of information machines generate and how to prioritize patient alerts.

Four ideas have emerged:

1. More specific alarms. “[N]o longer is it OK to have very sensitive alarms that are nonspecific,” Frassica told MedCity, referring to the need for the sensitivity to signify an urgent condition. “Most of the industry is working on building more specificity into their systems.”

2. Customizable or flexible alarm settings. More patient-specific and/or provider-specific alarm settings are under review that would enable institutions to set parameters and thresholds to match their own scoring criteria. The idea is to help caretakers to detect subtle signs of patient deterioration earlier and to generate a log so that nurses taking a blood pressure reading every shift, for example, can report an early warning score to a central system. That addresses the possibility of crucial information being missed when shifts change. Health-care organizations would review alarm logs to see which ones have a high volume and to define parameters that would generate an alert or alarm.

“We know that most of our monitoring systems are built for very sick patients so the triggers are cued to patients that are likely to have an event,” Frassica told MedCity. “If you take that monitoring and put it on patients who are not as sick, alarms might be triggered by patient activities that are nonactionable events, like shaving or [using the bathroom].”

3. More interaction among medical device alarms. This is about intelligent machine design. This is about devices that map data from different sources to render a visual display that helps clinicians identify trends in a patient’s condition quickly at one glance.

4. Creating an alarm escalation plan. Johns Hopkins Hospital in Baltimore eliminated duplicate alarms and used the experience of nurses to develop a system to triage alarms via their pagers. It also switched some alarms from alerting by sound to alerting by display. The ECRI Institute recognized Johns Hopkins for its efforts at addressing alarm fatigue.

Reducing alarm fatigue remains in its infancy, but at least there’s an industry-wide recognition that it threatens patient safety and generally can impair the quality of care. It also reinforces the wisdom of hospital patients having an advocate at their bedside for the duration of their stay.

For more information, see our newsletter, “Protecting a Loved One in the Hospital.”

Among the casualties of superstorm Sandy’s massive destruction was the security people feel about the safety of being hospitalized. As described by public interest advocate ProPublica, “It is a hospital's nightmare: The power goes out and backup generators don't kick in, leaving critically ill patients without the mechanical help they need to breathe.”

Hospital generators failed again during Sandy, most notably at New York University Langone Medical Center, which had to evacuate all 215 of its patients. Patients at New York’s Bellevue Hospital and New Jersey’s Palisades Medical Center also were evacuated when generators failed.

The ProPublica story invokes the horrors of Hurricane Katrina, when medical personnel were reported to have hastened terminal patients’ deaths when New Orleans was deprived of electricity and water. It recalled how generators at two hospitals failed last year during a blackout in San Diego, and how a Connecticut hospital had to be evacuated when its generator failed during Hurricane Irene.

As pointed out on PopTort, a sassy blog produced by the Center for Justice & Democracy at New York Law School, “Thanks to the almost super-human heroic efforts of doctors and nurses, no NYU-Langone patient died during this experience, but the doctors and nurses were no less heroic during Katrina. It was just sheer luck that the ambulances could make their way down city streets.”

Perhaps most troubling is that these failures and their dire consequences weren’t exactly a surprise. Dr. Arthur Kellermann, formerly of Emory University’s emergency department and now a policy analyst at the RAND Corporation think tank, tweeted during the NYU evacuation: "Hospital preparedness and well-functioning backup systems are a costly distraction from daily business, until they are needed. Like now."

Later, he told ProPublica, “What I find most remarkable about this story is that [more than seven] years after Hurricane Katrina, major hospitals still have critical backup systems like generators in basements that are prone to flooding."

Newly constructed hospitals are supposed to site generators and fuel in close proximity, above flood level. Older hospitals are not subject to this common sense policy, and many don’t redesign their facilities to do so because it’s too expensive.

Pop Tort referred to a story on Bloomberg News that said 1 in 20 hospitals is unprepared for power disruptions.

In New York, the tale of failure is long and, apparently, never-ending. Bellevue Hospital lost all power during the New York City blackout of 1977. In 1987, a 22-minute power failure led to the death of a 40-day-old baby. In 2003, when the city lost power again, according to an official report: "Despite prior testing according to applicable State and accreditation standards, [some] generators malfunctioned, experiencing, for example, problems with switches and overheating. ...In a few cases hospitals reported that fuel supplies for generators fell to dangerously low levels, in part because of transportation difficulties encountered by fuel delivery trucks."

And after Sandy blew through town late last month, a trustee at NYU publicly acknowledged that the facility’s infrastructure was outdated and vulnerable.

Hospitals are required by the Joint Commission, an independent body that accredits them (see our post about hospital accreditation) to have back-up power capabilities and to "load test" them monthly.

Kellermann told ProPublica that despite their failures, New York City's hospitals and health department "have taken preparedness more seriously than nearly everyone else in the country, particularly since 9/11/01." A recent RAND test of disaster drills at different city hospitals went well.

That highlights the need to do more than simply what the rules require. Dr. Dan Hanfling, a disaster planning expert, said that evacuating patients might be “the new normal,” and that hospitals should be prepared with an evacuation plan.

During Sandy, NYU, hospital chairman Kenneth Langone was battling pneumonia in his own facility, and was one of the patients evacuated. As reported on Pop Tort, Langone said, “So last night God decides to give us a test and our machines failed. …Machines fail, airplanes take off in great shape and they have malfunctions. Why do we always need to blame somebody for something that could just have happened? Why not write a story about what people did because things happened? Let’s be a little positive once in a while.”

That’s a nice sentiment, but it doesn’t always keep you from harm.

If you or a loved one is scheduled to spend time in a hospital, ask its patient advocate about the facility’s disaster plan. Find out about its capacity for generating electricity, and where its generators are located. If you’re given the brush-off or admonished for unnecessary worry, remind these folks about what happened in New York during Sandy.

Two studies about how hospitals care for patients confirm the wisdom of researching the facilities where you’re considering having an inpatient procedure, and for enlisting a strong patient advocate to act on your behalf once you’ve been admitted.

In our Better Health Care newsletter, we've addressed how to find the best hospitals and the importance of having someone to protect your interests while you’re hospitalized.

As reported on ScienceDaily.com, patients treated in “magnet” hospitals—or those recognized for their nursing excellence—recorded lower death rates than those in nonmagnet hospitals. The study, by the University of Pennsylvania School of Nursing, involved four states and 564 hospitals. The designation of “magnet” is conferred by the American Nurses Credentialing Center, and recognizes high-quality patient care, advanced nursing education and nursing innovation.

Approximately 400 U.S. health-care facilities are recognized as magnet hospitals, or about 8 in 100. The University of Pennsylvania study studied hospitals in California, Florida, Pennsylvania and New Jersey, representing more than 20 in 100 annual hospitalizations. Nearly 100,000 registered nurses were included in the study, which was published in the journal Medical Care.

Researchers analyzed data from 56 magnet and 508 nonmagnet hospitals with a focus on differences for surgical patients in the odds of mortality and “failure to rescue.” That term indicates measures taken to prevent adverse events, such as hospital-acquired infection, cardiac arrest, shock, etc. According to the Agency for Healthcare Research and Quality (AHRQ), this measure can signal the quality of monitoring, the effectiveness of actions taken once early complications are recognized, or both. The Pennsylvania researchers determined that magnet hospitals had 14 percent lower odds of death, and 12 percent lower odds of failure to rescue.

The study’s authors concluded that “Magnet recognition identifies existing quality and stimulates further positive organizational behavior that improves patient outcomes.”

Another study of interest to potential hospital patients was reported in the Annals of Surgery. It suggested that medical mistakes often are made during the postoperative care of patients who have undergone major elective surgery, putting them at risk for serious complications. Researchers found that patients at teaching hospitals routinely experience as many as five procedural mistakes during their recovery.

The most common of these errors are receiving the wrong drugs or drugs delivered the wrong way, and being given incorrect instructions, test results or diagnoses.

According to a story on Aboutlawsuits.com, more than half of what are known as “process failures” result in serious harm to patients; most, it appears, can be prevented.

The study was unusual in that its focus was what happens after, not during, surgery. The researchers investigated a large gastrointestinal surgery center and observed patients from the day after surgery until they were discharged. In 659 days of observed post-op care, there were 256 process failures. In more than 8 in 10 of those cases, the failure was preventable; in half of the cases, patients suffered harm as a result of the failure.

“Interventions to prevent process failures will improve the reliability of surgical postoperative care,” the study authors concluded, “and have the potential to reduce hospital stay.”

To find a magnet hospital, check out the resources of the American Nurses Credentialing Center.

Even when surgery is necessary, it’s scary. Common patient concerns include anesthesia, operating on the wrong body part, infection, and surgical stuff left inside your body after you are closed up. All these prospects are fairly remote, except for the risk of infection. But then you read a story like the one recently published in the New York Times and you wonder if you’ll ever consent to being cut open.

Four years after undergoing a hysterectomy, Sophia Savage experienced extreme pain and vomiting. A CT scan found that a surgical sponge, an artifact of her hysterectomy, had lodged in her abdomen. She underwent another operation to remove it, but it had adhered to her bladder and other viscera, and caused an infection that required the removal of a large segment of intestine.

Savage sued the original hospital and won $2.5 million in damages. But that award has been appealed, and her health has declined seriously. Unable to work, Savage has bowel problems, anxiety and depression. It’s a sad coincidence that nursing was her own former profession.

According to The Times, 4,000 cases of so-called “retained surgical items” occur every year in the U.S. Most of the items left behind are the gauzelike sponges used to absorb blood. A long operation might require dozens of them.

Failing to remove these infectious time bombs, experts say, is the result of surgical teams using a clunky method to account for their use. Usually, a surgical nurse keeps a manual count of sponges used, but an OR can be chaotic, and it’s easy to miscount. In 4 out of 5 cases in which sponges were left behind, the surgical team had declared them all accounted for.

Despite efforts by groups such as the Association of periOperative Registered Nurses and the American College of Surgeons many hospitals, The Times says, haven’t updated their procedures.

So patients are left at risk, Dr. Verna C. Gibbs, professor of surgery at the University of California, San Francisco, told The Times.

“In most instances, the patient is completely helpless,” said Gibbs, who is also the director of NoThing Left Behind, a national surgical patient safety project. “We’ve anesthetized them, we take away their ability to think, to breathe, and we cut them open and operate on them. There’s no patient advocate standing over them saying, ‘Don’t forget that sponge in them.’ I consider it a great affront that we still manage to leave our tools inside of people.”

Although sponges account for about 2 in 3 retained items, post-surgical patients are carrying around all sorts of stuff: clamps, scalpels, even scissors. But they’re easier to spot in a surgical cavity than balled-up, blood-soaked sponges, which are more likely to be left behind during abdominal operations and in overweight patients.

Technology to the rescue! Sponges can be tracked via radio-frequency tags, which are about the size of a grain of rice. As reported on PubMed.gov, one study reviewed 2,285 cases in which sponges were tracked using a system called RF Assure Detection, which alerts the team at the end of an operation if any sponges remain inside the patient. In this study, 23 forgotten sponges were recovered from nearly 3,000 patients. The cost was about $10 per procedure.

Another tracking system employs bar code technology. Every sponge is scanned before use and again when it’s retrieved.

But as effective as electronic tracking can be fewer than 1 in 100 hospitals use it, Dr. Berto Lopez, chief of the safety committee at West Palm Hospital in West Palm Beach, Fla., told The Times. His advocacy of the technology comes from personal experience: He was sued in 2009 for leaving a sponge inside a patient. Two nurses had assured him that all sponges had been accounted for, but they weren’t. Now he won’t operate in any hospital that does not use electronic tracking.

Depressingly, Lopez believes hospitals resist electronic tracking because they don’t want to spend the 10 bucks.

But Gibbs, of NoThing Left Behind, believes technology should augment manual counting, not replace it. Some hospitals, she told The Times, use inexpensive “counter bags” in which each sponge has its own compartment. If a compartment is empty at the end of an operation, a sponge is missing. Then the electronic tracking system can help find it.

Gibbs also believes that counting sponges should not be the responsibility of only nurses: Everyone in an operating room must share accountability. “Technology is but an aid,” Gibbs told the Times. “The way that safety problems are corrected and fixed is by changing the culture of the O.R.”

If you or a loved one is scheduled for surgery, inquire about the hospital’s procedures about retained surgical items. The hospital’s patient advocate and/or your surgeon should be willing to discuss it. Ask if there is a technological tracking procedure as well as a manual count. If you are not satisfied with the response, you might consider other hospital options.

To read about some surgical mistakes that proved to be learning opportunities, see our blog “Medical Mistakes that Led to a Greater Good.”

Much of the time, when a patient experiences medical harm, the ensuing conversation and activity is focused on malpractice liability. But, finally, a common-sense ethical notion seems to be taking hold: patients who suffer harm deserve to be informed promptly, and measures need to be taken to prevent that harm from being repeated.

We’ve previously addressed the fact that mistakes happen, and that acknowledgment and accountability go a long way toward repairing the harm. A program at the University of Illinois Hospital and Health Sciences System (UIHHSS) that relies on communication, disclosure and financial remediation has been doing just that.

A commentary by Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality (AHRQ) was posted recently by the Institute of Medicine. It describes “Seven Pillars,” the model embraced by the UIHHSS.

A full-disclosure policy adopted by the University of Michigan Health System in 2001, Clancy writes, is credited with reducing costs for each claim by half, and 98 in 100 of the system’s faculty physicians approved of it. The Seven Pillars process was adopted five years later by the UIHHSS, but still is considered unusual because it doesn’t rely as heavily on the medical liability system to resolve patient harm as other institutions.

Seven Pillars focuses on transparency to eliminate patient harm and learn from patient safety events. The pillars are:

1. patient safety incident reporting;
2. investigation;
3. communication and disclosure;
4. apology and remediation, including waivers of hospital and professional fees;
5. system process and performance improvement;
6. data tracking and performance evaluation; and
7. education and training.

In two years at the UIHHSS, the process generated more than 2,000 incident reports, prompted more than 100 investigations and claimed nearly 200 specific improvements. It has served as the basis for more than 100 disclosure conversations and 20 full disclosures of inappropriate or unreasonable care that caused patient harm.

To find out if similar programs would work outside of the contained environment of an academic medical center, the AHRQ is funding a three-year demonstration project in 10 diverse, private, insured Chicago-area hospitals. Five are implementing Seven Pillars and five serve as a control group.

Preliminary data from the intervention hospitals show an increase in incident reporting and disclosures from physicians and residents, even in early settlement offers. One hospital reported a significant decrease in serious safety events and open claims within 18 months. When hospitals identify incidents of inappropriate care, hospital and physician fees are waived.

Final results won’t be available for a year, but the progress so far is notable. Even better, several other states are pondering how to implement elements of the Seven Pillars process.

“From AHRQ’s perspective,” Clancy writes, “Seven Pillars incorporates much of what we believe is paramount to lasting gains in patient safety and quality improvement. First and foremost, it seeks to prevent patient harm by reporting—and correcting—flaws in processes that can undercut the work of the most dedicated clinicians. Second, the environment fostered by communication and disclosure builds respect and trust, which figure prominently in the well-being of patients and physicians. That trust is enhanced by substantial involvement of patient advocates in designing the study. Third, the Seven Pillars process establishes and reinforces a culture of learning, especially among medical residents who previously have had few opportunities to identify and learn from patient safety events.”

Slowly but surely medical providers are starting to understand and accept that patient safety is paramount and that the best practice in resolving adverse events in patient care is not avoidance and silence, but, in fact, the opposite.

A Maryland-based medical staffing agency is at the center of allegations that it placed a rogue radiological technician into a number of hospitals in Maryland and other states. The technician is believed to have infected dozens of people with hepatitis C.

Maxim Staffing Solutions, a national firm with headquarters in Columbia, Maryland, placed technician David Kwiatkowski into three Baltimore hospitals: Baltimore Veterans Affairs Medical Center, Johns Hopkins Hospital and Maryland General Hospital, and also at Southern Maryland Hospital in Clinton, between 2008 and 2010.

Kwiatkowski was arrested in late July in New Hampshire after he was caught in a hospital stealing narcotic drugs that were intended for patients. He now faces federal charges.

The four Maryland hospitals are sending notices to several hundred patients to get testing for hepatitis C, a viral infection of the liver that, in bad cases, can lead to liver destruction and need for transplant.

Whether Maxim had reason to suspect the technician's danger to patients has yet to be determined. Lawsuits are likely against Maxim and another staffing agency that sent him to hospitals in as many as seven states in the last few years.

It's also unclear whether any of the Maryland hospitals had an inkling of problems with the technician. But at least two other hospitals, the prestigious UPMC Hospital in Pittsburgh and the Arizona Heart Hospital in Phoenix, fired Kwiatkowski after finding him with narcotic drugs.

A couple of months ago, we wrote about the sloppy, widespread clinical practices that put patients at risk of contracting hepatitis C, but this case, it appears, goes well beyond carelessness.

Maxim Staffing is alleged to have sent Kwiatkowski to UPMC in the spring of 2008. There, he was observed by another employee placing a syringe containing fentanyl, a Schedule II narcotic, in his pants. He replaced the missing syringe with another containing another liquid. Management confronted him, found three empty syringes with fentanyl labels on his person and an empty morphine syringe in his locker. His urine tested positive for fentanyl and opiates.

He was fired.

But UPMC did not report the theft, use or diversion of its controlled substances to any government agency or law enforcement authority. The technician was free to practice his alleged crimes elsewhere, and Maxim placed him in a matter of weeks into the first of four Maryland hospitals where he worked.

By the time he tested positive for hepatitis C in June 2010, dozens of patients who had undergone cardiac catheterizations at the hospitals that had employed him had been exposed to a common strain of hepatitis C. Most of them have learned only in recent months of their diagnosis. Based on this information, thousands of cardiac catheterization patients at hospitals where he worked are being tested for hepatitis C.

As noted in our backgrounder, hepatitis C can cause liver failure. The blood thins, and patients bleed easily. In the worst cases, called fulminant hepatic failure, the brain swells and the patient goes into a coma. About half of these patients die without an emergency liver transplant.

In July, a warrant was issued in New Hampshire for the technician’s arrest for acquiring a controlled substance by misrepresentation, fraud, forgery, deception or subterfuge, and for tampering with a consumer product with reckless disregard for the risk he posed to others of death or bodily injury, and for the serious bodily injury that has befallen others.

It’s shocking enough that a drug addict in a position to contaminate hospital equipment with a deadly virus not only would be hired and rehired and rehired without regard for his illness or the harm he created for others. But that the hospital and the staffing agencies that knew about the risk failed to report his crimes is unconscionable.

The tech was placed by Maxim into the four Maryland hospitals AFTER his firing from the Pittsburgh hospital. What excuse does Maxim have for failing to find out what had happened in Pittsburgh and for enabling his further crimes? We will find out in the coming lawsuits.

We do know this much. As a result of this infected technician being given access to patients in seven states across the country, dozens of people face a dire infection, and countless others are left to wonder if and when it will strike. With a hep C diagnosis comes significant costs for treatment and care, the possible loss of livelihood and maybe even life itself. And none of it had to happen.

Anyone who has ever reviewed, inquired about or disputed an itemized medical charge has been introduced to the arcane world of bill coding. Every procedure, from the administration of an aspirin in the hospital, the use of a surgical sponge or the blood draw for a lab test, is assigned a code number.

As reported by Merrill Goozner earlier this month, the manipulation of codes can significantly boost a provider’s fees through “upcoding,” or inflating the seriousness of a medical condition in order to generate more tests. And more fees for them.

The codes, as explained in a recent story in the New York Times, require some subjective evaluation, and are meant to reflect how much care is being delivered. An emergency department patient with a simple case of indigestion would be classified by the hospital as using few resources, and would be reimbursed by Medicare only $50.

But a patient suffering from a presumed heart attack might require oxygen, be placed on a cardiac monitor and be sent for a CT scan. Those are higher, more expensive services that Medicare would reimburse for $323.

Referring to the story in The Times, Goozner describes the situation with HCA, a hospital chain we recently wrote about after an investigation found that it performed unnecessary cardiac procedures that boosted its profit. Apparently that wasn’t enough bottom-line helper. As Goozner notes, “In 2008, [HCA] introduced a new coding and billing system that over … two years … tripled the share of emergency room visits that received the two highest reimbursement rates paid by Medicare.”

“In other words, almost overnight, people visiting its emergency rooms got a lot sicker.”

Except, of course, they didn’t. They only seemed sicker on paper thanks to upcoding. And it isn’t the first time HCA has indulged in that unsavory practice—in 2000, the company paid $840 million to settle fraud claims for allegedly overcharging Medicare for upcoding pneumonia patients.

Goozner says that HCA is hardly alone; during the two years tracked by The Times, the percentage of emergency room patients receiving Medicare’s top two billing codes jumped from 58 percent to 74 percent.

It appears to be typical in the U.S. “The system,” Goozner says, “creates a powerful incentive for providers, especially those that operate as for-profit businesses, to shift patients into those sicker categories.” It’s a perversity of the fee-for-service model that’s undermining the ability to control health-care costs in the U.S.

The “diagnostic related group” (DRG) system for reimbursement was introduced more than 30 years ago. Between 1989 and 1996, according to a Dartmouth University study, the share of pneumonia and respiratory infections assigned the most serious DRGs increased 10 percentage points at nonprofit hospitals and 23 percentage points at for-profit hospitals.

In 2010, a Health and Human Services (HHS) report concluded that elderly patients requiring extensive rehabilitation therapy in skilled nursing facilities increased from 17 to 28 percent of that population between 2006 and 2008. But the age and diagnoses of the patients when they were admitted to the facilities hadn’t changed. That’s upcoding.

And according to the HHS study, for-profit nursing facilities were far more likely to recommend more extensive services. Thirty-two percent of patients at those facilities were given “ultra high therapy,” compared with 18 percent at nonprofits and 13 percent at government-owned skilled nursing facilities.

Medicare Advantage is the federal Medicare program that provides coverage via the private insurance market. As Goozner writes, “When President George W. Bush in 2003 announced that payments for beneficiaries in Medicare Advantage plans would be adjusted to reflect their medical conditions, the reported health status of those in the plans declined sharply over the next 12 months.”

And the “risk scores” for people in Medicare Advantage plans rose much faster over the next two years than people covered by more traditional Medicare.

As long as the predominant health-care business model is “the sicker they are, the richer we get,” the system will be gamed and costs will rise.

Hospital patients yearn most of all to shed the label of patient and go home. But the day of discharge carries some special dangers for last-minute testing, according to a new study. The takeaway lesson: Don't let the joy of new freedom cloud your watchfulness as you're on the way home.

The study published in the Archives of Internal Medicine showed that tests ordered on the last day of a hospital stay account for nearly half of all test results that are not reviewed. They also represent a larger proportion of abnormal test results.

We've written previously about the need to manage a complete transition from hospital to home. (See our post, “Safely Handling the Transition from Hospital to Home.”)

Because patients are deemed ready to go home, most tests ordered on the day of discharge are unlikely to change care and many aren’t even necessary. But, the researchers wrote, “if an important test result is required to guide care at discharge, providers need to figure out a process to ensure follow-up.”

Timing is key: Tests requested early in a hospital stay are more likely to be reviewed than those requested later. “Tests ordered on the day of discharge have a very limited chance of being reviewed,” researchers concluded.

More than 20 in 100 tests ordered on the day of discharge were not followed up, compared with not quite 2 in 100 tests ordered on other days. In addition, day-of-discharge tests were more likely to show abnormal results--nearly 15 in 100 of all unreviewed tests at discharge were abnormal, but of those given on the day of discharge, 65 in 100 were abnormal.

As the researchers noted, 1 in 5 patients experiences an adverse event during the transition from hospital to home, and 6 in 10 of those are preventable. No matter when they were given during a hospital stay, failure to follow up tests once a patient has gone home contributes to the risk of an adverse event. The risk is greater if they’re given on the day of discharge because results aren’t always available the same day a test is given, and if they are, there’s a smaller window for review.

There’s a cynical result here, too. “It appears that at least some late admission tests represent an opportunity to optimize test ordering,” the researchers wrote. “Tests ordered as a result of poor discharge planning may well be unnecessary….”

Their solution to the oversight and possible bill-padding practice is to implement discharge protocols that trigger computer alerts when discharge-day tests are ordered electronically to advise clinicians either that it is unlikely that results will be posted before discharge or that the tests have a high risk of being missed.

Our solution is for hospital patients and their advocates to make sure they know:

• when their doctors plan to discharge them;


• what tests are planned and when;


• when all tests conducted in the hospital can be reviewed; and


• when they have been reviewed.

A disturbing story published last week in the New York Times raised anew questions about how profit sometimes is the primary consideration in performing medical procedures. Following a major hospital chain’s paper trail, The Times told a story of widespread overuse of cardiology resources with serious implications for patient safety.

In 2010, Stephen Johnson, the chief ethics officer of HCA, the largest for-profit hospital chain in the U.S, received a letter from a former nurse at a Florida hospital claiming that a doctor there was performing heart procedures on patients who didn’t need them. A two-month internal investigation confirmed the charge in a confidential memo by Johnson. The doctor was slapped on the wrist, but the nurse lost his job. That decision, Johnson said in the memo, was because he blew the whistle on the cardiologist.

“But the nurse’s complaint,” The Times reported, “was far from the only evidence that unnecessary — even dangerous — procedures were taking place at some HCA hospitals, driving up costs and increasing profits.”

According to The Times, Medicare reimburses hospitals about $10,000 for a cardiac stent—a tiny tube that holds an artery open. But recently, doctors have been less eager to implant stents, preferring drugs to treat blockages.

Another invasive test, cardiac catheterization, which Medicare reimburses at about $3,000, is used to diagnose blocked arteries. A long, thin, flexible tube (the catheter) is inserted into a blood vessel in the arm, groin, or neck and threaded to the heart, where it is used to inject dye into the heart's blood vessels to take x-ray pictures.

Even if necessary, these procedures pose a range of risks from infection, nerve damage, pain to death. Cardiologists generally don’t operate on coronary arteries unless they show at least 70 percent blockage. (See our story about unnecessary surgery here.)

Although The Times’ story focused only on HCA, a story published last week by ProPublica, an independent investigative organization, said that the practice of inflating the need for cardiac procedures is widespread.

ProPublica referred to a study published last year in the Journal of the American Medical Association that found that only half of 144,000 nonemergency heart catheterizations were appropriate.

"It's presented in the media as if it's an aberrancy, when actually it's the rule," Dr. David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School of Medicine told ProPublica. "The medical system is addicted to the revenues that it generates."

Last year, Medicare spent nearly $1 billion on the procedures that boost revenues for doctors and hospitals but cost taxpayers, raise insurance premiums and put patients at risk—about 3 in 100 patients experience serious complication.

Since 2002, HCA itself had uncovered evidence that some cardiologists at several of its Florida hospitals were unable to prove the need for many of the procedures they were performing. To justify them, according to internal HCA documents, doctors wrote inflated medical reports to make it seem as though they were necessary.

Approximately half of one HCA hospital’s cardiac catheterizations—about 1,200—were deemed to have been performed on patients without significant heart disease, according to a 2010 confidential review.

At one hospital, a 44-year-old man who came to the emergency room complaining of chest pain suffered a punctured blood vessel and a near-fatal irregular heartbeat after a doctor performed a procedure that an outside expert later suggested might have been unnecessary. The patient had to be revived.

In another incident at the same hospital, a woman with no significant heart disease went into cardiac arrest after a vessel was cut when a cardiologist inserted a stent. She was hospitalized for several days.

Last month, the U.S. attorney’s office requested information on reviews assessing the medical necessity of interventional cardiology services provided at 10 of HCA’s hospitals. The Justice Department, according to the Associated Press, also will review billing and medical records at 95 HCA hospitals.

HCA declined to provide evidence that it had alerted Medicare, Medicaid or private insurance companies of its findings, or that it reimbursed them for any procedures the company determined had been unnecessary, never mind that such action is required by law.

HCA told The Times that it took the steps necessary to improve patient care, and that “significant actions were taken to investigate areas of concern, to bring in independent reviewers, and to take action where necessary.”

But HCA declined to show that it had ever notified patients, who might have been entitled to compensation from the hospital for any harm. And some of the doctors accused in the reviews of performing unnecessary procedures still practice at HCA hospitals.

How “significant” can its actions have been?

The Times reviewed hospital communications and concluded that rather than asking whether patients had been harmed or whether regulators needed to be contacted, hospital officials asked for information on how the physicians’ activities affected the hospitals’ bottom line.

Maybe that’s because HCA is less concerned about doing no harm than in recouping expenses for its chronic bad behavior. In 2000, HCA settled one in a series of huge Medicare fraud cases with the Justice Department that tallied $1.7 billion in fines and repayments, mostly concerning charges of overbilling.

Only two years after that fraud settlement, HCA started uncovering the “questions regarding the medical necessity of some of the procedures” that remain problematic.

Today, the surgeon who inserted a cardiac stent after the whistle-blowing nurse (and others) had seen no blockages in the images of the patient’s artery continues to practice at the same HCA hospital. This, despite the fact that an outside heart specialist found problems with 13 of the 17 cases the surgeon performed, including unwarranted cardiac catheterizations and patients who were needlessly subjected to multiple procedures.

To learn more about options for treating coronary problems, visit the website of the Informed Medical Decisions Foundation.

We spend a lot of time criticizing health-care practitioners, facilities, insurance and pharmaceutical companies because when it comes to harming patients, some of them deserve it. We’re always happy when somebody within the medical establishment looks at its problems with as much skepticism as we do.

Dr. Bob Wachter is a hospitalist—that is, a physician who works solely treating sick patients in hospitals —and the author of Wachter’s World. The blog, as it tagline says, is about “lively and iconoclastic ruminations on hospitals, hospitalists, quality, safety and more.”

In a recent post, Wachter comments on U.S. News & World Report’s annual “honor Roll” of “America’s Best Hospitals” for 2012-13. He applauds that U.S. News has moved from rating facilities almost exclusively by their reputations among the medical community to include more patient satisfaction factors as a measure of quality. We also have found fault with ratings that exclude the actual patient experience.

For the first time in more than 10 years of the magazine’s ratings, Wachter’s hospital, the University of California, San Francisco Medical Center (UCSF), has fallen out of the Top 10, moving from No. 7 last year to 13. But even more compelling to Wachter is that Johns Hopkins Hospital in Baltimore lost the No. 1 position it held for 21 years.

“When US News launched its Best Hospitals list with its April 30, 1990 issue,” Wachter wrote, “the entire ranking (which, then and now, considers only large teaching hospitals with advanced technologies) was based on reputation—a survey of 400 experts in each specialty rated the best hospitals in their field. Was this a measure of quality and safety? Maybe a little. But I’d bet that the rankings had more to do with the prominence of each hospital’s senior physicians, its publications and [National Institutes of Health] portfolio, the quality of its training programs and its successes in philanthropy than with the quality of the care it delivered. While the magazine changed the methodology to include some nonreputational outcome and process data in 1993, the reputational survey remained the most important factor.”

But this year, the magazine rejiggered the metrics, making “reputation” worth less than one-third of the total, and promoting other measures of patient-safety quality, such as nurse staffing.

Now, the Top 10 list is less predictable—less, say, like the Yankees in the playoffs (again) and more like, say, the Kings winning the Stanley Cup (say what?). Former Top 10 institutions fell to the teens, and others fell out off the list (which ends at 17) altogether. Former also-ran hospitals have pushed them aside.

Medicare’s introduction of the Hospital Compare website in 2003 was a wake-up call not only for any organization that rates hospitals, but for the institutions themselves, whose compensation will depend in part on how well they perform in patient-safety areas such as readmissions. Medicare also requires hospitals to have patients complete satisfaction surveys.

After UCSF scored relatively poorly in some categories on the 2003 U.S. News rating, Wachter says it transformed its approach to quality, safety and patient experience, and, he writes, “Without question, UCSF is a far better hospital today than it was then, and I don’t think that would have happened without public reporting and rankings.”

When it comes to putting a priority on patients, we also like Planetree, a nonprofit organization that promotes patient-centered care in hospital design and management, and The Leapfrog Group, an organization of businesses that promotes high-quality, cost-effective health-care as part of employee benefits.

There’s no shortage of hospital rankers. As Wachter points out, “Americans love rankings, and the hospital ranking game has become big business.” Even The Joint Commission, an independent, nonprofit organization that accredits and certifies more than 19,000 health-care organizations and programs in the U.S., has joined the ranking ranks.

Like Yelp or Angie’s List, hospital surveys that include subjective consumer criteria can skew results if enough people are more interested in retribution than they are in informing. And more important, as Wachter notes, hospitals might be motivated to address ranking criteria at the expense of other important but unmeasured factors. “Just consider all of the attention being lavished on preventing hospital falls and central line infections, safety problems that are not nearly as consequential or common as diagnostic errors (which have received considerably less attention because they’re so hard to measure). Great performance on some measures—like ultra-tight glucose control or the four-hour door-to-antibiotics measure pneumonia—was ultimately proven to be harmful to patients.

“And, as long as many of the outcome measures (such as mortality and readmission rates) are judged based on ‘observed-to-expected’ ratios, hospitals will find it a lot easier to improve their ranking by changing the ‘expected’ number (through changing their documentation and coding) than by actually improving the quality of care.”

Still, we’re glad that U.S. News & World Report now measures a more complete picture of quality care, and we agree with Wachter that the benefits of hospital rankings that embrace this wider range and patient input outweigh the pitfalls. “Ranking and public reporting does serve to motivate hospitals to take quality and safety seriously, and to invest in systems and people to improve them.”

Earlier this month, we mentioned a column by Maureen Dowd in The New York Times concerning the unnecessary death of 12-year-old Rory Staunton from septic shock, who was misdiagnosed as having a stomach bug.

The sad story has legs not only because we’ve learned more about what happened that day at New York University Langone Medical Center, but also because medical errors remain an intractable problem in the U.S., as reported last week by ProPublica, a nonprofit investigative news organization.

Rory had been taken to the hospital’s emergency room in March. He was diagnosed with a gastrointestinal problem and sent home. Three hours later, his lab results showed that his white blood cell count was nearly five times higher than normal. The hospital notified neither his doctor nor his family of the lab results. As reported by The New York Times, the incident prompted the hospital to revise certain procedures, including that ER doctors should be notified immediately of certain abnormal lab results and that the patient and his or her doctor also be notified when results are reported after the patient is released.

Excuse me? Isn’t it plain to anyone with even a shred of common sense that lab results should be reviewed, interpreted and communicated promptly?

Rory suffered septic crisis—when a treatable infection becomes life-threatening—a few days after cutting his arm while playing basketball. That’s probably when the bacteria entered his bloodstream. A common medical problem turned into a fatality because nobody was paying attention.

Dr. Joshua Needleman, a specialist in pediatric pulmonology at Weill Cornell Medical Center in New York, told The Times:

“The big questions are about how to integrate new information that doesn’t fit with the perception you have formed. How to listen to the patient when they are telling you something that doesn’t fit with your internal narrative of the case. These are the hardest things to do in medicine and yet the most important.”

Another expert, Dr. Robert E. Lynch, director of pediatric critical care at Mercy Children’s Hospital in St. Louis, said that Rory’s lab results were “virtually incompatible with a diagnosis of viral gastroenteritis,” which is what he was diagnosed with.

Even with assurances by NYU Langone that the problem has been addressed, ProPublica isn’t optimistic. Medicine does not have a good record in this regard. “[W]e wish we could tell you that this case will spur changes in emergency rooms across the nation, that never again will a hospital make such an avoidable mistake,” wrote its reporters. “But, sadly, decades of experience covering such incidents suggest the medical system may prove resistant to change. Forget about every hospital rewriting its procedures. History suggests it would be a victory if NYU Langone manages to follow its own new rules as we all hope they will.”

According to ProPublica, nearly 100,000 people die annually in the U.S. from medical errors in hospitals. “Despite the resulting national focus on patient safety, patients continue to be harmed and killed by medical shortcuts, inadequate training and breakdowns in communication.

“Unlike the airline industry, which relies on a safety net of checklists, the medical community has been slow to adopt them in all areas and often puts its faith in the outdated idea that doctors are infallible.”

Here are some of the horrific but common errors enumerated in its story:

• Between 2002 and 2008, NYU Langone repeatedly was penalized by the New York State Department of Health for errors that led to patient deaths, including one delay in diagnosing an infant's herniated bowel and deteriorating condition in the emergency room. The hospital also has a record of operating on the wrong body part.


• Three times in 2007, surgeons at Rhode Island Hospital, the main teaching hospital of Brown University's medical school, drilled into the wrong side of patients' heads


• In 2009 at the same hospital, a surgeon operated on the wrong side of the patient's mouth during cleft palate surgery.


• Also in 2009 at Rhode Island Hospital, a surgeon operated on the wrong finger of a patient.

Remember Martin Luther King Jr./Drew Medical Center, another chronically deficient hospital in Los Angeles? Starting in 2003, stories began to emerge about how a nurse in the cardiac monitoring unit failed to notice that her patient's heart had slowed and stopped for more than 45 minutes. On the patient’s chart, she wrote that she was not in distress. Two weeks later another patient on a monitor died after her failing condition also went unnoticed.

Health officials demanded that nurses and technicians in monitoring units be retrained and new procedures established. In the next two years, however, five more King/Drew patients died in similar circumstances. Some nurses not only neglected patients as they lay dying, but purposely turned down the alarms on the monitors or lied about their actions on patient charts.

In Las Vegas, the nation’s largest clinically based outbreak of hepatitis C occurred in 2008. Nurses at a colonoscopy clinic were reusing syringes and single-use medicine vials, infecting more than 100 people with the deadly disease. Last month we wrote about the widespread misuse of injectable drugs, four years after the high-profile crisis in Nevada.
When inspectors in Las Vegas investigated other facilities, they found the same problems.

And despite a campaign by the Centers for Disease Control and Prevention to raise awareness by providers of the need to use only one needle and syringe per patient, earlier this month, the Colorado Department of Public Health and Environment said thousands of patients may have been put at risk of HIV and hepatitis because a local dentist had used needles and syringes repeatedly for days at a time.

If you or a loved one has been harmed while undergoing medical care, ProPublica invites you to share your story here.

In concluding its report, ProPublica said that medical errors don’t usually occur because medical providers are malicious. They occur because of the culture of an institution. “Administrators need to empower front line staff,” advises ProPublica, “no matter their rank, to speak out when they see safety lapses before they cause harm — which is difficult in a system that reveres doctors above others.

“Addressing the types of failures that led to Rory Staunton's death depends on redirecting resources at a time when they are scarce and accountability amid the chaos of busy hospitals.”

It’s difficult to rewire institutional thinking. But it’s a matter, literally, of life and death.

Suppose you need gall bladder surgery. Suppose there’s a prestigious urban teaching hospital nearby with lots of famous doctors and researchers who get a lot of media attention for all the ground-breaking work they do. Suppose it’s in your insurance network and your surgeon has privileges in its OR.

Perfect, right?

Maybe. But suppose you undergo the operation and something goes wrong, as it sometimes does, and you suffer lasting harm because somebody made a mistake.

You retain an attorney, sue the hospital for damages and win the trial. Although you can’t undo the error, at least it was recognized and compensated, right?

Not necessarily. Or so it seems from a recent story in the New York Times. “Several of the city’s most troubled hospitals are partially or completely uninsured for malpractice…,” according to the story, “forgoing what is considered a standard safeguard across the country.”

The problem isn’t limited to New York, although certainly the Big Apple appears to have a serious problem, particularly in underserved, poorer neighborhoods. But it can happen anywhere.

You’d think any hospital would insure itself for what sometimes is the cost of doing business that has such great potential for causing terrible suffering. But as reported on Pop Tort, a consumer advocacy project of the Center for Justice & Democracy, a recent Consumer Reports survey revealed that 30 of the 50 lowest-rated U.S. hospitals in terms of quality of care were found in New York City. New York-Presbyterian, home of TV’s “NY Med,” for example, features open-heart surgery performed by star surgeon Mehmet Oz, and it performed 18 percent worse on the survey on than the national average.

Pop Tort referred to Time magazine’s article, “Why The ‘Best’ Hospitals Might Also Be The Most Dangerous," and commented, “Clearly, the days when New York hospitals were more well known for their rampant medical errors (and tiny percentage of harmed people who sue) than superstar miracles, seem a distant past.”

Although many are insured, some aren’t. Without malpractice insurance, facilities are playing with fire, and it’s the patients who will get burned. As The Times pointed out, although some of these hospitals have financial reserves to cover liabilities, others have exhausted them. That means awards or settlements are paid from funds otherwise used for patient care. Some have closed certain practices, such as obstetrics, to reduce their exposure.

Many hospital executives claim tight budgets and high insurance premiums make it impractical to pay millions of dollars a year for insurance. But that’s just penny-wise, pound-foolish behavior that isn’t in the best interest of patients, and can place hospitals and their bondholders, including state-backed bonds, at risk if large judgments force them into bankruptcy.

Insurance law professor Tom Baker, from the University of Pennsylvania, told The Times, “From a social perspective, it’s very irresponsible. They’re taking in these people knowing they’re not able to make good on the harm they caused. Even a really good hospital is going to have a certain amount of medical malpractice. It’s inevitable.”

And hospitals don’t have to tell consumers if they are going “naked” or “bare,” as they call it in when they don’t carry insurance. That information at least would give you the option to seek treatment somewhere else.

So if you or a loved one requires hospital care, contact the patient advocate at each facility you’re considering and ask about its medical malpractice coverage. Whether or not your request for information is granted, consult the hospital comparison website from the Department of Health and Human Services to see how well your options stack up against national norms for patient care.

In addition, read our articles about hospital errors, and hospital ratings to help narrow your choices for care and understand when you might need legal counsel if something goes wrong.

No one goes to a hospital for fine dining, fabulous room views or 500-thread count sheets. A hospital is not a hotel. Nor, according to a recent study, is it a place for a good night’s sleep.

Hospitals are where people go to be treated and to heal. And because healing generally requires sufficient rest, the study results, published in the Annals of Internal Medicine, put scientific muscle behind common sense.

Sounds commonly heard in hospitals were deemed by researchers to be noise pollution, which can disrupt sleep and impair brain activity and cardiovascular function. The sounds with which hospital patients regularly must cope include:

• intravenous alarms;


• telephones;


• ice machines;


• voices in the hall;


• outside traffic; and


• helicopters.

Even subtle noises—those that didn’t awaken the patient—affected the sleeping person’s heart rate. As one of the study’s authors noted, "While these effects were modest in size, our concern is that repeated disruptions, as might occur in a hospital room, may jeopardize the health of our most vulnerable populations."

The researchers hope that by quantifying negative health effects of what many people assume is merely annoying that hospitals will adopt “acoustic performance guidelines,” beginning with design and construction and including altered night-care routines and less intrusive communication technology.

Medical consumers now have another way to gauge how well hospitals safeguard patients. Courtesy of Leapfrog, a nonprofit organization composed of businesses and organizations whose mission is to improve the quality, safety and cost-efficiency of health care, a new assessment tool is available online.

We regularly cover hospital safety issues, including how to rate hospital care and how to find the best hospital.

As reported by NPR in conjunction with Kaiser Health News, Leapfrog graded 2,651 hospitals on 26 different criteria collected by the organization from hospitals that agreed to participate and by Medicare. Measures such as hospitals’ adherence to safe practices (prompt removal of catheters, for example, to minimize infection risk) and how well they kept records of adverse events (bed sores, for example) were included.

The results: 729 hospitals got an A grade, 679 got a B and 1,111 received a C. Hospitals scoring lower were described as “grade pending,” for which 132 qualified. Ratings will be updated in six months, when the grades of D and F will be introduced.

You can look up ratings here.

Because even objective ratings are subject to interpretation and can be founded on subjective inquiry, and because this is the health-care industry in which there is no straight line from point A to point B, not everyone applauded Leapfrog’s efforts. The American Hospital Association disputed the survey, saying that Leapfrog “has supported several good quality measures but many of the measures Leapfrog uses to grade hospitals are flawed, and they do not accurately portray a picture of the safety efforts made by hospitals.”

The chief quality officer at the Cleveland Clinic objected because he said much of the data were as much as two years old, and many hospitals have improved since. Like some hospitals, Cleveland Clinic dropped out of Leapfrog's surveys in recent years because the government began requiring more information for purposes of publication.

To design the scoring method, Leapfrog consulted with nine experts representing institutions including Johns Hopkins, the University of California, Davis and the Harvard School of Public Health.

Some high-profile institutions scored less than impressive marks. New York-Presbyterian Hospital in Manhattan and the Cleveland Clinic hospital got C grades. UCLA Ronald Reagan in Los Angeles got a "grade pending."

But some other well-known facilities got an A, including the Mayo Clinic in Rochester, Minn., and Cedars-Sinai Medical Center in Los Angeles, as well as several obscure community hospitals.

“The hospitals that achieved an A came from all walks of life, across the gamut of hospital types and people they serve,” said Leah Binder, Leapfrog’s executive director. “Safety appears to be something that all hospitals can choose.”

Three states—Massachusetts, Maine and Vermont—were the only ones where half of the hospitals or more got a grade of A. Half or more of the hospitals got a C or "grade pending" in 24 states and the District of Columbia. The worst performers were D.C., Oregon and New York, where at least 2 in 3 hospitals got a C or worse.

Leapfrog executives hope that groups of employers that purchase insurance will disseminate the ratings to workers and use them when selecting health care providers. You can do your own investigating on Leapfrog’s site, and at Medicare’s hospital comparison site.

Martha Deed is exactly the person anyone would want as his or her patient advocate. A psychologist and member of the Consumers Union network of patient advocates, she is trained in patient advocacy and has a profound understanding of patient safety issues.

Yet when her own chronically ill daughter was subjected to a daunting cross-current of hospital specialists and treatment, even Deed felt like a sock being tossed around in an industrial washing machine.

She recently wrote about the experience on Sporkworld.org, and came away with valuable lessons for all.

As designated advocate for her 36-year-old daughter, Millie, who suffered from Behcet’s disease, an obscure autoimmune disorder, Deed had been through multiple medical emergencies and hospitalizations. She knew her daughter’s wishes, her response to various medications and her complicated medical history.

When Millie contracted a respiratory infection, few of Millie’s treatment providers had ever encountered a person with Behcet’s and none had ever spoken to her about how she wished her illness to be handled.

On admission to the hospital, Deed soon learned the limits of her superior knowledge. “I knew only what Millie’s previous illnesses had taught me. Each new hospitalization required a steep learning curve. [This] hospital was not treating Millie for Behcet’s. They were treating her in the ICU for respiratory failure due to swine flu. Behcet’s, to them, was an interesting side issue that they had little time for in an emergency.”

What ensued was a torturous adventure trying to communicate with uninformed professionals and coordinating care for two diseases whose treatment options often were contradictory. Medications that exacerbated Behcet’s were given to Millie without Deed’s knowledge, and sometimes in defiance of her directions.

We’ve written frequently about patient advocacy, including “Bringing an Ally with You to the Doctor’s Office,” “Protecting a Loved One in the Hospital” and “When the Doctor Isn’t Sure: What You Can Do.”

After Millie’s death, Deed learned:

• If you do not have accurate information about your family member’s treatment, you cannot advocate effectively.


• If staff does not accept documented medical facts about the patient, the hospital’s patient safety efforts may fail.


• Patient safety personnel cannot work effectively if there are gaps in handling a patient’s concerns.


• If you don’t know who is in charge, your concerns may not be addressed.

If hospitalization is a surprise:
1. Read the hospital’s orientation material carefully. Find out who is in charge of your loved one’s case. Be present for rounds by that physician.
2. Make sure that others are available to visit and comfort the patient if you are engaged in advocacy.
3. Have someone stay with the patient as close to 24/7 as possible--problems can occur day or night. Do not attempt to do it all by yourself.
4. Get some rest yourself so that you can remain helpful and clear thinking.
5. Keep a log so as not to lose track of what is happening with your loved one’s care. Include notes of any contact with medical staff. This can help prevent misunderstandings as well as mistakes.
6. The hospital probably prefers a single contact person. But that person—you, the patient advocate—can benefit from discussing the patient’s treatment with someone who knows the patient well and is trusted by him or her. The back-up can help identify communication or treatment gaps.
7. Be polite, even in an emergency in which you must engage the highest levels of hospital hierarchy.

The concept of coordinated care is considered a best practice, but in light of a recent survey and story by NPR, the Robert Wood Johnson Foundation and Harvard School of Public Health, it’s hardly a widespread one.

A few years ago, we wrote about what happens to hospital patients when the facility’s right hand doesn’t know what the left hand is doing. The story told how the lack of coordinated care resulted in 1 in 5 Medicare patients being readmitted to the hospital within 30 days.

Earlier this year, we reported that some health insurers are beginning to appreciate the wisdom of coordinating patient care in terms of both health outcomes and cost savings.

Coordinated care involves a therapeutic plan that integrates the efforts of all of the patient’s medical and social service providers. It might designate a single person to manage all of the collaborators or simply might be an understanding they share to ensure efficiency and communication. The point is to maximize resources, minimize duplicate procedures, reduce costs and, ideally, prevent harm.

That didn’t happen for Andrew Dasenbrock, one of the subjects detailed in the NPR story.

A 32-year-old a self-employed IT consultant, Dasenbrock says he can't afford health insurance. When he woke one night with intense stomach pain — "like shards of glass traveling through me," he said—he went to an urgent care center nearby. Doctors ran several tests, couldn’t settle on a diagnosis and sent him to the hospital.

The hospital was part of the same system, but its staff was not alerted to Dasenbrock’s arrival, nor were his records transferred. He was forced to fill out the same questionnaires and repeat all the same diagnostic tests. He remained in excruciating pain.

The hospital diagnosed an ailment that, while painful, wasn’t serious and required only that Dasenbrock ingest a lot of fluid. He went home. Two days later he received two bills totaling thousands of dollars.

"I laid the two bills next to each other and it was literally word for word, letter for letter and line item by line item the same charges ... for all the tests I had gone through," Dasenbrock said. He had to pay double what he should have for his care.

Another tale was told by Jacki Bronicki, whose father was 80. He had Parkinson’s disease, but the retired engineer and physics teacher was mentally acute and responding well to his treatment.

Last year he fell, broke three ribs and was admitted to the hospital. His mental state began to deteriorate by the second day. "He wasn't even coherent by the third day," Bronicki said.

Bronicki said that the parade of doctors who saw him seemed to assume that his confusion was, for him, normal, and reflected his age and condition. Bronicki said she had to explain to each new doctor that he had Parkinson's, that his mental deterioration was not his normal, that he usually was coherent.

Finally, a neurologist finally figured out that all the different doctors had prescribed different pain medications, and the drugs were interfering with Brown's Parkinson's medication. That caused his mental deterioration and made his limbs rigid.

His prescriptions were realigned, and he improved. But Bronicki and her sisters felt they had to remain at his hospital bedside 24 hours a day to prevent another medication error. And, she reported, "He has a lot more dementia than he had a year before. He can't walk anymore. And I'm not sure if it would have normally progressed like this, or if we really sped it up."

It wasn’t they who sped it up; more likely, it was the lack of communication and coordination among all of his caregivers.

Certainly, many of the survey respondents were pleased with their care. But of people hospitalized in the last 12 months:

• 30 percent said doctors, nurses and other health-care professionals communicated poorly with each other;


• 24 percent said doctors, nurses and other health-care professionals didn’t communicate information about their condition or treatment.

It’s another episode in the continuing drama of technology lust. Device manufacturers love to market their new, advanced and invariably expensive wares, hospitals love to leverage them for marketing and bill-enhancement, and doctors love them like middle-schoolers love the latest version of the iPad.

But the Da Vinci Surgical System continues to rack up a troubling record of patient harm. The robotic device, used in a variety of surgical procedures, enables surgeons looking at 3-D images through eyeholes to maneuver multiple arms with a joystick and perform surgery through tiny incisions. We’ve raised previous concerns about Da Vinci, and its most recent problem reports involve accidental tears and burns to internal organs, according to AboutLawsuits.com. Some of these adverse effects require multiple surgeries to repair, and some its patients have died.

Intuitive Surgical Inc., which manufactures Da Vinci, promotes the robot’s treatment of bladder, colorectal, gynecologic, kidney, prostate and throat cancers. It’s also marketed for coronary artery disease, endometriosis, heavy uterine bleeding, kidney disorders and obesity.

Questions about whether surgeons are being trained adequately in the use of the machine, and whether the higher cost of using it is worthwhile, are growing louder. A recent report by the Office of Medical and Scientific Justice joined the chorus of concern.

Da Vinci is complicated, and the journal Reviews in Urology said it can take 200 cases for some surgeons to become proficient with robotic surgery. Often, patients experience inferior outcomes while their doctors are scaling this learning curve. Some surgeons, the journal reported, simply don’t have patient volume sufficient to master the technique.

At a cost between $1 million and $2 million, the machines are used by hospitals to gain competitive edge, and surgeons may feel pressure to employ Da Vinci before they’re ready. In fact, the Journal of Clinical Oncology suggested that the increased cost of this technology over that of a traditional hysterectomy did not bring a noticeable benefit. The journal also said that women treated for endometrial cancer had about the same complication rates through traditional laparoscopy as they did with Da Vinci surgery, but that Da Vinci cost about $1,300 more.

Lawsuits prompted by the most common problems involve tears and burns to blood vessels, intestines and reproductive organs, complicated by the fact that problems generally aren’t apparent until after surgery, resulting in delayed treatment.

One lawsuit concerns a woman who suffered an artery burn during her hysterectomy. That prompted blood to pump directly into her body cavity, requiring three subsequent emergency surgeries. She died a couple weeks after the initial surgery. The lawsuit claims that Intuitive Surgical failed to adequately research the device or warn patients and the medical community that its use comes with substantial risk of complications and injuries.

Is Da Vinci defective? Is it defective only in less than skilled hands? Is it defective only for some applications?

Maybe lawsuits will answer these questions, maybe not. In the meantime, find out if there is a safer, equivalent means of performing your surgery. If your surgeon is adamant about using the device, ask how many such procedures he or she has performed. Ask how long the hospital has owned the device, and if you can see adverse reports about it. Consult the Manufacturer and User Facility Device Experience (MAUDE), a public database of voluntary reports of adverse events involving medical devices.

Just because your surgeon, your hospital and a manufacturer are excited about technology doesn’t mean it works for everyone.

Most people are aware of the increasing scrutiny of hospital performance in terms of patient safety. Better infection control and attention to readmission rates are among the criteria by which hospitals are measured and, in the case of Medicare, sometimes reimbursed.

But ambulatory facilities don’t fall within traditional hospital oversight, and a recent post on KevinMD by David B. Nash, dean of the Jefferson School of Population Health at Thomas Jefferson University, might raise some helpful consciousness about standards of care at these increasingly popular medical providers.

Ambulatory care facilities provide a range of medical services, including surgery, to outpatients who don’t require overnight care. (See our article, “Same Day Surgery.”)

We reported about one study concerning ambulatory surgery centers, but Nash invokes a report in 2000 by the Agency for Healthcare Research and Quality (AHRQ) noting that very little research actually has been done on medical errors and injuries in ambulatory settings. The AHRQ report made 11 recommendations to stimulate care standards research for ambulatory facilities.

Twelve years later, Nash notes, “almost none” of the recommendations has been implemented. This matters, he says, because a disproportionate and growing number of Americans are receiving care in ambulatory settings. “According to the American Medical Association,” he writes, “300 people are seen in ambulatory settings for every person admitted to a hospital.”

How hospitals care for patients is easier to study than how ambulatory centers do because hospital patients remain hospitalized for a longer period of time. Medical errors such as incorrect medication or the wrong dose of medicine are more difficult to track if the patient isn’t there when the symptoms present or the mistake is realized.

Sharpening the focus on ambulatory quality and safety is challenging because, unlike hospitals, such facilities don’t employ risk managers, compliance officers and chief quality officers to ensure that rules are established and followed. But something must be done, Nash says, because the vulnerability of patients in ambulatory centers was made clear by a recent study of outpatient malpractice claims.

Nash doesn’t say where the study was published, only that in 2009, paid malpractice claims tallied 4,910 for outpatient care and 4,448 for inpatient care. The total amount was higher for inpatient claims, but 2 in 3 of the outpatient claims involved major injury or death.

For the most common outpatient claims:

• 45 in 100 were for diagnostic problems;


• 30 in 100 were for treatment problems; and


• 14 in 100 were for surgical problems.

1. Conduct a large national study on the epidemiology (the incidence, distribution and control of disease in a given population) of ambulatory patient safety using accepted tools to screen for errors and chart reviews to detect harm in large ambulatory care clinics.

2. Identify and pursue an early and easily achievable goal, such as timely follow-up of abnormal test results.

3. Engage patients, their families and community organizations in ambulatory safety improvement efforts.

4. Link the ambulatory safety agenda to high-profile inpatient safety initiatives; for example, in concert with the initiative for reducing hospital readmissions, emphasize and study the role of ambulatory care clinicians in ensuring patient safety before, during and after hospitalizations.

5. Foster the development of a national system of clinics and practices that function as ambulatory safety “laboratories.”

The AHRQ has earmarked $74 million to research ambulatory quality and safety via health information technology, which signals the importance of increased scrutiny. But patients must be proactive as well.

If you intend to seek care from an ambulatory facility, ask to see its infection control procedures. If it doesn’t have one, go elsewhere. Find out if the providers who will treat you are board-certified in their fields. Research the facility’s medical professionals on your state’s medical licensing board’s website to find any complaints that have been lodged (states vary in their ability to track this activity, and in their ability to organize it for public consumption).

If you’re having surgery, find out the status of the surgery center’s license and certification, which enforce standards of care; just because the surgery center looks clean and professional doesn’t mean it meets professional standards. State health agencies keep a list of licenses for same-day surgery centers.

Ask: Who is giving me anesthesia? What are his or her qualifications? Ensure this person is at least a qualified registered nurse anesthetist, even for sedation.

Of course, if your problem is an emergency you might not have time for advance research. But you should always ask questions and persist until you’re satisfied with the answers.

In medicine, a culture shift may be underway in venture capital, which subsidizes the cutting-edge technology that keeps a culture moving forward.

As reported by Kaiser Health News (KHN) in conjunction with NPR and KQED, for venture capitalists, the bloom is fading from expensive medical gee-whizzery. These days, such deep-pocketed supporters are more in favor of improving medical efficiency than in staking a claim to such glitzy endeavors as robotic surgery, whose questionable benefits we recently covered.

Hospitals love boasting about their amazing new machines and surgeons love using them. Insurance companies don’t love paying for them, so their enormous costs are passed along to employers and patients.

As the recession took hold, however, and the Affordable Care Act (ACA) was passed, the financial engine behind high-tech R&D began to reassess where to put its fuel. As one Silicon Valley venture capitalist told KHN, “If you come in with [a device] that’s 10 percent better and twice as expensive, it’s hard to get anyone to care.”

Venture capitalists look for opportunity wherever it occurs, and these days it’s in areas such as helping hospitals figure out how to reduce readmissions. It’s expensive when a recently released hospital patient must be readmitted because of complications, and under the ACA, readmissions carry financial penalties.

Because the ACA will increase the number of people who are covered by high-deductible insurance plans, venture capital is funding a technology company that helps them choose the least expensive care. Another less-than-glamorous funding recipient, but one with an enormous impact, addresses the often torturous process of health-care billing.

“There’s a half a person per hospital bed on average that sits in the hospital doing coding and collections and trying to get paid,” according to one venture capitalist. His solution is to replace the labor-intensive manual coding with software that can understand repetitive charges and devise efficiencies that minimize repetitious functions.

That doesn’t mean new medical developments are all about process instead of product, but the products are simpler. Infections, notoriously borne by the widespread use of catheters, are being controlled better through the venture-capital development of a plastic device that kills microbes. The DualCap catheter costs less than a dollar.

Sometimes, the most thoughtful investment isn’t about the sexiest new surgical tool that helps 10 rich people find a place in medical history; it’s about helping millions of average patients gain access to competent, affordable care for the long run.

Most of the time when a doctor prescribes care for a hospital patient, it involves tests, drugs and other medical interventions. But one physician, self-identified as the Happy Hospitalist, has some decidedly less clinical advice for hospital patients and their loved ones.

Hospitalists are physicians who care only for inpatients; generally, they do not have a private patient practice. We’ve written about this medical specialty before, and although their reviews are mixed, hospitalists are in a unique position to provide perspective about the culture of a hospital.

Courtesy of KevinMd.com, herewith are some of HH’s tips for minimizing the trauma and discomfort of being in the hospital.

• Request a hospitalist. They get you out quicker and less sick (which doesn’t necessarily mean healthy).


• Bring an accurate, current medication list with you. You’re vulnerable to hospital errors if your doctor gave you medication you haven’t taken in months or if you miss medications that haven’t been updated in who knows how long.


• Write down all your questions in advance. Your doctor visits your room only once a day (Medicare pays only for daily visits), so unanswered questions must wait until the following day.


• Be patient. No one knows when tests are scheduled to be performed, not even the doctor doing the procedure.


• You’ll be told things that contradict each other multiple times a day. That’s normal among doctors and nurses with their own perspective and experience. There is no right answer to many of your questions. Choose the answer that makes you feel the best, and believe it.


• When you are admitted, request the highest hospital floor for your room. Most doctors take the elevator to the top and work their way down during rounds. If you don’t want to be last patient seen on rounds, try to be at the top.


• Bring a laptop computer or request one from the hospital. Hospitals all have free wireless these days and some provide a laptop if you ask.


• Bring your own pillow!

Progress is being made in the national effort to let patients know which hospitals do the best job in preventing infections. But patient safety advocates are worried that some of the early reports of hospital-specific data may be overly rosy because of fudging in the way that infections are counted.

Last week we wrote about how infections acquired from intensive care units are more dangerous for children than adults. Most hospitals have made progress in addressing the issue of infection control, and a report issued recently by the Department of Health and Human Services promotes transparency in that effort.

HHS compared hospital ICUs across the country in terms of central line associated bloodstream infections (CLABSIs), which research shows are highly deadly but highly preventable with good care. The information for each hospital is posted on the federal Hospital Compare website, updated quarterly. In the future, infections in addition to CLABSIs will be included.

The Centers for Disease Control and Prevention (CDC) estimated that 18,000 patients developed CLABSIs in the ICU in 2009. As many as 1 in 4 of these patients die. The CDC death toll for all hospital-acquired infections is estimated at 100,000 annually; such infections might cost as much as $45 billion.

Consumer advocates, including the Safe Patient Project of Consumers Union, lobbied for years to enable a hospital infection-tracking system. That organization estimates that 2 million patients a year contract an infection in the hospital.

Since January 2011, hospitals have been required to report ICU-acquired CLABSIs to the CDC in order to receive payment from Medicare. Most states that require infection reports use the same system.

As part of the national campaign, a recent California report was rosy: According to California Watch, rates of infections from catheters are nearly half the national average. But there’s a caveat here that other states embrace as well: Hospitals might be under-reporting the incidence of infections. State authorities are reviewing results of an in-depth infection-reporting audit of four types of infections reported by 100 hospitals. But a lack of funding compromises its ability to fully vet all hospital-generated reports.

As Consumers Union noted, the new reporting requirements apply to hospitals that participate in the Centers for Medicare and Medicaid Services (CMS) “pay-for-reporting” program for all patients, not just those covered by Medicare. Most U.S. hospitals participate because their Medicare payments are higher.

To determine how well your hospital stacks up in the infection-control department using Hospital Compare, Lisa McGiffert of Consumers Union advised comparing its rank with the national benchmark. “If your hospital is no different than the national benchmark, that means too many patients are still suffering and dying from infections that could have been prevented with better care,” she said. “The benchmark for success that hospitals should be striving to reach is zero.”

Reports on surgical site infections will begin in 2013. The CDC estimates that such infections account for 1 in 5 hospital-acquired infections. Catheter-associated urinary tract infections also will be tallied as of 2013.

There’s been a lot of good news lately about what hospitals are doing to protect patients: Many have improved their infection control practices, many are looking at the value of “hospitalists” (doctors who practice exclusively with inpatients) and many have embraced palliative care.

Yet for every two steps forward for patient safety, it appears as though many hospitals are taking at least one step back. As reported last week in The New York Times, a federal report concluded that hospital employees recognize and report only 1 in 7 errors, accidents and other events that harm Medicare patients.

An even more shocking revelation in the report by Department of Health and Human Services investigators is that once hospitals do investigate preventable injuries and infections, they seldom change their practices to thwart them from recurring. This despite the fact, as HHS Inspector General Daniel R. Levinson pointed out, that Medicare reimbursements to hospitals are contingent on them tracking such errors and adverse events, analyzing and addressing them.

“Adverse events” are those that cause significant harm experienced by patients as a result of medical care.

As the Times reported, “Despite the existence of incident reporting systems,” Levinson said, “hospital staff did not report most events that harmed Medicare beneficiaries.” And, he said, some of the most serious problems, including some that caused patients to die, were not reported.

The report found that “hospitals made few changes to policies or practices” even after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not signify any “systemic quality problems.”

Among the problems enumerated were:

• medication errors;


• severe bedsores;


• hospital-acquired infections;


• delirium caused by overuse of painkillers; and


• excessive bleeding linked to improper use of blood thinners.

Whereas once hospital employees were afraid to admit mistakes for fear of reprisal, that doesn’t seem to be the problem here. Rather, Levinson said, it’s that hospital employees don’t recognize “what constitutes patient harm,” nor do they realize that certain events harm patients and should be reported. And sometimes they just assume someone else will report the episode, they believe it to be so common as to be insignificant or they assume it is an isolated event unlikely to be repeated.

For more information about hospital errors, and what you can do about them, see this page on our website.

In response to the confusion described by the HHS report, Medicare officials said they would develop a list of “reportable events” hospital employees could use to eliminate questions about what’s required and what isn’t. In addition, the Medicare agency said, hospitals should give employees “detailed, unambiguous instructions on the types of events that should be reported.”

You mean they haven’t already done so?

Article first published as Two Steps Forward, One Step Back in Hospital Patient Safety on Technorati.

Isn’t it refreshing to read about a medical adventure in which all parties got it right?

“Doing Things Right: Why Three Hospitals didn’t Harm My Wife” is the tale told by Michael L. Millenson on the Kaiser Health News website earlier this month.

“My wife was lying in the back of an ambulance, dazed and bloody, while I sat in the front, distraught and distracted,” he begins. “We had been bicycling in a quiet neighborhood in southern Maine when she hit the handbrakes too hard and catapulted over the handlebars, turning our first day of vacation into a race to the nearest hospital.

"The anxiety when a loved one is injured is compounded when you know just how risky making things better can get. As a long-time advocate for patient safety, my interest in the topic has always been passionate, but never personal. Now, as Susan was being rushed into the emergency room, I wanted to keep it that way. ‘Wife of patient safety expert is victim’ was a headline I deeply hoped to avoid.”

Millenson, a visiting scholar at the Kellogg School of Management, wrote “Demanding Medical Excellence: Doctors and Accountability in the Information Age.” So if this patient-safety expert is happy with the outcome of a medical emergency that could have gone wrong in so many ways, what these providers did should serve as a model for everybody.

Susan, who suffered a fractured vertebra at the base of her neck and broken bones in her elbow and hand, was treated at a 50-bed community hospital, a large teaching hospital and a large community hospital. As Millenson says, “There were plenty of opportunities for bad things to happen—but nothing did. As far as I could tell, we didn't even experience any near misses.”

Millenson notes that preventable errors kill 44,000 to 98,000 people in hospitals every year. His wife wasn’t among them, nor among the tens of thousands more who are needlessly damaged beyond their injuries because of what he calls three variables: consciousness, culture and cash.

1. If a hospital is conscious of its errors and what caused them, it’s less likely to repeat them. When patient advocates (in this case, Millenson) are involved, and ask appropriate questions, mistakes are less likely to occur.

2. Sustained consciousness requires a supportive culture. Hospitals with programs that enumerate efforts to improve outcomes and publicize them are sustaining conscientious efforts on the behalf of patients. Common examples are surgical safety checklists and infection-control procedures.

3. It’s difficult to change an unacceptable culture without money. No surprise that the lowest-rated hospitals often claim the poorest patient populations. Millenson’s wife was lucky to be treated at hospitals in affluent areas.

Not every accident victim has the relative good fortune to experience an emergency in a good place, nor with the perfect patient advocate. But Millenson’s story has helpful take-home messages for anyone who wants to be prepared, just in case.

We’ve written numerous times about hospital readmissions—circumstances that prompt a hospital patient to re-enter the hospital within a short time of his or her release. Often, readmission rates are a clue about the overall quality of care provided by a facility: When patients come back too often and too soon, it can be a sign that they weren't fixed right on the first go-round. And because hospital care is notoriously expensive, readmissions can signal the cost-effectiveness of a health-care provider network.

Sometimes a patient’s problems require returning for in-patient care. But sometimes readmitting someone to a hospital is less a matter of absolute need than lax oversight. As noted in a recent report by NPR, WNYC and Kaiser Health News, unnecessary hospital readmissions are associated with worse treatment and health outcomes as well as higher costs to taxpayers.

As the NPR/WNYC/Kaiser report makes clear, paying for avoidable care is undesirable if you're the government or a private insurance company. But for paid caregivers, repeat customers are a lucrative market. “Dr. Eric Coleman of the University of Colorado says for too long hospitals have benefited from a system that rewards them for excessive care. A hospital might get 15 to 25 percent of its revenue from readmissions.”

Assigning a “good” or “bad” label to a hospital depending on how many readmissions it registers isn’t that simple. One doctor writing in the New England Journal of Medicine argues that readmissions aren't the best indicator of unnecessary care — even though they're an easy target for budget-cutters. Many hospitals with the highest readmission rates, he writes, also serve the poorest areas with the biggest health problems.

"Readmissions are caused by what hospitals do, who the patients are and what's happening in the community," Dr. Ashish Jha said. "You want hospitals to fix the things they can, but you don't want to punish them for taking care of poor people, and you don't want to punish them for being located in a poor area."

Regardless of patients’ reasons for being readmitted or the facility’s motivation for accepting them, one hospital is trying to reduce the incidence. Heart failure readmission rates for Mt. Sinai Hospital in New York are among the worst in the nation, according to the report. Its hospital administrator challenges how federal data on readmissions are gathered, but says that getting readmissions down is a top priority even though they have been lucrative for Mt. Sinai.

The hospital is hoping to reduce its readmission rates through its Preventable Admissions Care Team (PACT). The program includes measures such as patients meeting with a social worker and nurse practitioner, and only occasionally with a doctor. Such “transitional care” is designed to make patients more self-sufficient and less likely to end up in the emergency room.

It seems to be working. In the program's first full year, its 500 patients notched a 40 percent drop in readmissions and a 55 percent drop in emergency room visits. For one heart failure/diabetes patient who had 20 visits to the emergency room and overnight admissions in the 12 months before joining PACT, Mt. Sinai billed Medicare almost $140,000. In the last 12 months, as a participant in PACT, he went to the ER and had an overnight admission seven times, which cost taxpayers a little more than $54,000.

Mt. Sinai is covering his twice-weekly PACT visits. The program will cost the hospital about $1 million this year, and it's not clear how long Mt. Sinai can foot the bill for PACT, especially if it turns out to be less expensive just to pay the penalty.

As we’ve advised, any patient who knows he or she is going into the hospital should conduct due diligence about the facility’s record. But be mindful that readmission rates alone are only part of the quality-of-care picture.

Thanks to the proliferation of crime procedural TV shows, most Americans understand the value of autopsies in identifying a catalog of biological factors that add up to being able to nab the perp. But in hospitals, medical mistakes are being buried without autopsies, and that's a problem for safe, high quality medical care.

A recent report from ProPublica, Frontline and NPR makes clear that the autopsy, a valuable tool in posthumous diagnosis, is increasingly ignored.

In the middle of the last century, according to the report, autopsies were an integral part of American health care. They were performed on approximately half of all patients who died in hospitals to pinpoint the cause of death, to assess how effective were the treatments and to identify diagnostic errors. Today, only about 5 in 100 patients who die in hospitals are autopsied. Hospitals are not required to offer or perform autopsies.

The consequences are significant, writes ProPublica’s Marshall Allen.

"Diagnostic errors – which studies show are common – go undiscovered, allowing physicians to practice on other patients with a false sense of security. Opportunities are lost to learn about the effectiveness of medical treatments and the progression of diseases. Inaccurate information winds up on death certificates, undermining the reliability of crucial health statistics. For families that lose loved ones under mysterious circumstances, an autopsy can provide answers that would otherwise remain out of reach."

Most deaths that occur in hospitals are deemed “natural.” If they are unexplained, unobserved or occur within 24 hours of admission, according to some state laws, they must be reported to local coroners or medical examiners. But those agencies rarely accept hospital cases unless foul play is suspected.

That means if someone dies for unclear reasons, it’s difficult to determine if someone or some procedure was at fault and should be held responsible. In addition to a natural aversion to finger-pointing and possible legal ramifications of accountability, the report says, hospitals are reluctant to conduct autopsies because it’s expensive.

"Hospitals have powerful financial incentives to avoid autopsies. An autopsy costs about $1,275. ... But Medicare and private insurers don’t pay for them directly, typically limiting reimbursement to procedures used to diagnose and treat the living. Medicare bundles payments for autopsies into overall payments to hospitals for quality assurance, increasing the incentive to skip them."

If the next of kin consents, a deceased patient’s doctor may order a clinical autopsy to explore the disease process in the body and determine the cause of death. But even at teaching hospitals, which are typically nonprofit and whose mission is education, autopsies are performed only in about 20 in 100 deaths. The rate at private and community hospitals, which constitute the lion’s share of U.S. facilities, can be close to zero. Some new hospitals are being built without a place to perform autopsies.

It’s not only hospitals that decline to conduct what can provide definitive answers to the questions surrounding death; many doctors, too, are autopsy-averse thanks to their growing reliance on and confidence in sophisticated diagnostic tools for living patients such as CT scans and MRIs.

But studies have demonstrated that doctors using these devices, as useful as they are, can make mistakes. The report refers to a review of academic studies by the federal Agency for Healthcare Research and Quality that found when patients were autopsied, major errors related to the principle diagnosis or underlying cause of death were found in 1 of 4 cases. In 1 of 10 cases, the error appeared severe enough to have led to the patient’s death. Critics of such studies claim that cases undergoing autopsy are typically the most complex, so it’s likelier that a doctor would make a mistake in these circumstances.

ProPublica interviewed pathologists who said they often find diagnostic errors. “We often identify things that the imaging study could not,” said one. Other supporters of the procedure said autopsies can help identify and resolve hospital-acquired infections, and improve the treatment of heart disease.

Advocates of more routine use of hospital autopsies have suggested ways in which they could be integrated into medical care and subsidized. Pay pathologists for doing them, pay bonuses to hospitals that reach certain autopsy rates, and penalize them if they don’t. Medicare should encourage more autopsies and use them as a performance standard. Insurance companies and the government could pay for them. But the former reject that notion, saying that autopsy is not reimbursed because it doesn’t prevent or treat a sickness or injury. And everyone is aware of the budgetary constraints on government.

Never mind that the cost of an autopsy is small relative to what’s spent on drugs, treatment and diagnostic imaging; that routine autopsies and the payoff could save lives and money.

Said one pathologist, “We are letting go of something which we could really use tomorrow to improve the health care of patients.”

Article first published as Autopsy-Averse Hospitals Bury Their Mistakes on Technorati.

Unless the patient needs really intensive, round-the-clock care, most hospital-type care can be done in the patient's home -- where it's safer, more comfortable and less expensive. That lesson is so well accepted that it was written into the federal health care reform law -- to provide financial incentives for outfits called Independence at Home Organizations.

The problem is that the rules for the new home care organizations are supposed to go into effect on January 1, 2012, but Medicare is behind on writing the rules. So there will be delay in getting this started. The current rules discourage moving hospital-style care home because, among other things, Medicare won't pay for home visits.

An internist named Jack Resnick, M.D., writing an op-ed in the New York Times, talks about his own practice on New York City's Roosevelt Island, caring for infirm and elderly patients. He makes a persuasive case for the home care organizations, writing:

Patients who are treated at home by a doctor and nursing staff who know them intimately and can be available 24/7 are happier and healthier. This kind of care decreases the infections, mistakes and delirium, which, especially among the elderly, are the attendants of hospital care. And it is far more efficient.

In the past, evaluating the impact of hospital accreditation was challenging because there was no nationally standardized data. So the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) compared hospitals it accredited with those it didn’t using other evidence-based measures of quality. Those included data that are mandatory to report publicly for common diseases such as heart failure and pneumonia.

From 2004 to 2008, according to a study in the Journal of Hospital Medicine, 8 in 10 accredited U.S. acute care and critical access hospitals outperformed nonaccredited hospitals by these measures.

The study concluded, “Hospitals accredited by The Joint Commission tended to have better baseline performance in 2004 than nonaccredited hospitals. Accredited hospitals had larger gains over time, and were significantly more likely to have high performance in 2008 on 13 out of 16 standardized clinical performance measures and all summary scores.”

The differences, the report says, became significantly more pronounced over five years of observation. But it also says that it’s unclear whether accreditation is solely responsible for improved performance or simply reflects general hospital characteristics associated with performance.

So the study’s authors note that nonaccredited hospitals shouldn’t necessarily be considered substandard because even hospitals lacking accreditation had a “reasonably strong” adherence to quality-of-care standards.

It’s a good idea, however, for hospital patients and prospective patients to find out if their treatment facility is accredited by the commission, simply because such status appears either to promote improved performance, or to indicate that a hospital’s standard procedures are associated with improved performance.

Other things to keep in mind about the Joint Commission’s accredited hospitals:

• They tend to be large, for-profit operations, located in urban areas.


• They are less likely to be government-owned, located in the Midwest or to be defined as critical access.


• The proportion considered high performers – 90% adherence to 13 of the 16 measures – was notably higher in accredited hospitals than those that were never accredited.

Paralleling the growth of the hospice industry, the number of hospital-based palliative care programs has more than doubled since 2000. According to a new survey by the Center to Advance Palliative Care, nearly two-thirds of hospitals surveyed had palliative care teams.

Palliative care focuses on easing the symptoms, stress and pain of serious illness, whether chronic or terminal. In the latter case, it often precedes hospice care, whose goal also is to alleviate suffering, but only for people who are terminally ill.

The report concludes that, thanks to the growing cost of treating an aging population and because it’s simply more humane, palliative care should receive more financial support. The researchers say that previous studies conclusively demonstrated that many seriously ill patients suffer treatable pain and distress, and are financially devastated because of the high costs of medical care. Palliative care, they argue, offers a logical and patient-centered approach to improving medical care by focusing on quality of life and by matching to patient and family needs.

As reported by Kaiser Health News, unlike hospice services, palliative care programs are more common at nonprofit hospitals. That accounts for some stark geographic differences in the survey results – nonprofit hospitals are less common in the South.

As described on WebMD, a Center to Advance Palliative Care poll showed that 9 in 10 people have no idea what palliative care is. But once it's explained to them, 9 in 10 say they would want it for themselves or for their loved ones.

But that requires a prescription – only a doctor, not the patient or relative – can request palliative care. And sometimes you must remind your doctors that you need to be treated as a whole patient, not a body part. If a doctor is focused on treating your tumor, he or she might not ask about your trouble sleeping, your skin rash, how exhausted your spouse is. But that’s exactly the job of a palliative care professional.

Now, for the study’s state-specific report card.

Regions where larger hospitals more were most likely to have palliative care teams:

• District of Columbia -100%


• Vermont - 100%


• Maryland - 90%


• Nebraska - 93%


• Minnesota - 89%


• Oregon - 88%


• Rhode Island - 88%


• Washington - 83%

The District, which only has big hospitals, is the only jurisdiction where every hospital patient has access to palliative care.

States where hospitals were least likely to have palliative care teams:

• Kansas - 47%


• New Mexico - 44%


• Georgia - 43%


• Louisiana - 43%


• Texas - 42%


• Arkansas - 38%


• Oklahoma - 30%


• Alaska - 29%


• Alabama - 28%


• Delaware - 20%


• Mississippi - 20%

If you or someone you love is planning a hospital visit with the potential for ongoing treatment, find out if the facility where you will be treated has a palliative care program. If not, consider the options within your health plan network, and if none offers a palliative care program, ask your insurance company why not.

And make sure your primary care doctor and your surgeon understand your interest in receiving such care.

Fact: About 1 in 20 patients contracts an infection related to his or her hospital care.

Fact: An average of 1 in 7 Medicare beneficiaries is harmed in the course of his or her care, costing the government an estimated $4.4 billion every year.

Fact: Nearly 1 in 5 Medicare patients discharged from the hospital is readmitted within 30 days. That’s approximately 2.6 million seniors at a cost of over $26 billion annually.

In April, Health and Human Services Secretary Kathleen Sebelius introduced a new program in which a coalition of health-care interests – hospitals, professional medical provider organizations, patient advocates, insurers, pharmaceutical companies – define and establish standards to turns these facts into old news.

Called the national Partnership for Patients (NPP), the program aims to address problems such as medication errors and lack of infection control that, Sebelius said, can happen “when hospitals do one thing, health plans do another and Medicare goes in a third direction.”

To see the generic pledge NPP members make, link here.

Sebelius said the administration’s Affordable Care Act would earmark as much as $1 billion in funding and considerable human resources to reach two primary goals for the next three years:

• Keep patients from getting injured or sicker. Reduce preventable hospital injuries by 40 percent, which will prevent 1.8 million injuries and save 60,000 lives; and


• Help patients heal without complication. Cut preventable hospital readmissions by 20 percent, which will save more than 1.6 million patients from complications prompting a return to the hospital.

The effort is doomed to fail if it’s not embraced industry-wide with something more than lip service. It’s easy for a single establishment or organization to express support, and considerably more difficult for it to enumerate exactly how it intends to effect positive change.

Clearly, with so much energy and funding being directed to the NPP, the government must demand accountability. Sebelius’ promise that hospital Medicare and Medicaid payments would reward those delivering the best care nods toward that obligation, but patients and anybody who cares about hospital safety have a right to expect to be told the whole story as it unfolds. What have members promised to do? How is their progress being tracked and measured? What are the consequences of failure?

Western medicine is often perceived as conservative and traditional, and unwilling to consider alternate therapies. But a new study by the American Hospital Association (AHA) and nonprofit Samueli Institute says that hospitals are broadening their treatment horizons.

More than 4 in 10 of the hospitals surveyed indicated that they offer one or more complementary and alternative medicine (CAM) therapies.

CAM includes acupuncture, chiropractic, homeopathy, diet and lifestyle changes, herbal medicine and massage therapy. It’s the whole-person approach to wellness — body, mind and spirit.

“Hospitals have long known that what they do to treat and heal involves more than just medications and procedures,” said Nancy Foster, vice president for quality and patient safety at the AHA. “It is about using all of the art and science of medicine to restore the patient as fully as possible.”

According to the survey, patient demand and clinical effectiveness were the top reasons for offering CAM services.

Other survey results:

• most respondents offer wellness services for patients and staff, including nutritional counseling, smoking cessation, fitness training and pastoral care;


• massage therapy is in the top two services provided in both outpatient and inpatient settings;


• more than 7 in 10 hospitals that offered CAM were in urban settings;


• 3 in 4 cited budgetary constraints as the biggest obstacle for implementation of CAM programs.

It’s enough to make you want to shrink-wrap yourself in your hospital bed.

A report published in the American Journal of Infection Control concluded that as many as 6 in 10 uniforms worn by hospital caregivers tested positive for potentially dangerous bacteria.

Swabs of the uniforms of 75 RNs and 60 M.D.s at a 550-bed university-affliliated hospital yielded cultures containing multidrug-resistant germs including methicillin-resistant Staphylococcus aureaus, or MRSA – also known as the “super bug.”

That’s not a compliment.

According to AboutLawsuits.com, MRSA infections represent more than 60% of hospital staph infections, and the Centers for Disease Control and Prevention tally some 126,000 hospital MRSA infections every year, resulting in about 5,000 deaths. Some researchers believe that the number of deaths every year from MRSA in the U.S. is about 20,000 if community-acquired infections are included.

As you might imagine, the number of infection-related lawsuits filed against hospitals also has increased in recent years.

Even if the clothing itself does not present an immediate risk of disease transmission, the results are disturbing for what they reflect about antibiotic-resistant strains in close proximity to hospital patients — the people most vulnerable to contracting disease.

The key message here for hospital staff isn’t necessarily to wash your uniform; it’s to practice what every thinking health caregiver has been preaching for years: Wash your hands.

“Any clothing that is worn by humans will become will become contaminated with microoganisms,” said Russell Olmsted, president of the Association for Professionals in Infection Control and Epidemiology. “The cornerstone of infection prevention remains the use of hand hygiene to prevent to movement of microbes from these surfaces to patients.”

The World Health Organization pegs the risk of health care-associated infection in some developing countries at as much as 20 times higher than in developed countries like the U.S. But they’re still relatively common here, they can be deadly and they are expensive to treat. Prevention is the only way to guarantee patient safety.

As we’ve reported before, if you or a loved one is scheduled for a hospital stay, ask in advance for a copy of the facility’s infection prevention and control program. And if a hospital or clinical caregiver forgets, don’t be too timid to ask that person to wash his or her hands before attending to you.

Check out this graphic display of some of the statistics of hospital hazards. Infections, malpractice, errors due to poor record keeping, medication errors, mistakes due to sleep deprivation of trainee doctors: It's all displayed here, courtesy of a group called Medical Billing and Coding Certification.

It’s an unfunny truism that if you want to avoid getting sick, stay out of the hospital. But that may be starting to change for the better.

The unacceptably high number of hospital patients who contract an infection after admission has long been in the news. We have covered the topic frequently.

According to federal estimates, 1 in 20 people admitted to a U.S. hospital develops an infection – or about 1.7 million people every year. Such infections represent a top 10 cause of death in this country; approximately 99,000 people die annually from hospital infections, at a health-care cost of $33 billion.

Scrutiny of this problem has generated policy changes – Medicare, for example, no longer foots the bill when inpatients are infected by microbes from catheters and intravenous lines. And, per the new federal health-care legislation (the Affordable Care Act), soon subsidies will be withheld to hospitals that fail to reduce their infection rates.

In a bit of good news from this patient safety front, many hospitals have committed to solving the problem and boast demonstrable results. As reported in the Los Angeles Times, a three-year campaign to reduce the incidence of hospital infections in California has saved lives, cut costs and institutionalized best practices to ensure continued vigilance and good results.

At the midway point of the campaign, the program has seen reductions of:

• ventilator-associated pneumonia by 41%;


• catheter-related urinary tract infections by 24%;


• blood poisoning by 11%.

About $11 million has been saved, and about 800 lives.

The health threat is particularly acute these days, thanks to the increasing use of outpatient clinics. That means hospitals are reserved for the sickest patients, and the sicker the patient, the more vulnerable he or she is to infection.

In California, Anthem Blue Cross is often the target of consumer and health advocates who have challenged its substantial health-care premium increases and its history of questionable recissions (dropping policyholders from coverage after the discovery of an expensive medical condition). But even this often soulless corporate entity acknowledges the unacceptable cost of hospital infections, and has funded the statewide Patient Safety First program with $6 million.

The company says it has recouped nearly double its investment in the program through reduced health-care spending. And its corporate parent, WellPoint, Inc., says it won’t increase payments to hospitals in 14 states that don’t meet its standards of infection control, readmission rates and other practices.

Some of the program elements employed by hospitals are:

• establishing and following safety checklists and documenting every step;


• frequent hand-washing by staff;


• more frequent brushing of patients’ teeth;


• enlisting respiratory therapists to swab the mouths of patients on ventilators several times a day;


• eliminating unnecessary procedures.

If you or a loved one is to be admitted to a hospital, ask if it has an infection-control checklist, and if so, ask to see it. After admission, make sure staff members wash their hands before they tend to you or your loved one. Ask when catheters and ventilators were last sanitized. Hospitals that care about your safety should not object to such scrutiny

As Dr. James Cleeman, an expert on health-care quality, told the L.A. Times, “Nobody should go into a hospital and wind up sicker than when they went in.”

Who runs a hospital better, a physician or a businessperson? And which is better for patient safety and healthy outcomes?

As reported in the New York Times, the conventional wisdom that doctors should focus on patient care and managers should run the infrastructure was challenged by a study in the journal Social Science & Medicine.

Of the nearly 6,500 hospitals in the U.S., only 235 are run by physician administrators.

In a review of 300 top-ranked U.S. hospitals specializing in a variety of disorders, "overall hospital quality scores were about 25% higher when doctors ran the hospital, compared with other hospitals," The Times said. "For cancer care, doctor-run hospitals posted scores 33% higher.

Study author Dr. Amanda Goodall said the finding was consistent with corollary research showing that research universities perform better when led by outstanding scholars and that basketball teams perform better when led by former top players.

Goodall said the results may reflect the fact that doctors truly understand “the core business of health. ... M.D. CEOs are more likely to prioritize patients because patient care is at the heart of their education and working life as a physician. When it comes to making hard budgetary decisions or rationing choices, M.D. CEOs may be able to make more informed decisions.”

The study results, Goodall pointed out, show only an association between high hospital scores and doctor CEOs; they do not prove that doctors make better leaders. Maybe top hospitals are more likely to seek out doctor leaders; maybe top doctor managers seek out the best hospitals.

Bottom line: The best hospitals seem to choose physician executives, and lower-ranked hospitals usually have managers with a business or administrative background.

That's something for patients to consider if they have a choice of hospital facilities.

No one wants to be treated in a hospital by a doctor at the tail end of a 36-hour shift who is falling asleep on his or her feet. So the organization that supervises training programs for resident doctors mandated an 80-hour work week limit.

A provocative piece in the New York Times Magazine makes the case that shorter hours for residents hasn't made hospitals any safer. Why?

• Handoff errors -- poor communications about patients between the doctor leaving a shift and the new doctor arriving -- are still rampant in hospitals, because of lack of systematic training in how to do a proper handoff.
• Lack of supervision, leaving residents to make decisions with little experience and no guidance.
• Many hospitals flout the new rules, and residents work longer than they should.

It's an issue that resists easy answers, as shown by the many comments to the article, which you can click here to read.

We have a good discussion of how handoff errors can lead to malpractice and preventable harm to patients on our firm's website.

In the 1990s, a new medical specialty emerged whose purpose was to help control the cost of hospital care and improve the outcome for hospital patients. “Hospitalists” are physicians who care only for inpatients; generally, they do not have a private patient practice. As noted in a recent report on NPR, the growing popularity of hospitalists does not appear to be reaping either the hoped for financial or health benefits.

The notion that hospitalist care is superior to that of a personal physician derives from the expertise a hospitalist develops because he or she practices solely within that setting. Dr. James Goodwin of the University of Texas, who studied the impact of hospitalist care among a large cohort of Medicare recipients, said these patients tended to be released sooner than those under the care of their personal physicians. He pegged the population of inpatients under hospitalist care at 30%-40%.

The sooner you leave the hospital, of course, the lower the cost of care. But the complication arises after release. The objective of Goodwin’s study, published in the Annals of Internal Medicine, was “to assess the relationship of hospitalist care with hospital length of stay, hospital charges, and medical utilization and Medicare costs after discharge.” It concluded that patients under hospitalist care were more likely either to be readmitted within 30 days, or to visit an emergency room than patients cared for by their regular doctor.

That represents, Goodwin concluded, additional costs for Medicare of more than $1 billion every year.

Hospitalists, it seems, are more likely to discharge their patients to a convalescent or rehabilitation facility than they are to their homes. And that’s expensive.

Dr. Joseph Li of the Society of Hospital Medicine, an organization that represents hospitalists, raised the possibility that patients who go home directly from the hospital might not be receiving adequate follow-up care, an issue we addressed last week in our discussion of care transition from hospital to home. Li also suggested that hospital patients who transition into a secondary care facility might be receiving the more appropriate treatment than if they had been discharged to their homes.

“These patients are being monitored 24/seven by health-care providers,” he told NPR. “Many of these patients being sent back are being appropriately sent back to the hospital for evaluation.”

Of course, it’s in his organization’s interest to draw that conclusion. That doesn’t mean it’s wrong, but clearly, the study indicates a need for hospitalists and the doctors of individual patients to coordinate care better to meet the needs of both budgets and health.

We've said it before, and we'll say it again -- being released is only the halfway point of a successful hospital experience. The shift from in- to out-patient status is known as "care transition," and it must be managed carefully to ensure the patient recovers fully.

Two new studies in the Archives of Internal Medicine reinforce the notion that one's chances of being readmitted to the hospital are significantly improved when health-care providers and patients follow a program of care transition.

That term, according to the the Care Transitions Program at the University of Colorado's School of Medicine, "refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness."

Although the new studies were small -- it proved difficult to recruit sufficient numbers of people -- real-world applications of what were previously controlled trials showed reduced rates of admission when the hospital discharge process included complete communication.

One program to reinforce post-discharge self-care instructions and the need for a follow-up physician visit reduced 30-day readmissions by 39% among participating Medicare patients in Rhode Island. Another program with different interventions but the same goal for heart failure patients in Dallas showed a 48% reduction in 30-day readmission rates.

A lower incidence of hospital readmission is important not only as a measure of improved care, but reduced cost. Sort of -- reduced for whom? Certainly the patient, but not necessarily the hospital.

In one of the studies, as described in MedPage Today, the advanced practice nurse-led program cost $1,1110 per patient but reduced in-hospital health-care costs by $524 from admission to 30 days afterward. And the hospital lost an average $751 in revenue by preventing readmissions.

No one is suggesting that being in the hospital longer than you need is a good idea, but the numbers do suggest a need for change in how hospitals are reimbursed for care administered but not for preventing adverse outcomes, according to Mitchell H. Katz, M.D., of the Los Angeles County Department of Health Services. He wrote an editorial about the studies.

Another fly in the reduced readmission ointment is patients themselves, who must be willing to participate in a prescribed transition program. That's proving elusive perhaps because people just want to be left alone to recuperate after their hospital experience, and the program can seem intrusive, with home visits and/or phone calls for the purposes of patient and family education and to monitor the patient's condition.

In a nutshell, care transition is about communication. It's an organized way, as CU's Care Transition Program says, to make the "handover from hospital to home go smoothly and to help you stay out of the hospital." Visit its transitions skills page for information about:

• The Personal Health Record;


• The Discharge Preparation Checklist;


• Medications;


• Follow-up Visit with your Primary Care Doctor or Specialist;


• Understanding your Health Conditions;


• Reaching Your Health Goals.

Kimberly White had a hysterectomy with a variety of attendant issues she thought were private matters between her and her health-care providers.

She says Tufts Medical Center is responsible for proving her wrong.

As reported in The Boston Globe, she sued the hospital and a primary care doctor for allegedly faxing sensitive medical history documents to a machine used by several of her co-workers.

Two of them, she said, read the records, causing her embarrassment sufficient enough to affect her daily life and her livelihood. As The Globe reported, "White said it exacerbated other medical issues and stalled her career. She has been out on disability for nearly all of the time since, she said."

White said she had asked her doctor to fax a required form for her work disability claim to her employer. Instead, she said, four pages of her medical records were sent. “I feel like I might have walked in (the office) naked,” White said.

White's personal records, she emphasizes, were delivered to people who know her. “I can’t go back there,” she told The Globe. “I am so embarrassed. ... I couldn’t live with knowing what these people knew about me.”

The hospital has denied wrongdoing, and a spokeswoman said it takes patient privacy very seriously.

U.S. News & World Report recently issued its ranking of Best Hospitals in the United States as well as a host of interpretive articles to help people refine their understanding of what constitutes "best" and how to locate the "best" hospital in your area.

The article "When a Hospital is Bad for You" explains that a facility offering excellent treatment for someone seeking treatment for, say, a broken leg can be less than the best place for someone who needs her aortic valve replaced.

Because the U.S. is a developed nation with regulatory oversight, few hospitals offer truly abysmal care. Such incompetence is rewarded with the withdrawal of credentials and a shuttered physical plant.

But there are important differences, and when it comes to your health, you can't be too careful about separating the merely good from the superior. As the magazine says, "Rates of postsurgical complications such as bleeding, infection, and sudden kidney failure vary surprisingly little, according to a recent study of nearly 200 hospitals across the country. What does differ are deaths from such complications," said John Birkmeyer, M.D., and the study's co-author.

Here, according U.S. News, are five signs that should prompt you to continue shopping for a hospital that meets your medical needs:

• 1. Low volume. This falls under the "practice makes perfect" category. A hospital should be able to provide figures for the most recent year, along with death and complication rates, and you should ask for them. If it doesn't have much experience with the procedure you need, go elsewhere. According to the Leapfrog Group, a business-sponsored organization that evaluates hospital performance, these are acceptable numbers, per year, for some common procedures:
  bypass surgery-- 450;
  coronary angioplasty and stenting--400;
  weight-loss surgery--125;
  aortic valve replacement--120;
  repair of abdominal aortic aneurism--50;
  removal of cancerous portions of esophagus and pancreas, respectively--13 and 11.

  If these numbers are low, ask your doctor about options.



• 2. Low surgeon volume. A hospital can register high-volume numbers for procedures, but individual surgeons might be low-volume practitioners. Some operations, such as aortic valve replacement, require lots of practice to maintain sharp skills. Your surgeon should be willing to supply the latest yearly total as well as rates of death and complications for your procedure. If not, or if he or she seems indignant at the request, seek alternatives.


• 3. No intensivist. Hospitals that employ specialists to care for patients in intensive care, versus the traditional practice of surgeons or other physicians taking charge of their intensive care patients show a decrease of deaths of 25% or more. Specializing in critical care, intensivists work primarily inside the ICU; surgeons, in contrast, spend most of their time in the OR. Hospitals with more than 250 beds should be able to summon an intensivist to the ICU within five minutes of being paged.


• 4. Not enough nurses. A study in the Journal of the American Medical Association found that a patient's risk of dying was much higher where nurses on surgery floors had more than seven patients during an average shift; the ideal number is four or fewer. Also, a nursing corps that holds four-year RN degrees versus two-year RN degrees notched a lower rate of surgery-related deaths. Patients should contact a hospital's director of nursing to find out its nurse-to-patient ratio.


• 5. Too many readmissions. This is a relative figure, so you must compare several hospitals to determine which has the lowest rate. The higher the rate of readmission, the greater the likelihood that a hospital struggles to coordinate care after discharge.

For more tips and practical websites for research, check out our firm's patient safety newsletter, which devoted an issue to finding the right hospital.

If you believe the stereotype, surgery isn't a warm and fuzzy medical specialty (that would be family doctors), it's a cold, clinical engineering-like pursuit. And a surgeon is more likely to be known as "the knife" than "the smile."

The head of one major transplant center, however, would like to rearrange the stereotypical furniture. Says Andrew Klein, M.D., "Operating rooms are social environments where everyone must work together for the patient's benefit. When a surgeon, who is in the position of power, is rude and belittles the rest of the staff, it affects everything."

Klein and Pier Forni, Ph.D., authors of an article about civility and medicine in the Archives of Surgery, said an operating room is a crucible of stress that can manifest in bad personal behavior that isn't good for anybody. They acknowledge that scientific studies are reinforcing perceptions that outcomes improve when the surgical team cooperates.

As reported in MedPage Today, Klein and Forni found that rancor and the rudeness it engenders may be tied to heart disease and depression. They point to one study that deemed that "high-risk" uncivil behavior in the surgical suite increased the risk of postoperative death and complications.

The incivility extends beyond the OR and so do its side effects. In one study, 96% of nurses for the Department of Veterans Affairs' reported witnessing disruptive physician behavior. A survey by the Institute for Safe Medication Practices showed that 75% of nurses sought a co-worker's help to understand a confusing physician's order because they didn't want to interact with the doctor themselves. Seven percent of the nurses blamed doctor intimidation for medication errors.

In their article, Klein and Forni lobby for surgeons and OR teams "to lead a civility initiative in healthcare." That includes reviewing hiring criteria for surgical employees to look beyond the traditional standards of "accomplishments, knowledge, training, and productivity" in the hope of identifying ways in which prospective candidates can be assessed for how they function in a social environment.

We're thankful that there appears to be a growing awareness of the value of the "what you learned in kindergarten" approach to a collegial work environment. See: Testing for Life-Saving Communications Skills in Young Doctors

"The temptation to ignore warning signs that a surgeon will not play well in the sandbox with peers and co-workers is seductive when large clinical practices and (National Institutes of Health) funding are at stake," Klein said.

Like other workplaces, the writers suggest, hospitals should develop a code of conduct for medical and administrative staff. They also champion the idea of cultivating relationships at work, because a culture of caring fosters loyalty.

If your doctor, your nurses, your patient advocate cooperate and have empathy for each other's professional roles and responsibitlities, your care will improve. Ask if the hospital where you are scheduled to be treated has a code of conduct. As a patient, you should not tolerate rude behavior among the people caring for you. If you don't think someone on your care team is being treated properly, speak up. It's the right thing to do for her, and the best thing for you.

Article first published as Does Being Polite Save Lives in the OR? One Surgeon Says Yes on Technorati.

MarylandReporter.com reports that the state will request an exemption from a new requirement by Medicare that hospitals demonstrate their quality of care. Taking effect Oct. 1, the requirement financially rewards hospitals that meet the new standard and penalizes those that don’t.

Robert Murray, executive director of the Health Services Cost Review Commission, said the state will document for the feds that “Maryland already has those programs in our system.” The commission has tracked the quality of hospital care for three years.

“The health reform act says you can be exempt from this regulation if you show you already meet or exceed [the national requirement]," Murray said.

Maryland is the only state in the country with a waiver from the Medicare payment methodology, which was negotiated in 1977 when Medicare agreed to pay hospitals in Maryland on the basis of commission-set rates. Other states since have been granted waivers but only Maryland has maintained its waiver.

It’s the morning of your surgery, and you have been a paragon of preparation. Your advance lab work is complete, you’ve fasted for 12 hours, you arrived 10 minutes ahead of schedule and are poised to sign the final paperwork before being directed to pre-op. You present the advance health-care directive you prepared months ago to the intake clerk, and begin to fill in the consent form.

But wait. One provision says that the hospital has opted “not to honor” advance directives. Can it do that? If so, what’s the point of being such a responsible person in the first place?

Yes it can, and many medical institutions do under the laws of “conscientious objection.” But there are good reasons for filling out such a directive, and for medical facilities to have the flexibility to override them.

According to the Centers for Disease Control and Prevention, the most common types of advance directives are living wills and do-not-resuscitate orders. Overall, 28% of home health-care patients, 65% of nursing home residents and 88% of discharged hospice care patients had at least one advance directive on record.

Advance directives protect the wishes of patients unable to speak for themselves. Outside of the surgical theater, directives generally address conditions associated with the elderly and others such as persistent vegetative states that are not acute, but ongoing. During surgery, if something goes wrong, such as an adverse reaction to anesthesia or an unexpected organ failure, doctors need to respond quickly; their goal is to ensure the success of the surgery, and a completely binding advance directive can hamstring a reasonable effort to address a sudden problem. You don’t want someone able to correct a situation quickly and successfully to be prohibited from doing so by a document intended to address a more long-term issue.

But the time limits suspending a directive should be clear; medical providers, even if they aren’t bound by its terms during surgery, must be aware of them afterward. And if the surgeon or hospital refuses to honor your documented wishes during recovery, most states require them to make a reasonable effort to transfer you to providers who will.

Patients can protect their rights and enhance their surgical outcome by:

asking before surgery about the hospital’s policy on advance directives. If you don’t like it, look elsewhere for your procedure, but understand that most hospitals won’t comply with a directive during surgery;

understanding the time limits of the suspension—it should cease once you’re in recovery;

ensuring that you have an advocate with you who understands your wishes—a relative or friend who acts as your agent to make health-care decisions if you’re unable.

A study examining outcomes of heart and lung transplant surgery has concluded that patients fare essentially the same whether the transplants are performed during the day or at night. Two smaller previous studies – one on kidney transplants and the other on liver transplants – had indicated that patients tended to fare worse if the operations took place in the middle of the night.

The new study, published in the Journal of the American Medical Association, took into account all of the nearly 30,000 heart and lung transplants performed in the United States over 10 years. Researchers were surprised by the results, which indicated that, contrary to conventional wisdom, patient outcomes had little to do with the time of the operation or the fatigue of the surgeon. Rather, they seemed to hinge on the reliability of the surgical team.

Unlike surgeons in other specialties, cardiothoracic surgeons almost always work in the operating room with the same team of highly specialized anesthesiologists, nurses, physician assistants and technicians. The team’s familiarity with and constant repetition of the same complex steps — placing patients on bypass machines, performing certain intraoperative studies, even executing specific suture sequences — may be the key to ensuring consistent performance, whatever the time of day.

When performing a transplant, “the surgeon isn’t doing a complicated operation in the middle of the night with an anesthesiologist who usually staffs gynecology procedures and a nurse who works in the orthopedic operating rooms during the day,” says Dr. Ashish Shah, a co-author of the study and assistant professor of surgery at the Johns Hopkins University School of Medicine. “We need to think about doctors less like airline pilots and more like a part of a special forces military team. Those teams carry out complex tasks at a very high level and under less than ideal physiologic or environmental conditions.”

Source: The New York Times

You can read an abstract of the study here.

Maryland hospitals reported significantly more serious patient care problems, including malpractice and preventable injuries, in 2010 than in the previous year. According to the state’s annual report on patient care and safety, there were 265 adverse events causing death or serious injury to patients reported in 2010, compared with 190 the year before.

However, health officials attributed the increase to better identification and reporting - particularly when it came to pressure ulcers (bedsores) - not to a real increase in problems.

Falls continue to be the No. 1 adverse event at hospitals, followed by pressure ulcers and delays in treatment. No hospitals were named in the report, but larger ones with more complex cases reported more problems, according to the Maryland’s Office of Health Care Quality, which has been collecting the information from hospitals for 6 years.

The director of the office, Nancy Grimm, praised Maryland hospitals’ continued efforts to improve patient safety. "Increased reporting by hospitals is an indication of engaged and proactive patient safety programs, which ultimately promotes positive patient safety outcomes,” she said. “The greater the reporting, the better results for patients."

Source: The Baltimore Sun

Doctors who aren't directly involved in patient safety issues often sail through their careers without much awareness of how commonly errors and malpractice infect hospitals, clinics and medical offices. Then they become patients, and suddenly their world is turned upside down.

Itzhak Brook, M.D., has been a doctor for more than 40 years. He is an infectious disease pediatrician at Georgetown University Hospital in Washington, D.C. Then he got throat cancer a few years ago.

His cancer was successfully removed, but then it came back. He had to have his voice box -- the larynx -- removed, and the throat was reconstructed.

It was then that the errors began to pile up, or, as he puts it, “mistakes occurred at all levels of my care.”

Dr. Brook recorded these incidents before, during and after his surgery:

* Surgeons had failed to timely diagnose the recurrence of his cancer. It was finally observed by an astute resident via a basic procedure that allowed visualization of the pyriform sinus, which was where his tumor was located. Had his experienced surgeons done the same basic procedure, his tumor most likely would have been observed and removed much earlier.

* Surgeons mistakenly removed scar tissue instead of the cancerous lesion. A week after the surgery, pathological studies revealed that the tumor was actually farther down in the pyriform sinus. This error could have been avoided if frozen sections of the lesion itself, not just its margins, had been analyzed in the operating room. As a result, he had to undergo additional surgery to remove the tumor, which was more difficult because of swelling and changes to the surgical site due to the original operation.

* While still in the ICU one day after surgery, he experienced an airway obstruction and couldn’t find his call button, which had fallen on the floor. Though he was only a few feet away from the nurses station, he was unable to get the attention of staff but was ignored. (He couldn’t call out because he no longer had a larynx).

* In what was probably the most serious error, he was fed soft food by mouth far too early, which, following laryngectomy with flap reconstruction, can lead to failure of integration by the flap. It took 16 hours before the feeding was stopped, and only after Dr. Brook brought this to the attention of a senior surgeon. The error occurred because the order to start feeding was in fact intended for another patient.

In addition, nurses and other staff:

Did not clean or wash their hands.

Did not use gloves.

Took oral temperature without placing the thermometer in a plastic sheath.

Used an inappropriately sized blood pressure cuff (which produced alarming readings).

Attempted to administer medications by mouth intended to be given by nasogastric tube.

Dissolved pills in hot water and fed them through the feeding tube (thus irritating the esophagus).

Delivered an incorrect dose of a medication.

Connected a suction machine directly to the port in the wall without a bottle of water.

Forgot to rinse the hydrogen peroxide used for cleaning the tracheal breathing tube (causing
severe irritation).

Did not write down verbal orders.

Fortunately, despite all these errors, Dr. Brook did not suffer any long-term consequences. Still, his experience made him realize that a hospital is the least safe place for patients, and that all hospitalized patients should have a dedicated patient advocate such as a family member or a friend at their bedside.

Dr. Brook writes extensively about his experiences as a throat cancer patient on his blog. He also lectures to medical groups to try to get doctors and nurses to understand the human costs of the epidemic of medical error.

You can also read Dr. Brook’s account of his hospital experiences in the Journal of Participatory Medicine.

You see them walking around hospitals, and sometimes even on the street: health care workers wearing surgical "scrubs." It's something of a fashion statement, but also a potential carrier of infections, yet no one has really carefully studied the problem to know for sure.

The old adage among patient safety advocates that “you can’t improve what you don’t measure" describes what we know about infection rates in hospitals. As long as little or no data on infection rates are collected, the problem tends to be sidelined.

There is no data about a possible link between hospital scrubs worn outside the operating room and infection rates. Scrubs can carry harmful pathogens, and because the transmission modes of drug-resistant pathogens are more prevalent than previously thought and are no longer confined to hospitals, some patient safety advocates say it’s time hospitals addressed the issue.

One such group, the Empowered Patient Coalition, which works on patient education and empowerment issues, wants hospitals and other health care organizations to start by gathering data on scrubs in their facilities and by looking at the data about the types of pathogens that are found, and then developing policies to keep both their workers and the public safe.

But, the group says, for such a policy to be effective, a hospital would have to:

1-Promote a culture where the policy is the norm, not an additional burden.

2-Communicate the policy efficiently to staff using supervisors who believe in the action.

3-Ensure that ignoring the policy will have consequences and would be considered an employment standards issue.

Source: University of Southern California Reporting on Health

Washington state lawmakers have proposed a bill that would give more rights to people who file licensing complaints alleging medical mistakes. Up to now, when something terrible happens to a patient in a hospital or under a doctor's care, families often file complaints with the Medical Quality Assurance Commission (MQAC) - the state's medical disciplinary board - but hear nothing for months or even years, only to finally be told that the official finding is "insufficient evidence" or "no cause for action." Not surprisingly, this leaves many families wondering if the physician and/or hospital have covered up what really happened to the patient.

Last year, nearly 1,400 Washington families filed complaints with the MQAC. Like most state medical boards, the MQAC typically closes most without action - of the 1,400 complaints, 950 were investigated and disciplinary action taken in only 94 cases, says its legal manager, Michael Farrell. Current Washington state law doesn’t require MQAC to divulge evidence during investigations or to detail its reasoning, Farrell says, and for the most part, it doesn’t.

But Lisa McGiffert, director of Consumers Union's Safe Patient Project, a national patient-safety effort, says that “many patients who file complaints end up getting frustrated because they feel like their report disappears into a bureaucratic black hole." Under the proposed law, which has already been passed by the House and is currently before a Senate committee, patients would have a "better opportunity to be heard."

The proposed law, which is being touted as model legislation for other states, would require a health profession's disciplinary board to promptly respond to complainants' queries about the status of an investigation, provide copies of files on request once a case is closed and, when deciding whether to reconsider its original finding because of new evidence, provide an explanation of its reasoning. For the first time, families would be given the right to tell board members how they've been affected - in writing or in person and before a case is closed - and recommend sanctions.

Source: The Seattle Times

Hospitalized patients are right to be terrified of getting a serious infection from the hands of their doctors or nurses. But is there any option to barking at everyone who comes in your room: "Did you wash your hands?"?

Yes, says gastroenterologist Steven Kussin, author of the forthcoming book “Doctor, Your Patient Will See You Now.”

Here's the problem Dr. Kussin identifies if you ask the "did you wash your hands" question:

Doctors or staff members who respond “no” are guilty of a grave medical lapse. If they didn’t wash and then lie to you, they’re also guilty of a grave ethical lapse. Either way, the question raises their defenses and their hackles. Instead, if you didn’t witness a hand-washing ritual, then assume it didn’t happen. You’ll probably be right. Physician hand-washing compliance runs about 33 percent.

And his answer, in a letter to the editor in the New York Times:

If you show them, they will wash. When they, or anyone, approach your bedside, give them notice of your intent. Hold out a bottle of sanitizer with a big smile. As you squirt them say: “I know how busy you are, and I am sure you’ve already done this a million times a day. But I’m terrified of those infections I’ve been reading about. I hope you’re O.K. with this.”

That’s it. Easy, pleasant and effective.

Good advice. I have more about avoiding infections in the hospital, and other avoidable medical harms, in my patient safety newsletter, which you can read here.

The new federal "Partnership for Patients" safety initiative has drawn enthusiastic early endorsement from safety mavens like Dr. Bob Wachter of UCSF. It should: By his own insider's account, Wachter helped inspire HHS leaders to finally take seriously the national scandal of preventable harm in hospitals and clinics. Here's his story.

The official government announcement with details is here.

Medical mistakes account for between 18 and 45 cents of every health care dollar spent in the U.S., and a medical error or adverse effect occurs in one out of every three hospital admissions, researchers say.

According to studies published in the journal Health Affairs, the single most expensive cause of harm is infection after surgery, with more than 252,000 infections costing $3.36 billion reported in 2008, while pressure ulcers (bedsores) are the most common preventable event, with with nearly 375,000 cases in 2008 costing $3.27 billion.

Following a shocking 1999 report that showed that as many as 98,000 people die annually due to medical mistakes, hospitals have tried to reduce such adverse effects, but serious mistakes persist. In 2006, for instance, medical mistakes contributed to as many as 187,135 deaths and 6.1 million injuries that cost between $393 billion and $958 billion.

“There are some examples of excellence; we have many [intensive-care units] that have eradicated central line infections. But surrounding those examples of excellence we have serious adverse events going on,” said Dr. Mark Chassin, president of the Joint Commission, a nonprofit organization that accredits health care programs. “Every week in the United States, up to 40 patients undergo a procedure meant for somebody else or the wrong body part,” he said.

The costliest medical errors were:

1. Infections after surgery (252,695 in 2008, cost $3.36 billion)

2. Pressure ulcers - Bedsores (374,964 in 2008, cost $3.27 billion)

3. Complications from noncardiac implants and grafts (60,380, cost $1.07 billion)

4. Complications from lower back surgery (113,823, cost $1 billion)

5. Excessive bleeding complicating a procedure (78,216, cost $680 million)

You’ll find more information about the Health Affairs studies here.

A bill before Oregon’s state Senate would give non-nursing hospital staff members workplace protection when reporting health care practices that endanger patient safety.

Currently, Oregon nurses are legally protected against retaliation in hospitals when reporting practices that jeopardize patient health or safety. If it becomes law, Senate bill 237 would extend the same protections to Oregon’s non-nursing hospital staff, including lab and X-ray technicians, certified nursing assistants, licensed practical nurses and others.

Advocates of the bill say it is necessary because workplace retaliation against healthcare workers who report patient safety issues is common, and filing a complaint with a regulatory agency or speaking truthfully to an on-site regulatory inspector can pose significant career risks. The bill would improve patient care and safety by legally prohibiting retaliation against staff by their hospital employers.

The Senate committee studying the bill also heard testimony that because of the “warm and fuzzy” relationship between hospitals and state and federal legislators, hospital health care workers also need protection from retaliation from state and federal regulatory agency employees. In addition, state Senators were urged to prohibit the disclosure of any personal identifiers of any complainant to any other person or entity.

Source: Salem Statesman Journal

You can read the draft legislation here.

Medication errors in a hospital’s psychiatric unit were cut drastically with two techniques: an electronic prescription drug ordering system and a computerized method to report adverse events, according to new research from Johns Hopkins University.

The leader of the study, Geetha Jayaram, MD, MBA, an associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, says that “with the use of electronic ordering, training of personnel and standardized information technology systems, it is possible to eliminate dangerous medication errors” altogether.

The findings published in the March issue of the Journal of Psychiatric Practice illustrate how the psychiatric unit at The Johns Hopkins Hospital in Baltimore went from a medication error rate of 27.89 per 1,000 patient days in 2003 to 3.43 per 1,000 patient days in 2007. And none of the medication errors during the study period caused death or serious, permanent harm, Javaram notes.

“Having something typed eliminates bad writing — and most errors — immediately,” she says. “It’s a good reason for going electronic.” Medication errors, which can be lethal, are known to be caused by illegible handwriting, misinterpretation of orders, fatigue on the part of medical personnel, pharmacy dispensing errors and administration mistakes. A pharmacy may misread what a physician has written or give the wrong medication or the wrong drug dose to a patient.

The computer program used in the psychiatric department also includes integrated decision support for drug dosage selection, drug allergy alerts, drug interactions, patient identifiers and monitoring — things that can be lost with a manual system that relies on layers of human beings to ensure the correct decisions are made, Jayaram says. The more the number of steps involved in the process, the greater the likelihood of mistakes.

Source: Scienceblog

You can read the complete study here.

“Alarm fatigue” caused by the rising use of monitors is distracting and numbing hospital personnel with deadly results, the Boston Globe reports.

An investigation by the newspaper reveals that more than 200 hospital patient deaths in the U.S. between January 2005 and June 2010 are linked to problems with alarms on patient monitors that track heart function, breathing, and other vital signs.

Typically, the problem isn’t the equipment, but rather the failure by medical personnel to react with urgency or notice the alarm. As monitor use continues to increase, the audible beeps from the machines can become so relentless that nurses become desensitized. How relentless? At a 15-bed unit at Johns Hopkins Hospital in Baltimore, staff documented an average of 942 alarms per day — about 1 critical alarm every 90 seconds.

Nurses said the number of alarms can be so overwhelming that they turn into background noise — although a dozen nurses interviewed by the Globe said they have never seen a nurse purposely ignore an alarm. The problem, says one nurse, is that “everyone who walks in the door gets a monitor. We have 17 [types of] alarms that can go off at any time. They all have different pitches and different sounds. You hear alarms all the time. It becomes . . . background.’’

In addition, the devices themselves have flaws that contribute to alarm fatigue. For example, monitors can be so sensitive that alarms go off when patients sit up, turn over or cough. Some studies have found more than 85 percent of alarms are false (i.e. they go off when the patient isn't in danger. Over time this can make nurses less and less likely to respond urgently to the sound.

In many cases, of course, nurses miss alarms warning of problems that aren’t life-threatening. But even the highest-level crisis alarms, which are typically faster and higher-pitched, also may go unheeded.

In one extreme case, a cardiac monitor blared 19 dangerous arrhythmia alarms for nearly 2 hours before staff silenced the alarms temporarily without treating the patient, who died. In other instances, staff have misprogrammed complicated monitors or forgotten to turn them on.

Hospitals that have experienced alarm-related deaths have aggressively addressed the issue, hiring nurses and technicians whose sole job is to monitor the monitors and modifying monitors to make them less sensitive to unimportant changes and less prone to false alarms. But overall, hospitals and the medical device industry have yet to seriously tackle the issue.

Source: The Boston Globe

Yet more evidence that expensive technology drives treatment decisions in medicine: A new survey of prostate cancer treatment shows that once a hospital invests the $1 million to $2.5 million it takes to get a surgical robot, men in the area start to get a lot more prostate removal surgery than they otherwise would.

Although heavily marketed, robotic surgery has never been proven to reduce the two big risks of prostate removal: incontinence and impotence. And each surgery with a robot is about $2,000 more expensive than those done the traditional way.

An excerpt from a New York Times piece on the new study:

One reason for the increase in operations in hospitals that own a surgical robot may be that the technology helps a hospital lure potential surgical patients away from the competition. But the data also suggest that once a hospital obtains a robot, patients who might be candidates for nonsurgical options are more likely to be steered toward robotic surgery instead.

“This may be the medical embodiment of the phrase, ‘If you’re a hammer, everything looks like a nail,’”said the lead study author, Dr. Danil V. Makarov, assistant professor of urology at New York University’s Langone Medical Center. “If you have the technology, it will get used.’’

...

“If you’re a hospital and you get a robot, clearly you want to use it,’’ said Dr. David Penson, a study co-author and director of the Center for Surgical Quality and Outcomes Research at Vanderbilt University. “There are some real pressures here that have nothing to do with science,” he said. “We have this interplay of patients’ fascination with technology coupled with business interests on the part of the hospital and device makers, pushing people to try a new technology perhaps before it’s been fully tested.’’

And here's a good bottom line point for patients, also from the Times article:

“For patients, there are a lot of choices in prostate cancer,’’ said Dr. Makarov. “Knowing that technology can influence both what they want and what their physician may advise them should make them a little more skeptical and maybe make them ask a few more questions.’’

Anyone who believes it's inevitable that some babies will get injured during childbirth may have a change of heart after reading how a New York City hospital dramatically cut staff errors and reduced medical malpractice payouts by 99%.

In a report published in the American Journal of Obstetrics & Gynecology, the head of the obstetrics team at New York Weill Cornell Medical Center describes how the safety initiatives they introduced reduced avoidable deaths and serious injuries to zero in 2008-2009, down from five in 2000.

“Any hospital could do it — it's not about money, it's about changing the culture to make it safer to deliver babies,” says team leader Dr. Amos Grunebaum. The new measures introduced by the team reduced errors and helped ward off lawsuits by clearly documenting everything doctors did right in cases where a bad outcome was not their fault.

Consumer advocates are hailing the report as a breakthrough in patient safety and a better way to curb malpractice costs than so-called tort reform.

Patient safety advocates like me, who represent patients in medical malpractice lawsuits, have said over and over that we would like to see lawyers get less business by making the medical system safer for patients.

The reforms at Weill Cornell resulted in annual medical malpractice payouts dropping from an average of $28 million from 2003 to 2006 to $2.6 million a year from 2007 to 2009. And since there were no sentinel events reported in 2008 and 2009, those numbers are expected to drop even more.

Among the changes were:

* Doing away with the labor and delivery unit's dry-erase whiteboard, which staff used to communicate patients' progress, and replacing it with a new electronic application.

* Not allowing any paper charting.

* Hiring a full-time patient safety nurse to educate staff on new protocols the doctors wanted and to conduct emergency drills.

* Hiring three physician assistants and a “laborist” (an obstetrician who works at the hospital full-time) who works nights and weekends, reducing on-call time for other obstetricians, in order to avoid errors due to sleep deprivation.

Though many aspects of the plan were costly, the authors concluded that the savings in medical malpractice payments "dwarf the incremental cost of the patient safety program.”

Source: Crain’s New York Business.com

You can read the article in the American Journal of Obstetrics and Gynecology here.

The number of bloodstream infections in intensive care units (ICUs) caused by tubes inserted into major blood vessels decreased significantly between 2001 to 2009, but unacceptably high rates of infection are still occurring for patients in other hospital units and for dialysis patients, government researchers say.

Central lines are tubes that are usually placed in the large veins of the neck or chest to deliver medicines and nutrition. Infections of these lines, which are largely preventable, can become serious problems, with death rates of 12-25%.

An estimated 18,000 ICU central-line infections were recorded in 2009, down from 43,000 in 2001, according to a report by the Centers for Disease Control and Prevention (CDC). This 58% decrease means that in 2009, between 3,000 and 6,000 deaths were prevented and as much as $414 million saved. And if the decrease in these ICU infections was steady from 2001 to 2009, as many as 27,000 lives and as much as $1.8 billion may have been saved.

(Note: These numbers are rough estimates. The 2001 figure of 43,000 infections could have been as low as 27,000 and as high as 67,000.)

According to the CDC, much of the decrease resulted from campaigns to improve techniques for managing the lines in ICUs, where they are most frequently used. Infections involving bacteria such as staphylococcus can be avoided with simple measures like washing hands, wearing sterile gowns and drapes, and following the proper techniques for inserting and maintaining the lines.

However, researchers noted that central line infections still occurred far too often, affecting 80,000 patients a year and killing at least 10,000. In addition, of the 350,000 patients who received dialysis in the U.S. in 2008, about 37,000 suffered central-line infections. Such infections are the second leading cause of hospital stays and death in people on dialysis after cardiovascular problems.

Peter Pronovost, MD of Johns Hopkins Hospital, a pioneer in patient safety, developed the simple "checklist" for using central lines in ICU patients, which was proven in a landmark study in the New England Journal of Medicine to cut the infection risk to close to zero.

Source: The New York Times

You can read an abstract of the study here.

A physician who gave nearly 100 veterans with prostate cancer incorrect doses of radiation has been sanctioned by the Nuclear Regulatory Commission (NRC). The errors involved the incorrect placement of iodine-125 seeds in patients to treat prostate cancer.

Out of 116 such brachytherapy procedures performed at the facility between 2002 and 2008, the VA reported that 97 were carried out incorrectly. The NRC investigation found that Dr. Gary Kao, a radiation oncologist at the VA Medical Center in Philadelphia, took part in 91 of the 97 incorrect procedures. In several cases, the incorrect doses were caused by Kao having implanted the seeds in nearby organs or surrounding tissue.

As a result, the NRC ruled that Kao cannot take part in agency-related activities without undergoing more training. The NRC also issued a separate order requiring Gregory Desobry, a medical physicist who worked at the same facility, to notify the agency if he accepts employment in that capacity involving NRC-regulated activities within 20 days of beginning such work. Last year, the NRC fined the Philadelphia VA hospital $227,500 over the incidents.

Source: Philadelphia Inquirer

To view a copy of the NRC decision, click here.

The state of Maryland is putting some financial sting in its efforts to get hospitals to lower the number of patients who contract deadly infections while hospitalized.

Nine hospitals are being fined a total of $2.1 million for having higher than usual infection rates.

The hospitals are: in the Washington, DC area: Prince George's Hospital Center, Shady Grove Adventist, Montgomery General, Doctors Community and Washington Adventist, plus University of Maryland Medical Center in Baltimore, St. Joseph Medical Center in Towson, Civista Medical Center in La Plata and Memorial Hospital in Cumberland (now part of the Western Maryland Health System).

Twenty-three hospitals - including Holy Cross, Howard County General, Suburban Hospital and Johns Hopkins in Baltimore - did better than the state average and will receive small bonuses.

The list of all hospitals included in the survey and their infection rates for fiscal year 2010 can be found by clicking here and then click on this line on the web page: Hospital Infection Related PPC Rates, FY 2010.

The state's effort is more ambitious than just infections. It follows a set of 49 PPCs: Potentially Preventable Complications. It sets up payment incentives and fines to encourage hospitals to reach goals of making patient care safer.

After transplanting a kidney into the wrong patient, the University of Southern California University Hospital has shut down its kidney transplant program pending an investigation.

While this may be a unique event at USC, mixups in transplants unfortunately pop up around the country on a regular basis, because of the lack of rigorous safeguards to check and double-check to avoid tragedies. In this case, luck prevailed.

The patient escaped harm apparently because the mistake involved a kidney that happened to have universal blood type “O,” making it a close enough match to avoid harming its unintended recipient.

Kidney transplants are often performed on short notice and outside of normal hours, and the number of people involved -- surgeons, anesthesiologists, nurses, transporters and patients (donor and recipient) -- make them a challenge to coordinate.

Although safeguards are in place to prevent such occurrences, there is never a direct one-on-one relationship between any two individuals involved, which means miscommunications remain possible. Ultimately, the surgeon is responsible for making sure that the patient who's now in the operating room is indeed a patient on this list and is the patient that they wanted to be calling in from this list.

After the hospital realized its mistake, the organ procurement organization performed a cross-match test using blood samples they already had to determine the transplant's compatibility. The hospital then began looking for a suitable recipient for the other kidney, which was later transplanted at a local hospital. The intended recipient of the misplaced kidney received another organ a few days later.

The mixup reportedly occurred after two kidneys from separate donors arrived at the transplant center simultaneously on Saturday, Jan. 29. According to an official with the One Legacy kidney transplant program, the kidney’s packaging and documentation was accurate, suggesting the mistake was the result of human error.

In a statement, the hospital confirmed that it had temporarily and voluntarily halted transplants and said no patients were harmed as a result of the mistake. But it did not provide any details as to the nature of the error and declined to answer questions. The state Department of Public Health is investigating the incident.

“The hospital inactivated the program while clinical protocols are assessed and additional safeguards to the kidney transplant program are developed," the hospital said in statement. The hospital also notified United Network for Organ Sharing (UNOS), a federal program that organizes the distribution of organs for transplant, that the kidney program had been halted. As of Feb. 11, USC had 508 patients waiting for kidneys, including 313 men and 195 women, according to UNOS.

Source: ABC News

More than two dozen hospitals in Ohio that collaborated to reduce hospital infections and drug mix-ups saved $12.8 million in health care expenses by doing so, according to a recently released report. The Solutions for Patient Safety initiative, launched by a coalition of business and hospital groups in January 2009, included 17 hospitals acute care hospitals and eight children’s hospitals.

The report said hospitals were able to achieve the changes by sharing successful data-collection techniques and best preventive medical practices with one another.

Seventeen central Ohio hospitals cut methicillin-resistant Staphylococcus aureus (MRSA) infections by 42% and catheter-related central line associated bloodstream infections (CLABSI) by 37%, thereby avoiding an estimated 918 patient days in the hospital and preventing 14 deaths. Meanwhile, the eight children's hospitals cut surgical infections by 60% and adverse drug events by 35%, preventing more than 3,500 children from being harmed while in the hospital and saving $5.3 million in medical costs.

Two processes - hand hygiene and "scrubbing the hub" - emerged as critical to significantly reducing infection rates for MRSA and CLABSI. Hand hygiene was the primary area of focus for the collaborative’s efforts to reduce MRSA infections, and an inverse relationship between hand hygiene and incidence of MRSA was observed. Since the beginning of hand hygiene data collection by specially hired observers in September, the rate of compliance with washing hands upon entering and leaving a patient’s room, even while wearing gloves, has improved by more than 20 percent. For CLABSI related infections, the observers identified a critical point of infection transmission related to the length of time the “hub” (the access point in a catheter where fluids and medications are administered) is cleaned.

Source: American Medical Association News

You can read the report here.

Last spring, we reported in this blog about an obscure medical journal study that punctured the balloon of the U.S. News "Best Hospitals" rankings.

The study by Dr. Ashwini Sehgal found that the rankings were based almost purely on the subjective reputation of the hospitals among similarly situated health care institutions, a self-fulfilling prophecy. More important, the rankings have almost nothing to do with a hospital's core job of keeping patients safe, which is something for which objective measures do exist.

Now I'm delighted to report that this study has been spotted by the New Yorker's Malcolm Gladwell. As part of a long takedown of the silliness of rating systems in general -- he skewers everything from the "Best Colleges" ratings of U.S. News to the top cars rankings of Car and Driver, he had this to say about the medical study:

You can read the whole thing on the New Yorker's site here.

As I said in my piece last spring, one radical idea would be to ask patients what they think of hospitals where they've recently stayed. There actually are some very good correlations between quality of care and patient satisfaction: Clear communications, clean rooms, and good pain control are all important elements of going home safe and sound.

Medicare's "Hospital Compare" website publishes patient satisfaction reports for each hospital in the country. Check them out here.

Federal and Massachusetts state health investigators have cited a Boston teaching hospital for making at least three surgical errors in the last four months of 2010, all of which involved surgeons operating on the wrong vertebrae during spinal surgery. Two of the surgeries were performed by the same surgeon, whose name has not been released.

The spike in spinal surgical errors at the Beth Israel Deaconess Medical Center -- one of Harvard's teaching hospitals -- was notable, because hospitals across Massachusetts had reported only 11 similar incidents from 2006 through 2008. Officials noted that the incidents were unrelated and attributable to human error on the part of the surgeons.

Wrong-site surgical errors are considered to be “never” events (i.e. events that should not happen if the surgeon and medical staff follow the appropriate standards of medical care). The hospital said it had procedures in place to prevent such errors, and said it could not explain how the incidents happened if those procedures were being followed.

In a recent study, U.S. researchers found that errors in judgment were involved in 85% of wrong-site surgical errors and that in 72% of the medical mistakes in the operating room, the surgical team failed to take a “time out” to assess the situation and make sure their surgical plan was correct.

In all three cases at the Beth Israel Deaconess, the doctors completed the surgery without realizing that the vertebrae they were working on was undamaged and just below or above the part of the spine that was actually injured. Two of the errors were discovered during post-surgical X-rays, when patients continued to suffer back pains, and the third was discovered in a routine postoperative X-ray.

Source: About Lawsuits.com

You can view an abstract of the study in Archives of Surgery here.

With the exception of cancer care, university hospitals generally do not provide higher quality of care than other hospitals, according to a recent study that evaluated data from 118 university hospitals and compared them with data from general, acute and non-federal U.S. hospitals.

The study, titled “An Assessment of the Quality of University Hospital Care in the U.S.,” found that although university hospitals do very well as a group in cancer care and in overall medical care, in many clinical categories they either performed the same as non-university hospitals or sometimes far worse. For example, 89% of university hospitals fall below the national average in orthopedic care and 85% fall below the national average for general surgery.

"Most people assume that a university hospital will provide better quality care because these institutions typically conduct cutting-edge academic research, have lofty reputations and adopt the latest treatment protocols and technologies," says Dr. Thane Forthman, managing principal of The Delta Group, which produced the study. "We were especially surprised to see the study reveal that some of the nation's best-known university hospitals scored in the bottom quartile of all hospitals nationally for overall quality of hospital care."

Forthman focuses attention on university hospitals’ reliance on interns and residents. "Certainly more research is needed, but at university hospitals you have a large population of interns and residents who are still being trained. While under the supervision of an attending physician, they have the autonomy to make rounds, order lab tests and make clinical decisions, even though they lack time-tested, hands-on experience," says Forthman.

"More importantly, interns and residents often work extended shifts of up to 80 hours per week, which empirical research has shown dramatically increases fatigue-related medical and diagnostic errors, medication errors and other adverse events."

Other key study findings included:

* University hospitals appeared more frequently in the top 10% of all hospitals nationally in cancer care : 43% of university hospitals studied performed in the top 10% nationally for cancer care.

* Many highly-regarded university hospitals performed in the bottom 25% of all hospitals nationally for overall quality of hospital care, including: Emory University Hospital, Dartmouth-Hitchcock Memorial Hospital, George Washington University Hospital, Georgetown University Hospital, Hospital of University of Pennsylvania, Stanford Hospital, Shands Hospital at the University of Florida, The Johns Hopkins Hospital, The University of Chicago Medical Center and University of North Carolina Hospital (Chapel Hill).

* Of the 118 university hospitals evaluated, 17 were in the top 10% of all hospitals nationally for overall quality of care in three or more clinical categories:

* University hospital quality scores fall disproportionally below the national average for the majority of clinical categories: Orthopedic Care (89% fall below the national average); General Surgery (85% fall below); Major Orthopedic Surgery and Neurological Care (78% fall below, respectively); Overall Hospital Care (74% fall below); Overall Surgical Care (73% fall below); Major Neuro-Surgery (67% fall below); Cardiac Care (63% fall below); Major Cardiac Surgery (62% fall below).

You’ll find more information on the study here.

You can view the study in its entirety here.

Quick triage of patients who arrive at the Emergency Department isn't just important for patient safety. It makes hospitals a lot more popular with their consumers, as one hospital has found.

The emergency department at Texas Health Presbyterian Hospital in Plano launched a policy called the 30-Minute Promise in October 2009, pledging to treat patients within a half-hour of arrival. The result: the hospital’s patient satisfaction scores in the Emergency Department rising above the 90th percentile of hospitals nationwide.

Last month, the Texas State Board of Nursing highlighted the service in its monthly newsletter as a best practice in patient safety.

According to Michael Webb, RN, BSN, performance improvement project manager at Texas Health Plano, “the process we have implemented for rapid triage and bedside registration allows patients to be brought back into the emergency room where they can receive the care they need from clinical staff. The radiology and lab team members interrupt nursing staff in patient rooms if needed to expedite critical testing.”

In addition,Webb writes, “team-based care defined by zones in the ED increases communication among staff members, physicians and, most importantly, patients.”

The hospital also opened the “back door” of the ED by tracking and trending the discharge order times of their physicians with the highest in-patient volume to increase internal capacity. In-patient nursing staff are responsible to ensure that discharge planning is initiated early in the hospitalization and the patient is discharged in a timely manner when clinical criteria are met.

Source: Texas Board of Nursing newsletter, page 4

A study of ten hospitals in North Carolina finds a one-in-four chance of being hurt by medical care, a rate that hasn't improved in the ten years since a landmark study said that 100,000 Americans were killed by malpractice and medical error each year.

The new study, published in the nation's leading medical journal, the New England Journal of Medicine, looked at 2,300 randomly chosen admissions in the ten hospitals. North Carolina was chosen for the study because it has a high rate of participation in hospital safety efforts.

But the results were discouraging. One in four hospital admissions included harm to the patient due to medical care, and two out of three of those harms were judged to be preventable.

The researchers wrote: "[W]e found that harms remain common, with little evidence of widespread improvement."

What needs to be done? Patient safety experts know that provable techniques to reduce harm to patients haven't penetrated as well as they should into routine hospital practice. Among the techniques identified in this study:

* Computerized order entry systems, to prevent errors in medications.

* Hand washing by doctors and nurses to prevent infection spread.

* Reducing excessive hours by doctors in training and nurses.

* Mandatory, rather than voluntary, error reporting systems.

You can read the whole study here.

An orthopedic surgeon who performed the wrong operation on a patient now says he no longer sees any burden in The Joint Commission’s (TJC) Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. And he's gone on the record in a prominent medical journal to confess error and try to help other surgeons do it right.

TJC’s universal protocol recommends that surgeons:

1. Conduct a pre-procedure verification process.

2. Mark the procedure site before the procedure is performed.

3. Perform a time out.

The surgeon, David C. Ring, M.D., was treating a 65-year-old woman whom he had diagnosed 3 months earlier with trigger finger, a common disorder in late adulthood in which a finger or thumb snaps or locks before unlocking (like a trigger), caused by a swollen flexor tendon.

According to Dr. Ring’s own account, the correct arm had been marked at the wrist by the nurse but the planned incision site on the hand was not marked. Dr. Ring performed three other carpal tunnel procedures that day, one of which was performed on a patient who became extremely agitated before and after the procedure, causing the surgeon to vow that the next procedure would be the best carpal tunnel release he’d ever performed. In addition, the patient was moved to another operating room, resulting in a change of personnel which meant the nurse who had had performed the preoperative assessment would not be in the room during the procedure.

About 15 minutes after performing the carpal tunnel procedure, Dr. Ring realized he had performed the wrong surgery. After informing staff, he told the patient about the error, apologized and offered to perform the correct procedure. The patient agreed, and the trigger finger release was performed. Later, the patient’s son informed Dr. Ring that the patient had lost faith in him and would not return for followup care. A financial settlement was negotiated shortly after the event.

Dr. Ring asked that the case be published in the Case Records of the Massachusetts General Hospital to encourage the development and following of procedures that would minimize the risk of such events occurring again.

Source: New England Journal of Medicine

You can view and download a poster of the Universal Protocol here.

Any lingering doubts about the positive effects of comprehensive surgical checklist intervention should vanish following the release of a study conducted in the Netherlands and published in the New England Journal of Medicine.

The Dutch study evaluated the effects of a comprehensive surgical checklist intervention in six regional and tertiary care centers in the Netherlands and involved 11 distinct checklists applied
during different phases of preoperative, intraoperative, and postoperative care completed by
surgeons, anesthesiologists, nurses and other staff.

The checklists included nearly 100 items that address the availability of imaging information, equipment and materials, patient and operative site verification, communication of postoperative instructions between caregivers and discharge instructions. Outcomes improved substantially as a result of this intervention. The proportion of patients with one or more complications fell from 15.4 to 10.6%, while mortality dropped from 1.5 to 0.8%.

A large international study supported by the World Health Organization (WHO) released last year reported similar results, showing that checklists cut surgical morbidity and mortality almost in half. However, not everybody was convinced by the findings of the WHO study, because:

1. The pre-intervention/post-intervention study failed to control for confounding factors, such as the the “surgical Hawthorne effect,” which states that outcomes tend to improve rapidly when surgeons know they are being evaluated.

2. The study’s operating room checklist consisted primarily of common-sense items and processes of care that seemed unrelated to the most common serious complications of surgery, making it implausible for some that improved compliance with these practices could lead to such drastic reductions in morbidity and mortality.

3. Compliance of the eight study hospitals with the checklists had no bearing on the extent of improvement in outcomes. Overall compliance with processes of care on the checklists improved negligibly even in the two hospitals with the greatest reductions in morbidity and mortality, while conversely, the two hospitals with the greatest increase in compliance showed no change in outcomes.

The Dutch study avoided these pitfalls by including hospitals that had already been tracking their surgical outcomes with the same detailed registry for many years, so the results cannot be attributed to the effects of performance feedback.

It also documented a strongly positive relationship between checklist compliance and outcomes, in that patients with incomplete checklists had significantly more complications than those for whom checklists were more fully completed.

Finally, the study included a control group. At five similar hospitals that did not implement the checklist intervention, morbidity and mortality were unchanged during the study period.

An editorial published with the article concluded that surgery checklists now have advanced from a good idea to "standard of care."

Source: New England Journal of Medicine

You can view an abstract of the Dutch study here.

You can view an abstract of an editorial about the Dutch study here.

The Food and Drug Administration has issued Class I recalls of Hospira Symbiq One- and Two-Channel infusers and Medtronic Octopus Nuvo tissue stabilizers.

Class 1 recalls are the most serious type of recall and involve situations in which there is a reasonable probability that use of these products will cause serious adverse health consequences or death.

The FDA is recalling Hospira’s infusion pump products due to motor encoder failures in the pumping mechanism that causes the infuser to cease operation. Delay or interruption of therapy may result in serious injury or death in: patients receiving critical therapy, pediatric patients, and neonates. The company mailed an “urgent device field correction” to affected customers and issued a recall notification in February 2010. All the affected units were distributed from Dec. 23, 2006 to January 22, 2010.

Medtronic’s Octopus Nuvo tissue stabilizers were manufactured from February 19, 2010 through August 28, 2010 and distributed from March 8, 2010 through September 7, 2010. The device stabilizes and minimizes the motion of selected areas of the beating heart during minimally invasive cardiac procedures while directly visualizing the heart through a small cut in the chest cavity. The FDA ordered the recall because of the possibility that a component of the device could fracture during use and fragments could fall into the patient’s chest cavity and/or damage the heart tissue, causing serious injury or death. Fortunately, no action from patients is required, since any adverse event related to the device would occur at the time of surgery.

Medtronic sent an “urgent medical device recall notice” to its customers on September 14, requesting that they discontinue use of the device, quarantine all unused devices and return unused devices.

Hospira recall source: Bioscience Technology

To view the FDA ruling on Hospira, click here.

Medtronic recall source: Operating Theatre Journal

To view the FDA ruling on Medtronic, click here.

Victims of hospital malpractice hunger to be treated with respect as human beings by the hospitals who have destroyed or damaged their lives. A simple "we're sorry" is a good first step, but only a first step. Some forward-looking hospitals are learning that implementing patient safety changes as part of the healing process makes good business sense in addition to helping the patients and their families.

The online magazine, Hospitals and Health Networks, has a good article in its current issue on this. An excerpt:

When Sandra Coletta took the helm as president and CEO of Kent Hospital in Warwick, R.I., in October 2008, she received a trial-by-fire course in the management of medical error. Two years earlier, in July 2006, a high-profile medical error had occurred in Kent's emergency department when heart monitoring that a doctor ordered for a patient never happened, and the patient died hours after seeking help in the ED. When Coletta began her post at Kent, the legal case was still pending.

"No one from the hospital had talked to the family," Coletta says. "They had only been contacted by lawyers." The hospital had taken a causality defense, its initial position being that the patient's death could not be proven to be a result of its failure to monitor.

For Coletta, it was black and white. The hospital had made an error and was not owning up to it. The family was not getting answers they deserved, and no one was healing, including the caregivers involved in the error.

"There are many pressures from all fronts not to get involved, especially from a legal or public relations perspective," says Coletta. Instead, knowing it would be the only way for everyone involved to begin the healing process, Coletta chose to sit down with the family and do the unthinkable in a medical lawsuit—apologize.

Read more about this different approach to defending hospital malpractice lawsuits here.

Infectious disease specialists are raising the alarm over a variant of the e.coli bacteria that is resistant to most of the antibiotics used to treat bladder infections and could be responsible for more than 3,000 deaths a year.

E.coli ST131, an aggressive strain of multi-drug-resistant e.coli bacteria, may be responsible for as many as 1 million bladder infections a year, according to a recent study conducted by Dr. James Johnson, an infectious disease expert at the Veterans Affairs Medical Center in Minneapolis.

E.coli ST131 is one resistance gene away from being untreatable, Johnson warns. “I think it’s high time to worry. Before, resistant strains were wimpy. Now, we have a winner,” he says.

Although e.coli is best known as the intestinal bacteria that causes diarrhea when people eat tainted meat or vegetables, such as spinach, it actually occurs more often outside the intestines, causing far more infection and death. Extra-intestinal e.coli is responsible for about 80 percent to 90 percent of the urinary tract infections that occur annually.

Most e.coli variants respond to common treatments: guzzling gallons of water, swilling quarts of cranberry juice, and, if all else fails, heading to the doctor for a quick course of antibiotics. However, Dr. Johnson’s study determined that although the e.coli ST131 strain accounted for only about 17 percent of e.coli isolates overall, it accounted for more than 50 percent of bacteria resistant to more than one antibiotic, including the top two types used to treat most urinary tract infections, or UTIs, and also was responsible for nearly 70 percent of resistance to the biggest guns of mainline UTI treatment, fluoroquinolones and extended-spectrum cephalosporins.

E.coli ST131 probably caused the most significant multi-drug resistant e.coli infections in the U.S. in 2007, the year Johnson studied, constituting a serious public health threat.

Dr. Johnson’s findings add to the growing concerns about drug-resistance in common infections such as UTIs. New UTI guidelines that will restrict the use of fluoroquinolones for large infections are expected to be issued by the Infectious Diseases Society of America this fall.

Source: MSNBC
You can read an abstract of Dr. Johnson’s study here.

The frequency of malpractice claims against hospitals has declined slightly and the severity of those claims is leveling off, according to a report from Zurich, the insurance company.

The fifth annual Zurich benchmarking report on claims trends in the healthcare industry, which collected data from 1,600 U.S. hospitals between 1997 and 2007, indicates that claims severity, or the average amount per claim, has stabilized over the past several years, with an average annual rise over the past 11 years of 4%.

Zurich also reports that teaching and children’s hospitals have higher claim severity than acute care community hospitals and outpatient facilities. Non-profit hospitals have the lowest severity; and among non-profits, faith-based institutions have the lowest severity of all.

Leo Carroll, head of Health Specialty Products, Zurich North America Commercial, says:

“It’s interesting to note that severity does continue to rise among claims valued under $1 million, which are the claims considered more typical within an institution's loss experience, while the most severe claims (those valued above $1 million and $5 million) have stabilized overall, the frequency of those large losses has increased slightly.”

Carroll also noted that the most severity prone states continue to be New York, Illinois and Pennsylvania. Meanwhile, in Pennsylvania, Gov. Edward G. Rendell has vetoed a bill that would have frozen primary medical malpractice insurance limits for 7 years, saying the bill would destabilize the medical malpractice insurance marketplace and undermine the state’s ability to attract and retain medical providers. According to Rendell:

“We have worked very hard in the last eight years to get to this new, improved place in which medical malpractice claims are down, insurance coverage is more available and affordable, and the number of medical providers is increasing. I vetoed Senate Bill 1280 because I do not want to impede that progress or put our doctors at risk. Further study, analysis and public input are warranted before implementing the changes contemplated in this bill."

Source: Insurancenewsnet.com

You'll find the complete Zurich report here.

Here's a new research finding that is encouraging but discouraging at the same time for patient safety.

After 16 Michigan hospitals began to share patient safety information, surgical complication rates dropped by nearly 10 percent, according to a recent study.

That's encouraging, of course. The disquieting piece is why it would take a major research study to reach such an intuitively obvious result, and why sharing of data doesn't already happen on a wide and routine scale.

The University of Michigan study followed a program called the Michigan Surgical Quality Collaborative, which involved 300,000 patients who had general or vascular surgery between 2005 and 2007.

The greatest reductions were seen in blood infections, septic shock, prolonged ventilator use and cardiac arrest. Death rates remained the same.

According to the study’s author, Darrell A. Campbell Jr., MD, a professor of surgery and chief medical officer of the University of Michigan Health System, “the collaboration of hospitals in terms of identifying and disseminating information about best practices is actually a much more effective way of improving quality than just relying on each hospital alone to come up with what they think is a way to improve quality. In other words, sharing ideas is important and it's effective." He added that this type of program could help achieve the health care reform goals of improving quality and reducing costs.

“Surgical complications are very expensive,” Campbell says. “Once something bad happens following surgery, it takes a lot of resources for the patient to recover.”

A preventable surgical complication can add weeks to a hospital stay and thousands in added costs. Contracting pneumonia from prolonged ventilator use following a surgical procedure, for example, can add $50,000 to a hospital bill.

Given the high cost of surgical complications, authors estimate that it would take only a 1.8 percent reduction in complications a year for three years to offset the cost of supporting the pay for participation program.

“If this system was adopted nationally, not just in Michigan, I think you would find a greatly accelerated pace of surgical quality improvement,” Campbell says.

Inspired by the Michigan group, surgeons in Tennessee and upper New York have launched collaboratives. Similar ones are in the works in Pennsylvania, Virginia and Illinois.

Source: University of Michigan press release.

You can view an abstract of the study in Archives of Surgery here.

There are no simple diagnostic tests for sepsis - an out-of-control reaction to infection that can start shutting down organs in mere hours - but there are warning signs if healthcare providers pay close enough attention, according to Dr. James O’Brien, a critical care specialist at Ohio State University Medical Center.

“Minutes matter,” O'Brien says, noting that delays are too often simply a case of “not treating this like a medical emergency.” Millions of people around the world die from sepsis each year, and 30% of sepsis cases in the U.S. result in death.

The early symptoms of sepsis can be vague: confusion, shortness of breath, an increase in the heart rate, falling blood pressure and weakness, all of which could be caused for many other reasons. But the combination of symptoms without a clear benign cause is reason for aggressive care.

Sepsis occurs when the body overreacts while fighting an infection and damages its own tissues, which in turn can lead to shock and organ failure. Complex interactions between the microbe and the immune system cause the immune system to overreact to the point that even if the bacteria is eradicated, the damage continues to spread due to the toxic reaction of the immune system.

To better combat this deadly reaction, international sepsis experts recently formed a Global Sepsis Alliance to urge more aggressive care. The alliance wants hospitals to start antibiotics and intravenous fluids within an hour of suspicion of sepsis, as every hour of delay lowers survival by nearly 8 percent. Currently, many hospitals don’t begin appropriate care for four or even six hours, O’Brien says.

Scientists in Portugal, meanwhile, may have found an important clue as to what fuels sepsis, which is estimated to kill more than 200,000 Americans annually. During sepsis, red blood cells can become injured and leak an iron-based substance called heme that's normally part of the hemoglobin that carries oxygen.

But when it leaks into the bloodstream at the same time the body is experiencing lots of inflammation — a given during sepsis — the heme becomes toxic to organs. In a series of experiments with infected mice, the researchers showed that extrame heme leads to more deaths.

Although the body manufactures a molecule called hemopexin to clean up leaky heme, the level of hemopexin dropped as heme levels rose. When the researchers injected more hemopexin, more mice survived.

More research is needed to confirm the findings, the study authors say.

Source: Associated Press

To learn more about the global sepsis alliance, go here:

When Trevor Roberts' leg bones snapped during a high school football game near Wichita, Kansas, he received the standard orthopedic treatment: a resetting of the bones with a titanium rod to hold them in place. So why did he have to have an above-the-knee amputation because of gangrene six days later?

The surgeon who had to remove most of the boy's leg, Dr. Archie Heddings at the University of Kansas Medical Center in Kansas City, told USA Today he thought the health care system had failed Roberts in some way.

Dr. Heddings told the newspaper:

"To me, in all honesty, I think this is a failure of the doctor-hospital system. I don't want to impugn anybody. But ... one of the first things you're supposed to do when there's an open fracture is get tetanus and antibiotics. Then, you take that person to the operating room and you get out all the dirt, you get out all the bone that doesn't have soft tissue attached to it — that's dead bone — and you take out all the dead muscle. And then if there's any question 48 hours later, you take the patient back to the operating room and look at the wound and make sure there's no dead muscle. If there is dead muscle, those bacteria have something they can reproduce in. And they'll ... start wreaking havoc."

From the newspaper's account, the first surgery to put the leg back together occurred at a Wichita hospital on the same Friday night as the injury. The 17-year-old was sent to his home near Lawrence, Kansas on the following Sunday. Then he had a high fever and went to another hospital in Lawrence two days later. It's not clear what happened at that visit, but he didn't get definitive care until two more days when he was back in the Lawrence hospital with another fever and a blistered foot. That brought him to the care of the surgeon in Kansas City who told the young man he had to amputate to save his life.

An investigation is under way to get to the bottom of this sad story.

Read the whole newspaper account by clicking here.

Delays in the emergency room cause some patients to forgo treatment, according to a study by the University of South Florida. The study found that when ER patients have to wait to be admitted to hospital, the waiting time for other ER patients becomes longer, and the more likely it is that some of them will leave the ER and not get the treatment they need.

The problem is referred to as “boarding.” About 30% of ER patients need to be admitted to the hospital for further treatment, but often, they have to wait for inpatient beds to become free. As a result, waiting times for others in the ER increase.

The intent of the study, which monitored the ER at the USF-affiliated Tampa General Hospital, was to determine the number of ER patients that might walk out in frustration. The study determined that the longer those patients wait to be admitted, the more likely it is that other patients waiting behind them will leave the ER.

The research results have already been used to improve patient flow at TGH, which has implemented changes to the way patients are treated and admitted. However, study co-author David Wein, MD, says similar problems to those documented at TGH occur at hospitals across the country.

In 2007, almost 117 million people went to American hospital emergency rooms for medical attention, according to the National Hospital Ambulatory Medical Care Survey. In 2008, the number of visits increased to over 123 million.

Wein notes that the increased demand on emergency departments will be a problem if delays getting patients out of already busy emergency departments are not addressed.

Source: The Tampa Tribune

Five hospitals in New York City have joined a 3-year, $3-million program aimed at decreasing medical malpractice costs. The federally funded program will attempt to cut malpractice-related costs at the five hospitals by (a) revealing medical errors quickly; (b) offering early settlements; and (c) using judicial mediators to assist in settlement negotiations as an alternative to having cases go to jury trials.

The program is one of several funded by the federal government to encourage hospitals to acknowledge and reduce medical errors.

Four of the hospitals -- Beth Israel Medical Center, Mount Sinai Medical Center, Maimonides Medical Center, and Montefiore Medical Center – will focus on reducing obstetrical errors, while the fifth – New York Presbyterian Hospital – will try to prevent surgical errors.

Judges working as judicial mediators will help patients negotiate disputes with hospitals, though plaintiffs retain the option of seeking a jury trial. In addition, patients who use the judge mediators can have an attorney present during settlement talks.

However, concerns remain about how the program will protect the rights of patients – in particular, the right to a lawyer. Although participation in mediation is voluntary and patients are to be notified of their right to have an attorney represent them during the mediation, the fact that the patient is not required to have an attorney has led to concerns that hospital attorneys could take advantage of unrepresented injured patients and convince them to accept inadequate compensation. Another concern is that promoting a policy of early disclosure and settlement could allow hospitals to escape full liability

Sources: Renal and Urology News and 24/7 press release

The use of rapid response teams could be masking underlying patient care problems in hospitals, according to a patient safety expert writing in the Journal of the American Medical Association.

Rapid Response Teams (RRTs) are teams of doctors and nurses assigned to provide rapid bedside care for patients who are in critical condition.

The co-author of the article, Peter Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, says hospitals should focus more on why patients are deteriorating in the first place, instead of waiting until they crash.

Pronovost argues that the use of rapid response teams illustrates that the way hospitals manage patient flow can have an impact on patient health. For example, overcrowding can lead hospital managers to move patients who still need intensive care out of the ICU to free beds for even sicker patients. When patients are moved out of the ICU, they fail to receive the care they need, leading their conditions to deteriorate, and sometimes to a crash, at which point, a rapid response team takes over.

The main problem, however, isn’t lack of beds but rather how hospitals manage patient flow. For instance, many hospitals schedule all their surgeries during the beginning of the day and week; therefore, the ICU becomes overcrowded in the middle of the day and the middle of the week.

Pronovost worries that hospitals are using RRTs as a crutch. Instead, he says, hospitals need to better manage these conditions so as to prevent patients from worsening so that they don’t need to appeal to the use of rapid response teams, which, he says, only look good because patients are allowed to get so bad.

Source: RT Magazine online

You can read the original article in JAMA here (registration required)
J

Until now, it’s been easier to rate appliances and restaurants than surgeons in most parts of the country, but that should change now that surgeons who perform cardiac bypass surgery are being rated on objective quality measures in Consumer Reports magazine.

The consumer magazine recently published ratings of 221 surgical groups in 42 states online. The same ratings will be available in the October print issue. To date, only a few states, such as New York, compile data-based ratings of physicians.

The data Consumer Reports used to rate the physicians was collected the Society of Thoracic Surgeons, which includes more than 90% of cardiothoracic surgeons in the U.S. in its membership. Physician groups, not individual surgeons, were rated either above average, average or below average based on (a) complication and survival rates; (b) the surgical technique used; and (c) the type of medication(s) the patient was sent home with after surgery.

An article in the New England Journal of Medicine called the move to make this data public “a watershed event in health care accountability.”

The 221 groups rated in Consumer Report represent less than a quarter of physician groups that perform bypass surgery in the U.S., as only surgical groups that allowed their information to be published were rated. Of these, only five were rated below average, which is fortunate, because the gap in treatment between a below-average and an above-average surgical group can be extremely wide; for instance, at an above-average hospital, patients had a 92% chance of receiving the recommended medications when leaving the hospital; at one of the below-average hospitals, patients had only a 24% chance of getting the recommended drug.

For now, the information is available only to people who subscribe to Consumer Reports online and print subscribers. However, STS says it will make the ratings freely available on its web site in a few months.

Source: New York Times
Visit the web site of the Society of Thoracic Surgeons (STS) here.

Healthcare providers need to know more about the efficacy and potency of hydromorphone, a pain killer frequently used as a morphine substitute in post-operative patients, to avoid medication errors and adverse drug reactions (ADR), says an advisory from the Pennsylvania Patient Safety Authority (PPSA).

Researchers hired by PPSA reviewed 1,694 medication error and 937 adverse event reports involving hydromorphone from January 2008 to October 2009. They identified lack of knowledge about hydromorphone potency and the difference in potency between morphine and hydromorphone as the most significant factors causing serious medication errors, particularly when a patient is switched from morphine to hydromorphone.

Hydromorphone is administered in doses that range from 0.4 mg to 2 mg, whereas patients may receive as much as 7-10 mg of morphine. Incorrect dosing may occur when prescribing, dispensing or administering hydromorphone when a physician, pharmacist or nurse confuses hydromorphone and morphine. Other medical errors noted in the study were giving patients the wrong drug and not noting a documented allergy.

Some adverse drug reactions to hydromorphone also may be preventable. The study found that of the 447 reported ADRs involving central nervous system or respiratory effects, 292 (65%) were preventable, and, of these, 205 (70%) resulted from dosing errors.

To reduce the number of medical errors and ADRs involving hydromorphone, the study recommended implementing risk reduction strategies such as constraints and standardization, which focus on system improvement. It also recommended writing hydromorphone with the first five letters capitalized (i.e. HYDROmorphone) to further distinguish it from morphine.

Source: Pennsylvania Patient Safety Authority
You can view the report here.

Infections in the large-bore tubes that keep patients in intensive care units alive are often lethal but readily preventable. A simple checklist of sanitary practices was proven to cut the rate of these "central line infections" to nearly zero. But that was in one chain of hospitals in Michigan. What about the rest of the country?

Peter Pronovost, the Johns Hopkins safety guru who ran the study in Michigan proving that these infections could be eliminated, was given big grant money by the U.S. government and private foundations to spread the learning to the other 49 states. So what has he found? Here's an excerpt from what he wrote recently in the Journal of the American Medical Association:

Hospital enrollment in the program has been surprisingly slow. In many states, less than 20% of hospitals have volunteered to participate. Some hospitals have reduced infection rates, most have not. Some hospitals claim they use the checklist, despite having high or unknown infection rates. Some hospitals are content to meet the national average, despite evidence that these rates may be reduced by half. Some hospital administrators say their patients are too sick; these infections are inevitable. Yet, intensive care units in several large academic hospitals have nearly eliminated CLABSIs [central line infections]. Some hospitals blame competing priorities for their inattention to these infections. If these lethal, expensive, measurable, and largely preventable infections are not a priority, what is?

Perhaps most concerning is the response from nurses in participating hospitals when asked: "if a new nurse in your hospital saw a senior physician placing a catheter but not complying with the checklist, would the nurse speak up and would the physician comply?" The answer is almost always, "there is no way the nurse would speak up." Doubly disturbing, physicians and nurses uniformly agree patients should receive the checklist items. What other industry would
accept a routine safety violation that is associated with the deaths of tens of thousands of patients and not be held accountable? The US health care culture still does not support the questioning of physician behavior.

That last sentence is perhaps the most chilling -- because it shows, once again, that many patients are going to be doomed to preventable injuries and death until the medical culture begins to change, and doctors get off their pedestal and join the rest of the team trying to keep patients safe.

Doctors repeatedly blame patients for the high rate of Cesarean sections in this country. As one claimed in today's New York Times letters column, parents demand "nothing short of a perfect outcome" from childbirth and sue when they don't get it.

The reality is quite different.

Here's what I wrote in a letter published in the same New York Times issue:

A fundamental patient safety issue is at the heart of our high C-section rate. The reason that hospitals must have staff “immediately available” for an emergency C-section is that when a mother’s uterus ruptures, the baby’s lifeline is cut off and brain damage begins in around 17 to 18 minutes, according to the best studies.

Rupture occurs in about 1 percent of vaginal birth after Caesarean (VBAC) attempts. That’s a high enough risk — with lifelong consequences to the child and his or her family — that only the reckless or the ill informed would tempt fate by trying delivery in a facility without an obstetrician immediately available to do an emergency C-section.

According to your article, hospitals complain of the risk of being sued for a bad outcome if they follow the old guideline of having the surgical team “readily available,” which allows calling in a team from outside the hospital, as opposed to “immediately available.”

We should not let semantics obscure safety. Instead of blaming lawsuits for the high C-section rate, the focus should be on hospitals that don’t want to invest the resources necessary to make VBAC safe for mothers and families.

My law firm's website has more about VBAC and other types of birth injuries here and here.

As noted many times on this blog, nurses are the patient safety mainstays of good hospital care. So should hospitals be required to maintain a minimum nurse-to-patient ratio? California has done so, and nurse Theresa Brown wrote an op-ed recently in the New York Times discussing a proposed federal mandate (which seems to be going nowhere).

Now several nurses have interesting responses to the mandate issue in the Times' letters column, including this one:

As a staff registered nurse on a busy medical telemetry floor in a Midwestern hospital, I can certainly sympathize with Ms. Brown’s assertion that mandatory nurse-patient staffing ratios can improve patient care and save lives. But I disagree with legislative action to accomplish this end.

Patient acuity and staffing, as Ms. Brown well knows, are complex and individual issues that require thought and attention rather than bureaucracy. Nurses are not warm bodies with a nursing license. Nursing excellence and better patient outcomes can be achieved only with a well-educated, properly trained nursing staff dedicated to our profession.

Mandating staffing ratios will further destroy the idea that nurses can speak for themselves. Our voices are already a dim whisper in a discordant health care debate. The fragmentation of our care, increased patient complexity and the existing nursing shortage compound our difficulties in providing safe care, but one arbitrary staffing law will not fix this.

As an R.N., I’ve safely cared for seven surgical patients at night, and have had days when three acutely ill patients seemed too many. Our professional judgment as nurses is sophisticated enough to determine our staffing needs, and a well-run hospital will support quality care at every level, especially nurse-patient ratios. Let us not as nurses turn over yet another decision to someone else, especially legislators.

Jennifer Abraham
Normal, Ill.

Many other nurses favor mandatory minimums and look for other ways to assert nurses' autonomy.

One solution might be to require full disclosure of average nurse-to-patient ratios in hospitals. That would let patients readily see which local hospitals try to cut dangerous corners with their staffing.

It's such a relief to get a family member home from the hospital that many of us don't realize how crucial the next few weeks are in making sure the patient stays home and gets healthy. Hospitals don't always help the situation by giving out confusing and cryptic discharge instructions.

For this especially vulnerable time, patients and their family caregivers need to be very clear -- before leaving the hospital -- on the following key areas:

1. Is professional therapy needed? Physical therapy, occupational therapy, wound care and other types of care can sometimes be managed at home, as long as you have a caregiver willing to come to the house. If not, the patient may need to go to a transitional place first: a nursing home or rehab facility.

2. When is the next doctor appointment and who with? Don't leave the hospital without a specific appointment with the patient's primary care doctor. The hospital should help set up this appointment. The sooner after discharge this visit happens, the better the patient's odds of avoiding a readmission to the hospital.

3. What medicines need to be taken, and when? Insist on a specific list that takes into account whatever the patient was taking before the hospital stay and also whatever they need now.

4. Who do we call with any problems? The hospital's discharge instructions need to list a contact name and number, and also should say the types of problems that are worth a call.

5. What else do we need to do? If a family member is expected to give care -- like changing a dressing or helping the patient to walk -- make sure those instructions are precise and in writing.

The bottom line on all the above is that family members, especially when it involves an elderly patient, need to be very very clear on everything they need to know and do.

Here is a downloadable model form of a written discharge instruction sheet. This is from the Society of Hospital Medicine, a group of doctors who specialize in hospital care. Patients and families can use this template to make sure there are no gaps in what they need to know for a successful transition home.

The number is 1-800-MEDICARE (800-633-4227). It only applies if the patient is on Medicare, but it also works for protests of discharge from nursing homes too. The operator will send you on to your local Medicare QIO -- Quality Improvement Organization, a little-known patient safety organization that has power to investigate and reverse dangerous decisions by hospitals and other caregivers that want to send home a patient too soon.

Thanks to Karen Jones of the Oregon QIO for posting this phone number in a NY Times blog on patient discharge planning. She adds:

For more information about the QIO program activities, including a 14-state care transitions project aimed at reducing hospital readmissions, visit http://www.cms.gov/QualityImprovementOrgs/.

More about QIO's is in my book, "The Life You Save." The QIO is also useful if something bad has already happened to a loved one in a hospital or nursing home. You can request an investigation by the QIO, and thanks to a legal precedent won by Public Citizen, the QIO is required to tell you the results of their investigation. (In the old days, the QIO's were directed by the central Medicare office to invoke the veil of "confidentiality" to keep patients in the dark about what had really happened to them.)

The greatest fear for any patient in the hospital, and the biggest nightmare for their families, is that something will go wrong suddenly and no one will respond until it's too late. Beeping monitors are no help if their alarms go unheeded. Patient safety experts know that one basic way to keep patients safe and prevent death or injury from malpractice is to have enough nurses on hand.

How many is enough? Nursing leaders got the state of California, after a 10-year fight with the hospital industry, to mandate minimum nurse-to-patient ratios: one nurse for every five post-surgery patients, one nurse for every two intensive care patients, one nurse for every four children in the pediatrics ward.

If you have a family member in the hospital, these numbers are worth keeping in mind. Ask the bedside nurse how many patients he or she is in charge of. And don't let hospital management confuse the issue by pointing out how many aides they have. Aides can plump pillows and give other comfort measures. But only a nurse can recognize when a patient is in peril and give lifesaving treatment.

A new study by a nursing professor at the University of Pennsylvania, Linda Aiken, asserts that mandatory minimum nurse-to-patient ratios like California's could prevent as many as 14 percent of post-surgery deaths in New Jersey hospitals and 11 percent in Pennsylvania.

Another important outcome of ensuring that nurses aren't overwhelmed by too many patients is that nurse burnout and job turnover go down, and overall quality of care improves, according to the study.

Theresa Brown, an oncology nurse in Pittsburgh, has an op-ed piece in the New York TImes asking why bills in Congress to mandate minimums nationally haven't gone anywhere.

Saving money, of course, is the issue. But that's a penny-wise answer. Saving lives can be a lot cheaper in the long run.

Sometimes patients sign up for surgery with an experienced surgeon who then allows a doctor in training, with far less experience, to do the actual surgery. If this hasn't been disclosed up front by the surgeon and agreed to by the patient, the switcheroo is called "ghost surgery," and it's not acceptable. But exactly that has now occurred at the prestigious Cleveland Clinic, according to allegations in a new malpractice lawsuit reported by Diane Suchetka in the Cleveland Plain Dealer.

Retired Air Force Colonel David Antoon says in his legal complaint filed in court that he, his wife, and the surgeon, Dr. Jihad Kaouk, signed a consent form in advance agreeing that only Dr. Kaouk would do the surgery to remove Mr. Antoon's prostate gland. He alleges in the suit that he has been left incontinent of urine and sexually impotent as a result of Dr. Kaouk allowing junior doctors to do the surgery.

The patient also contends that the hospital ombudsman who investigated his informal complaints told him there was no such consent form in his records at the hospital.

Surgical volume is critically important to a good outcome for prostate surgery, as previously reported on this patient safety blog. The author of one study in the Journal of the American Medical Association said he didn't feel comfortable about his own competence with the "robot" device now widely used for prostate removal until he had had several hundred cases under his belt. So it's understandable why Mr. Antoon would feel outraged that his wishes weren't followed.

I discussed "ghost surgery" in my book, "The Life You Save." Here is my advice for how you can avoid having this happen to you:

First, have a good discussion with the surgeon about who is going to do the critical parts of your surgery. If you don't feel comfortable turning over those aspects of the surgery to a doctor in training, then say so.

Second, follow up by putting it in writing. One simple way to do so is on the consent form. It usually says something like "I authorize Dr. Jones and/or his designee to perform _____ [type of surgery filled in here] on me." All you have to do is cross out the phrase "and/or his designee" and initial your cross-out.

Third, if you're in a teaching hospital, you might want to consider some compromise that lets trainee doctors do the non-critical parts of the procedure. But you have every right to insist that only the experienced doctor do the delicate, critical work. If the surgeon resists your wishes, you may have to go to another surgeon.

The scandal of Dr. Mark Midei, the cardiologist at St. Joseph's Medical Center in the Baltimore suburb of Towson, Maryland, is scaling new heights in the number of victims counted. The hospital mailed letters to 585 Midei patients informing them that an independent review shows they may have received heart stents unnecessarily for artery narrowing that Midei grossly exaggerated. But now, according to the Baltimore Sun, many more patients are coming forward whose procedures were done outside the two-year arbitrary time limit the hospital set for its own review. It appears now that the total number of cases of unnecessary heart stents could easily exceed one thousand.

Read more here.

Hundreds of patients appear to have received cardiac stents that they didn't need from Dr. Mark Midei, a cardiologist at St. Joseph's Hospital in Towson, Maryland. So why did no one at the hospital blow the whistle? And why did the patients not realize that Midei was rushing them into unwise and risky surgery?

Heart surgery is highly profitable, and there are no incentives for doctors or hospital administrators to rock the boat by raising questions when one cardiologist is putting stents into far more patients than his colleagues.

As for the patients, we Americans have a bias toward dramatic action. If one doctor tells us we need a stent to prop open the coronary arteries in the heart, and another doctor says all we need to do is take a pill every day, most of us will tilt toward the big intervention. Which can be a big mistake, because we then get a piece of metal permanently implanted in a blood vessel, and we have to take medicines anyway for the rest of our life to avoid getting blood clots from the metal that could cause a devastating stroke or more heart damage.

Recently in this blog, I pointed readers toward an excellent review by the Harvard Medical School of the scientific evidence on who should -- and shouldn't -- get the balloon and stent treatment for opening their heart arteries. Many studies have found that unless a patient is having repeated symptoms, the stent treatment does nothing to extend his or her life, even if an artery looks dramatically narrowed.

In the case of Dr. Midei, it appears that outright fraud might have been involved. You have to have a significant narrowing of the artery, 70 percent or more, to even start to qualify for stent treatment, and Midei aggressively over-read his own X-ray studies of the heart's blood vessels to make it seem that patients had much worse narrowing than they really did, according to the published allegations about his practice.

This raises a Fox/Henhouse issue: How is it that a cardiologist can do his own testing to see if someone needs treatment, and then be the one to profit mightily if the decision is yes, they need it? Should second opinions be mandatory on any patient with blood vessel narrowing?

Dr. Bob Wachter, a patient safety pioneer at UCSF medical school in San Francisco, wrote a thoughtful blog on this topic. I'm reprinting part of it below, and urge readers to read the whole article here.

Dr. Wachter writes:

Obviously, the Mideis of the world could be caught by requiring that every cath [blood vessel X-ray] undergo an independent second reading. Some insurers in New Jersey now require such readings before they authorize a stent, and at least one SoCal Kaiser hospital mandates that each cath be presented at a conference before a treatment decision is rendered, analogous to what many tumor boards do for cancers.

Such required peer review might have benefits beyond simply preventing the rare case of fraud. If done well, it might also ensure that other conflicts of interest and non-evidence-based decisions are avoided to the degree possible. For example, a meta-analysis in last month’s Annals of Internal Medicine illustrates the limited value of percutaneous coronary interventions – whereas older studies found that PCI was more effective than medical therapy in treating angina, more recent studies show that these differences have narrowed or even vanished. I’d guess that, when recommending a treatment for a patient with mild angina and a 60% LAD lesion, a peer review group is more likely to pay attention to this kind of evidence than the average cath jock – who may not only be staring at his kid’s private school tuition bill but also at a patient whose bias is to see a stent as a more intuitively satisfying solution than “just medications.”

Some will argue that mandating second opinions for every cath is the equivalent of hitting a nail with a sledgehammer, and they might well be right. However, I do favor at least random over-reads of a sample of catheterization studies. Something like this already happens in a few specialties. In many teaching hospitals, a random sample of pathology studies is reviewed by a second provider. In a few forward-thinking practices, radiologists re-read a sample of x-rays, looking for discrepancies. In response to this case, in fact, St. Joseph’s now requires that 5% of its cath cases undergo a random and blinded re-review. Random audits won’t catch every case of fraud, any more than IRS audits catch every tax scofflaw. But they do help keep people honest, particularly if the audits are coupled with a culture in which the docs welcome feedback and strive for continuous improvement.

Speaking of which, the Midei case made me wonder about the institutional culture at St. Joseph’s. Was Midei a rogue interventionalist working in isolation? Perhaps so – it's common for no other doc to be looking over the shoulder of a cardiologist and his cath readings. But cardiologists don’t perform caths on desert islands – they are assisted by cath techs and nurses. In my experience, these folks become as adept at reading cath films as any physician. If the allegations against Midei are true, it strains credibility to think that no one in the lab knew that inconsequential lesions were being read as tight stenoses and treated with stents.

And what about the hospital administrators? Stents are big business. When Johnson & Johnson first launched their drug coated Cypher stent in 2003, Dr. Midei told the Baltimore Sun, “This is the hottest thing in cardiology in years.” And it was: Maryland hospitals chalked up nearly $250 million in stent business in 2009, and St. Joseph’s stent revenues were $38 million, up more than 50% in 5 years. Before the case broke, St. Joseph’s advertised itself as the busiest cath hospital in Maryland, averaging nearly 20 interventional cases daily. While it is possible that no St. Joe’s leader knew precisely what was happening, I'm guessing that some did but chose to look the other way: the pressure to steer clear of the golden-egg-laying goose must have been intense. Perhaps the fact that the hospital’s CEO and two other senior executives resigned after the case broke provides a clue as to who knew what when.

Cases like this one are terribly troubling, not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship. Part of the solution must be more robust oversight procedures, such as mandatory second readings of randomly selected cath films.

But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.

Patients need to know that this is not just an issue of a few rogue bad apples. Medicine's fee-for-service payment system pushes doctors toward advocating for more aggressive and profitable interventions. The only way to find out what your body really needs is to shop for second and third opinions, every time. I have more on this subject in chapter 9 of my book, "The Life You Save."

The chapter title says it all: "The Second Opinion: Always Your First Choice."

When you walk into the lobby of Johns Hopkins Hospital in Baltimore, you can't help but notice all the signs informing you that Hopkins is ranked No. 1 hospital in the United States by U.S. News & World Report. Hopkins is justifiably proud of reaching that top spot year after year, but does it mean anything for patient safety and quality of care?

A new study in Annals of Internal Medicine finds that for the 50 top-ranked hospitals, there is little correlation between their U.S. News rank and any objective measures of quality of care. But when the authors crunched the numbers, they found the hospital's subjective reputation among doctors accounted for 90 to 100 percent of the hospital's overall U.S. News ranking. In other words, the word of mouth reputation of the hospital among doctors -- not among patients -- counts for a huge amount of the news magazine's popular ratings system.

In my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, I discuss how to find the right hospital. The short answer is: It's not easy. But there are some simple steps. I would focus on the brand-name hospitals like Hopkins only if I had an exotic condition that very few doctors had ever seen. Here's a short excerpt of what I wrote about the U.S. News rankings, and what I think is a good alternative:

In its 20 years of rating hospitals, U.S. News has never asked a single patient what they think; its ratings of a hospital’s reputation in a particular specialty is based solely on what doctors in that specialty believe. But now Medicare has started requiring hospitals to have patients fill out a standardized survey when they leave the hospital, and the questions focus on a lot of issues that people care about and have a big impact on the quality and safety of their care, such as:

• Did the doctors and nurses always communicate well?
• Was the bathroom always clean?
• Was your pain always well-controlled?
• Was the area around your room always quiet at night?

Note that little word “always.” These are things patients have a right to expect – always.

You can find the results of the patient surveys on Medicare's Hospital Compare website by clicking here. You will find that many community hospitals do a better job than the mega-hospitals of taking care of patients in the ways that patients notice.

One chain that is quite good that I urge people to check out is called Planetree, which takes its name from the tree under which Hippocrates sat teaching medical students in ancient Greece. Planetree is dedicated to humanizing health care by making it “patient-centered.” Planetree has affiliated hospitals in 31 states; you can see a list at planetree.org.

The U.S. Senate Finance Committee is investigating deaths of patients at long-term care hospitals, in follow-up to a report in the New York Times last month. That report showed that the profit-making chains who run these hospitals, which cater to chronically ill patients, sometimes skimp on staffing and training, and disasters have resulted.

More on the original report in the Times can be found in our blog entry on the subject here.

These long-term care hospitals occupy a niche between large general hospitals and nursing homes. They do not treat specific kinds of patients but are defined only by the fact that patients tend to stay longer than at a regular acute-care hospital, but less time than at a nursing home. They are typically small, with around 60 beds. Many times they lease space from a regular hospital and will occupy a floor or wing in a larger facility.

The New York Times reports that it has received new information about disturbing events at hospitals run by the Select Medical chain. One example from the Times:

According to a doctor’s deposition in a lawsuit, nurses at a Select hospital in Tulsa, Okla., injected a relatively healthy 79-year-old woman with 10 times the amount of insulin she was supposed to receive back in January 2009. They then failed to notify her doctor for at least 90 minutes after they discovered that she had fallen into a coma. The woman, Ruth Tanner, died a month later without fully regaining consciousness, according to medical records and the lawsuit.

Select Medical generally does not comment on pending lawsuits, so out of respect for the legal process and the parties involved, it will not do so in the Tanner case, the company spokeswoman, Ms. Curnane, said.

Dan Graves, an attorney for Ms. Tanner’s family, said that family members agonized after the overdose. “Now their grief and loss has been multiplied by the knowledge that other families have suffered similar tragedies because of Select’s practices.”

To avoid becoming a malpractice victim, and to get the highest quality care, a useful safety credential for patients to look for in researching hospitals is called NSQUIP.

NSQUIP stands for the National Surgical Quality Improvement Program, developed by the American College of Surgeons. It was adapted from an error-reduction system started by the Veterans Administration system (a pioneer in patient safety and quality in several respects).

A recent report found across-the-board safety improvements in those hospitals participating in the NSQUIP since it was started in 2005.

The problem is that only about 250 hospitals in the United States participate. The College of Surgeons is now looking for ways to lower the $35,000 annual price tag for participation, which apparently has been a barrier to smaller hospitals to adopt the program.

Here is a list of the hospitals that currently participate in the NSQUIP.

The Wall Street Journal Health Blog reports on a new program growing out of NSQUIP which will help surgeons and patients calculate the exact risks of a proposed procedure and individualize it for their own hospital, based on data collected by the NSQUIP.

The NSQUIP program marks another step forward in giving patients the information they need to make intelligent choices about their health care. Unfortunately prospective patients don't have direct access to the NSQUIP data, but some of it is available indirectly through websites that gather hospital metrics, such as the Joint Commission "Quality Check" site and the Medicare Hospital Compare site.

I discuss the pros and cons of various hospital quality ratings in my book, "The Life You Save," where I conclude that one of the best measures now available is patient satisfaction, which is a survey that appears on the Medicare site.

Measured by results -- preventable deaths and injuries due to malpractice, medical errors, preventable infections, misdiagnosis and other events that shouldn't happen -- American health care has a lot of problems. Millions of patients are injured every year, and upwards of 200,000 patients die annually from preventable errors and hospital-acquired infections. The United States also lags far behind other developed countries in basic health outcome measures like life expectancy and infant death rates.

But when U.S. hospitals measure themselves with a different yardstick -- the "process" measures of how often certain important things get done for commonly treated diseases -- the results are astoundingly good. An annual report from the Joint Commission, the agency that inspects and accredits hospitals, finds steady improvement in the "process" quality measures that it looks at -- with most hospitals now performing in the 99% range on things like how often heart attack patients get standard treatments in the ER like aspirin and beta-blocker drugs.

The Joint Commission now measures 31 quality indicators. They cover the most common hospitalizable conditions: heart attack, heart failure (when the pump isn't pumping effectively), pneumonia, surgical care, and children's asthma. You can go to this website to look up information about a particular hospital.

The problems with the report are:

* Data is reported voluntarily by the hospitals, with no independent audit from anyone other than the Joint Commission. The Joint Commission says it's independent from the hospital industry but is often seen by critics as a cheerleader.

* Outcome measures -- deaths and injuries -- are not included in the report. Even infection rates, which could have required reports if Congress ever passes health care reform, are not yet reported.

Consumers Union has a Safe Patients Project. CU says it's high time for the U.S. health care industry to be required to report its results. Patient advocates like me agree wholeheartedly.

Memorize the name of this antiseptic wash and make sure your hospital uses it: chlorhexidine.

Research continues to pile up that diligent but inexpensive efforts by hospital staff can greatly cut the annual toll of an estimated 100,000 lives lost to hospital infections. The latest simple step involves greater use of the antiseptic chlorhexidine to wash patients before surgery.

In two studies reported in the New England Journal of Medicine, post-surgical infections were cut dramatically when either of two steps were taken:

* Disinfect the patient's skin just before surgery with a chlorhexidine-alcohol rub -- instead of the usual iodine prep.

* Have the patient shower for several days before surgery with a chlorhexidine-based soap, like Hibiclens.

Read more on this antiseptic at Wikipedia.

See Pam Belluck's article in the New York Times for more details on the new studies.

My book, "The Life You Save," lists simple ways patients can help reduce their risk of getting infections in the hospital, including chlorhexidine soap. So the latest studies are only confirming the wisdom of this advice. But because many hospitals don't yet do this, you should ask questions and make sure they have plenty of chlorhexidine on board.

The deadly MRSA infection, estimated to kill 19,000 Americans every year (more than the toll from AIDS), has been virtually wiped out in Norway, with three simple steps:

As described in a recent Associated Press article:

Norway's model is surprisingly straightforward.

-- Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

-- Patients with MRSA are isolated and medical staff who test positive stay at home.

-- Doctors track each case of MRSA by its individual strain, interviewing patients about where they've been and who they've been with, testing anyone who has been in contact with them.

Step No. 1, ratcheting back on antibiotic prescriptions and relying more on the old tried-and-true ones, won't go over well in America, where the prescription drug industry pushes all of us into a newer-is-better and more-is-better approach.

But step No. 2 -- test and isolate -- has been proven to work by itself to virtually wipe out the spread of MRSA once it gets into a hospital, by isolating people who are carriers.

The problem is that people can carry the bug on their skin without harm; a deadly infection only happens when it gets into the body of an already vulnerable patient. The answer: do nasal swabs of all incoming patients when admitted to the hospital to see if they are carriers, and if so, isolate them in special units.

Does your hospital do this? If not, you should ask why not. The safest hospitals in the United States do nasal swabs of all incoming patients at the time of admission. It's for their safety and everyone else's.

Actor James Woods' brother Michael died of a heart attack three years ago in an emergency room hallway in Rhode Island because no one was paying attention. Now, something good will come from Michael Woods' death, thanks to a settlement reached between the Woods family and Kent Hospital in the middle of a jury trial.

The settlement creates a new institute to help teach hospital staff how to pay better attention to patients and develop a more "human-centered" standard of care.

An impasse between the two sides in the trial was broken when the president of the hospital, Sandra Coletta, called James Woods the night before the actor was going to testify about his brother's death. As reported in the Providence Journal:

In that call, he said he heard something he’d never heard from Kent Hospital before, someone saying she was sorry for his family’s loss. ... Woods said the family’s peace of mind about the agreement was helped when Coletta met his mother, Martha.

“Sandra and my mother had a very personal moment, a mother-to-mother conversation,” Woods said, calling it a “sweet and dear way to express sorrow.”

“It was all I ever needed to see in my life,” Woods said, “one human being saying to another human being ‘I’m sorry for your loss.’ ”

In announcing the new Michael J. Woods Institute, which will be funded by $1.25 million of the hospital's money, hospital president Coletta said:

"We know we're not perfect at Kent Hospital. Mistakes were made. We can do better. The Michael J. Woods Institute will help establish a leadership role in promoting patient safety and developing new ways to improve the patient experience and clinical outcomes."

This is one often-overlooked benefit of the civil justice system: producing positive safety reforms to try to reduce the toll of medical error. An actor's celebrity helped make that a reality in Rhode Island. On a quieter level, similar positive events happen at the end of many lawsuits, where families who have lost a loved one insist that part of the settlement go toward education and system reforms to make hospitals safer places. Patient safety advocates like me believe this is one of our highest callings.

Medicare's "Hospital Compare" website is something every patient needs to know about. Based on statistics collected by the government program for medical care for patients over age 65, the website has a wealth of information -- not always easy to find, but interesting.

One recent addition to the site is information about the volume of business a hospital has for a variety of selected common surgical procedures -- such as coronary artery bypass, gall bladder surgery, intestinal surgery and a number of others. The numbers give you an idea of what a particular hospital's bread and butter is, and whether there is some hospital in town that does a lot more of that surgery.

As I wrote in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," it's best for a bunch of reasons to go with a hospital that sees many patients just like you. The doctors and nurses have more practice in handling your type of condition and are more aware of the kinds of complications that can occur and what to do to prevent or stop them short of disaster.

Another important website run by Medicare is "Nursing Home Compare.". This site is even easier to use because it has a five-star system of rating nursing homes. Within a short distance, you can find a huge range of quality, as measured by staffing, inspections and other quality indicators.

It's a lot harder to compare hospitals, because a hospital that is excellent for one kind of patient can be not-so-good for another. But both Medicare websites are worth a close look if you have a loved one who needs to go to a hospital or nursing home.

Patients who want to probe beyond the glossy pamphlets and flashy web sites of a hospital or nursing home to see what the real scoop is on the safety track record have one simple way to get the official government inspection report: Ask for it. You have a legal right to a copy.

The report is called a CMS 2567. That's the form from the Center for Medicare and Medicaid Services (CMS) that is filled out by the inspectors. It lists "deficiencies" in one column, and the institution's plan for fixing the deficiencies in the adjacent column. The inspectors work directly for regional offices of CMS or work for the state Health Department. In either case, you have a right to see the institution's report.

Here is a blank sample from the government. Here is an example of a report about a California hospital's deficiencies in counting sponges in an operation.

Consumers Union has an very good web page on how to read these forms. The information is oriented mostly to nursing homes but also applies to hospitals. Click here to read.

If the institution claims it doesn't have a copy of the report readily available, you can write to CMS or your state health department and obtain a copy under the Freedom of Information Act.

Investigative reporters for news organizations have used these reports to expose shocking problems at medical institutions.

Did you know that rupture of an Achilles tendon can be fatal? This common injury has one potentially fatal but preventable complication: a blood clot can develop in the calf while the leg is immobilized for healing of the injury, and if the clot gets big enough, it can travel to the heart and cause what is called a pulmonary embolism.

The Achilles tendon is the ligament that connects the calf muscles to the heel bone. When it ruptures, the patient must have the calf immobilized for several weeks. That can cause blood clots in as many as three in ten patients, because calf muscles when they flex act as a pump to help bring blood back toward the heart. Immobilized calf muscles allow the blood to pool in the deep veins of the leg and potentially clot.

Samuel Burton, a retired Coast Guard captain, died of such a clot, and a distinguished federal judge recently decided the death should not have happened. Judge Royce Lamberth, chief judge of the U.S. District Court for the District of Columbia, ruled that orthopedic surgeons at Walter Reed Army Medical Center had committed malpractice by failing to warn Capt. Burton when they were treating his Achilles tendon rupture about the risks of this blood clot and what he should do if he developed any of the symptoms of a clot.

When Capt. Burton died, his widow was shocked to learn from the medical examiner who performed the autopsy that two episodes of chest pain and shortness of breath, which Captain Burton had experienced in the weeks before his death, were signs of a potential pulmonary embolism. None of the doctors at Walter Reed had ever warned Captain Burton or his wife of this possible deadly complication and what to watch out for. She sued the government for medical malpractice under the Federal Tort Claims Act. After a trial, Judge Lamberth issued a verdict in favor of the widow, and he ordered the government to pay her $2,080,000. Judge Lamberth concluded that if the doctors had properly educated the patient and his wife, they were responsible people who would have appreciated the need to get to a hospital for treatment before it was too late. Both Captain Burton and his wife had assumed that his two episodes of pain and windedness were from deconditioning because he had resumed some physical activities after being off his feet for weeks.

The judge rejected Walter Reed's defense that since statistics showed that only about one in one hundred Achilles rupture patients died of pulmonary embolism, they didn't need to be warned about the risk.

Captain Burton's family was represented in their medical malpractice case by Patrick Malone & Associates.

Read the judge's decision here.

The CEO of Beth Israel Deaconess Medical Center in Boston is speaking out about his hospital's efforts to prevent deadly infections. The question is: How come few other hospital executives are talking about their efforts? Are they not making vigorous efforts? Or are they obsessed with secrecy, as so many in the medical industry are?

Paul Levy posted his hospital's numbers on reducing "central line" infections -- the infections that patients in ICUs get in the large-bore tubes that have to be inserted to monitor activity in the heart and deliver medicines to really sick people. When these infections occur, the already sick patient often dies. Pioneering work by Dr. Peter Pronovost proved that rigorous hand washing and other sanitation practices can reduce these infections to close to zero.

Mr. Levy is justifiably proud of Beth Israel's hard work at getting its infection rate down. But he wrote a blog entry that talked about his disappointment that others have not joined in. Here's an excerpt:

The response to my public and private entreaties in this realm has been silence -- from hospital professionals, from insurance executives who care about a transformation of this industry, and, indeed, from public advocacy groups who care about access to care and the quality of care delivered. Some observers attribute the medical profession's lack of engagement to an underlying fear of transparency. And yesterday, a world expert in this field, whose wisdom and advice I treasure, told me that he has come to accept gradual progress in quality and safety improvement, citing the kind of training doctors get, which does not emphasize these areas. That such a person has become content with gradual changes in the status quo is an indication of what it must be like to beat your head against this wall of recalcitrance for several decades.

My advantage, being without medical training and having had but a short tenure in this field, is that I retain a sense of outrage. Our collective failure to approach this problem using well established methods of process improvement -- including publication of current performance results -- represents a moral and ethical lapse by the clinical and administrative leadership of the medical establishment in this city. Why? Simply put, a profession that takes an oath to do no harm is, by inaction or incomplete action, doing harm. We are causing people to die who should not die. What would we call that if we saw it happening in other sectors of society?

Here's the full blog entry, which has comments below it.

I learned about Mr. Levy's blog from Consumer Union's excellent blog at their Safe Patient Project website.

Patrick Malone was interviewed on the People's Pharmacy radio show on how to avoid medical injuries and get the best care for you and your loved ones. You can listen to a podcast of the show by clicking here.

The hosts of this syndicated public radio show are an interesting couple. Joe Graedon is a pharmacist, and Terry Graedon is a medical anthropologist.

In their interview with Patrick Malone, Joe Graedon shares his own story about a medical tragedy that happened to his mother. The lesson: Any time you have a loved one in the hospital, you need to arrange for 24/7 presence there by a family member or close friend. It's very important to have an advocate with you at all times. Patrick Malone's book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, has an entire chapter on all the ways that an advocate can help prevent injury and get you home safely from a hospital stay.

Pennsylvania continues to lead the nation in showing how public health authorities can cast a little disinfecting sunshine onto the patient safety practices of hospitals.

In its latest report, the Pennsylvania Patient Safety Authority says that in 2008, a total of 194 surgery patients were sewed up with a foreign object still inside them. They have a term for it: RFO, for Retained Foreign Object.

To avoid leaving behind a sponge, needle or other instrument, the nurses and doctors involved in any surgery are supposed to go through a counting ritual. The problem is that the count doesn't always end correctly. In fact, the same Authority reported that last year, there were over 2,000 instances of incorrect counts, which doesn't always mean an object has actually been left behind.

One technique to follow up when there has been a discrepancy in the count is to do an x-ray of the affected area. That should show up any hidden objects.

The RFO problem is expensive for patients and hospitals. According to the Consumer Union Safe Patient Project, the average cost of a hospital stay for the corrective surgery and other problems that come from a retained object is $62,631.

A new series of investigative articles by the Hearst newspapers concludes that errors in medical facilities are still taking some 100,000 lives per year -- a decade after a national report first focused wide attention on the problem. Worse, the reforms that started after that report have been piecemeal and ineffective, according to the authors.

The series concudes:

[T]he federal government and most states have made little or no progress in improving patient safety through accountability mechanisms or other measures. According to the Hearst investigation, special interests worked to ensure that the key recommendations in the report -- most notably a mandatory national reporting system for medical errors -- were never implemented.

Among the key findings of the Hearst investigation:

• 20 states have no medical error reporting at all, five states have voluntary reporting systems and five are developing reporting systems;
• Of the 20 states that require medical error reporting, hospitals report only a tiny percentage of their mistakes, standards vary wildly and enforcement is often nonexistent;
• In terms of public disclosure, 45 states currently do not release hospital-specific information;
• Only 17 states have systematic adverse-event reporting systems that are transparent enough to be useful to consumers;
• The national patient-safety center is underfunded and has fallen far short of expectations;
• Congress approved legislation for "Patient Safety Organizations" as a voluntary system for hospitals to report and learn from errors, but the new organizations are devoid of meaningful oversight and further exclude the public;
• Hearst journalists interviewed 20 of the 21 living authors of "To Err is Human" -- 16 believe that the U.S. hasn't come close to reducing medical errors by half, the primary stated goal of the report;
• New York's reporting system has run out of money and staff -- its last public report is four years old;
• The law mandating reporting in Texas expired in 2007, and funding ran out -- a new reporting law has been passed, but no funds have been allocated;
• Washington State requires reporting, but doesn't enforce that requirement -- and the legislature failed to provide funds to analyze the results.

If there is a silver lining in this cloud, it is that safety experts now know a lot more about how patients can keep themselves safe and secure in the health care system. I report their recommendations in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

A new report from Public Citizen proposes 10 cost-cutting, patient safety measures that would save an estimated 85,000 lives and $35 billion a year. The report, "Back to Basics," analyzed the results of scientific studies of treatment protocols for chronically recurring, avoidable medical errors.

In contrast to the high-tech tests and procedures that many experts blame for staggering increases in the nation’s health care costs, most of the reforms in Public Citizen’s report involve fundamentals as simple as practitioners consistently washing their hands, sufficiently tending to patients to prevent bed sores, and following simple safety checklists to prevent infections and complications stemming from operations.

Many of the proposals on Public Citizen's list are the same that I discuss in my book, "The Life You Save." The only difference is that I believe patients and families can do their own health care reform at home to implement many of these safety measures. I discuss examples of things patient advocates can do at the bedside to help prevent pressure ulcers (bed sores), injuries from falls, blood clots, infections and medication errors. See Chapter 12: "Your Personal Advocate, in the Hospital and Out," and Chapter 13: "The Scandal of Infections in Hospitals and Other Health-Care Facilities, and What You Can Do."

Here is more from Public Citizen's news release announcing their new report.

Aside from the tragedy of needless deaths and injuries, the financial toll of failing to follow accepted safety procedures is astounding. Severe pressure ulcers cost an average of $70,000 apiece to treat. A catheter infection costs $45,000. Each instance of ventilator-associated pneumonia costs $5,800. Collectively, avoidable surgical errors cost an estimated $20 billion a year, bed sores $11 billion and preventable adverse drug reactions $3.5 billion.

"There are many incentives to order expensive tests and procedures and too few rewards for providing basic, sensible care," said David Arkush, director of Public Citizen’s Congress Watch division. "As the largest investor in the nation’s health care system, the federal government should ensure that fulfilling basic patient safety standards is a condition of receiving federal reimbursements. And the government should pay providers for doing the right thing. It will save money in the long run."

Public Citizen proposes that health care providers:

• Use a checklist to reduce avoidable deaths and injuries resulting from surgical procedures (saves $20 billion a year);

• Use best practices to prevent ventilator-associated pneumonia (saves 32,000 lives and $900 million a year);

• Use best practices to prevent pressure ulcers (saves 14,071 lives and $5.5 billion a year);

• Implement safeguards and quality control measures to reduce medication errors (saves 4,620 lives and $2.3 billion a year);

• Use best practices to prevent patient falls in health care facilities (saves $1.5 billion a year);

• Use a checklist to prevent catheter infections (saves 15,680 lives and $1.3 billion a year);

• Modestly improve nurse staffing ratios (saves 5,000 lives and $242 million a year);

• Permit standing orders to increase flu and pneumococcal vaccinations in the elderly (saves 9,250 lives and $545 million a year);

• Use beta-blockers after heart attacks (saves 3,600 lives and $900,000 a year); and

• Increase use of advanced care planning (saves $3.2 billion a year).

One hundred thousand preventable deaths from medical errors in hospitals each year: That is the usual statistic cited by patient safety advocates. It comes from a 10-year-old report issued by the Institute of Medicine of the National Academy of Sciences. The fact is, though, that the death and injury rate could be substantially higher. No one is sure, because no one is counting "adverse events" in a rigorous, systematic way, and evidence keeps piling up that hospitals under-report these events to health authorities and worse, cover them up.

An investigation by the New York Daily News of the city's municipal hospital system -- with eleven hospitals and 1.1 million patients treated last year, the nation's busiest city-run system -- found dozens of examples of failures to report egregious errors, and subsequent cover-ups including alteration of medical records to make it look like nothing had gone wrong.

The Daily News reported:

The coverups hid a trail of human suffering among patients who were maimed and relatives who were never told the truth about how their loved ones died or were injured unnecessarily.

The newspaper found a pattern of failures by state health authorities to act on evidence of fraudulent behavior in covering up the injuries. Moreover, it found that the state reporting agency itself was dysfuctional. According to the article:

The state is supposed to track and analyze all medical incidents and implement improvements. The problem is this oversight system — the New York Patient Occurrence Reporting and Tracking System (NYPORTS) — is a disaster.

Since 1999, all New York hospitals have been required to self-report a long list of medical incidents to NYPORTS, which in turn analyzes the incidents and implements patient safety reform.

Sunday NYPORTS barely functions. The Statewide Council that oversees it hasn't met in more than two years. Though NYPORTS is supposed to release "annual" reports, the last one filed is dated 2004.

To avoid needless injury, patients have to be vigilant about their own health care. That is why I wrote my book, "The Life You Save," which lays out a system of nine simple steps for patients to follow to get the best medical care and avoid the too-frequent disasters that happen in our fragmented care system.

Medicare has just published new information that helps patients determine if their local hospitals have a dangerous "revolving door" problem with some of their treatments.

The revolving door happens when a patient is sent home but then has to be readmitted to the hospital within one month. That means either that the patient was sent home too soon in the first place, or didn't get appropriate followup care outside the hospital to prevent the need to be rehospitalized.

Medicare's Hospital Compare website has added "readmission rate" reports for all U.S. hospitals for three types of illnesses: heart attacks, heart failure and pneumonia.

USA Today has done its own analysis of the Medicare data and made it easier to search for hospitals near you.

I discuss finding a top hospital using the Medicare information and other tools in Chapter 14 of my new book on health care, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

The news from Colorado that a drug-addicted surgery technician had exposed thousands of patients to the Hepatitis-C virus raises questions about the institutions' procedures for protecting patients.

According to news accounts, the surgery tech, Kristen Parker, swapped her dirty syringes, filled with saline, for clean ones filled with Fentanyl, in operating rooms at Rose Medical Center in Denver and Audubon Ambulatory Surgery Center in Colorado Springs. That way she could steal Fentanyl, a powerful morphine-based drug that is used for surgical anesthesia, and inject it into herself to feed her drug habit. Ms. Parker has just been charged in a federal criminal complaint.

The institutions are sending certified letters to 4,700 patients at Rose and 1,000 at Audubon advising them to get tested for Hepatitis-C. That's because Ms. Parker tested positive for Hepatitis-C, and several patients already have tested positive.

Hepatitis-C is a virus that causes chronic liver infection in about 75 to 85 of every 100 persons who get an acute infection. A few of those who get chronic infection go on to develop cirrhosis or liver cancer. There is no known cure for Hepatitis-C infection.

The Colorado Springs Gazette reports:

Parker worked at Rose from October 21, 2008 until April 2009. She resigned on April 20 from Rose, but the hospital refused to accept her resignation and instead fired her.
She went to work for Audubon shortly after being fired from Rose. She worked there from May 4 until Monday, said Dr. J. Michael Hall, Audubon's medical director.
Hall said certified letters are being sent to all patients who had outpatient surgery at the center's Circle Drive and Union Boulevard location May 4-July 1 advising them they may have been exposed and with instructions on what to do.

Surgical technicians are not licensed health care providers. Yet because their job involves preparing operating rooms for surgery, they have access to powerful drugs, so it's foreseeable the job can attract addicts. A similar incident occurred in Washington, D.C., a few years ago, where a tech at a major hospital was caught swapping out syringes filled with powerful pain reliever drugs for plain salt water so that he could inject himself with the narcotic drugs.

According to the Gazette:

Prior to being hired at Rose, she [Ms. Parker] submitted to a pre-employment blood test which tested positive for hepatitis C. She was allowed to start work but hospital officials counseled her about the disease and exposure possibilities.
Rose placed her on administrative leave following an incident in which a co-worker was pricked by a needle in Parker's pocket on March 23, 2009.
According to the affidavit, Parker quickly disposed of the needle and denied any use of narcotics. She was allowed to return to work after a drug screening test came back negative.
The hospital placed her on administrative leave again after a co-worker reported seeing Parker in an operating room to which she was not assigned. She was tested again for drugs and this time the results were positive for Fentanyl.

The questions yet to be answered include:

1. Why hire someone positive for a contagious disease like Hepatitis-C and give them access to needles which can spread the disease?
2. Why not fire her the first time she was found with a needle?
3. Why did the second institution hire her so quickly after she was fired by the first? Were references checked? Shouldn't she have been required to advise the surgery center who her most recent employer had been?
4. Should there be a central data bank so that health care employers can find out about fired or disciplined employees, so they cannot easily travel from job to job? There is such a data bank for licensed health care workers, but perhaps it should apply to unlicensed ones as well.

Nobody wants to go home from the hospital only to be readmitted within a few weeks. But that revolving door is very common in conditions like heart failure, where the patient's heart muscle doesn't pump effectively after it has been weakened by heart attack or other heart disease.

The open secret of the hospital industry is that the financial incentives of Medicare and private insurers are tilted toward keeping that revolving door going. Hospitals that actually invest money in following patients after they leave the hospital to try to keep them healthy find that they lose money on this follow-up care. Reed Abelson of the New York Times wrote a report describing how progressive hospitals that have tried to keep their patients from readmission have lost millions of dollars in the process. Those include the Park Nicollet Health Services in Minnesota and Catholic Healthcare Partners in Cincinnati.

One lesson from this story is that patients don't have to wait for medical payment reform to get better care and avoid the revolving door. If you or someone in your family has heart failure, here are the early warning signs that symptoms may be worsening and a doctor or nurse should be called:

* Weight gain. Patients need to weigh themselves every day. Sudden weight gain often means a buildup of fluids caused by the heart not pumping effectively.

* Shortness of breath. Fluid buildup often is most apparent in the lungs and is signaled by being out of breath.

* Ankle swelling. Another place where fluid buildup can be spotted early.

A phone call to the nurse can result in an adjustment of medication that may ease the problem. If that doesn't work, a visit to the doctor's office might be in order. The goal is to intervene before a crisis develops and you have to be rushed to the hospital in an ambulance.

If your doctor already has a system in place that helps you monitor yourself at home, that means you have a top-quality doctor. If you have a hard time getting such a monitoring system going with your doctor, then it might be time to switch to someone who is more responsive.

Patrick Malone discusses how to find a top primary care doctor in his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst