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?

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.

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.”

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 only Dr. Marty Makary could be everybody’s doctor. He’s a surgeon at Johns Hopkins Hospital and associate professor of Health Policy at the Johns Hopkins School of Public Health. Unlike many of his fellow professionals, he’s vocal about the deficiencies in the delivery of health care, and openly discusses the problems of medical malpractice.

Makary led the effort of the World Health Organization (WHO) to measure hospital complications and co-developed the life-saving checklist for surgeons that’s become best practice to reduce infection and mistakes and to improve patient outcomes. As author of “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare,” he’s often quoted about medical error, and his informed opinions widely reproduced.

We think highly of his work, and are sharing some excerpts from his book. Our selections come from a long story recently published on The Daily Beast.com/Newsweek, but he’s been widely quoted in other media, including The Wall Street Journal.

On Overtesting and Overdiagnosing
“A host of new studies examining the current state of health care indicates that approximately one in every five medications, tests, and procedures is likely unnecessary. What other industry misses the mark that often? Others put that number even higher. Harvey Fineberg, M.D., president of the Institute of Medicine and former dean of the Harvard School of Public Health, has said that between 30 percent and 40 percent of our entire health-care expenditure is paying for fraud and unnecessary treatment.”
…
“Politicians debate different ways to pay for our broken system. But if we are going to get serious about reducing health-care costs—and improving health-care outcomes—we need to address the 20 percent of medical care that is unnecessary and dangerous. The public should demand disclosure of a hospital’s patient-outcome statistics. After all, we have information on a car’s safety record to inform our decision about which car to buy. But when it comes to choosing medical care, the consumer is left to walk in blind. While we currently have a free market for health care, the competition is at the wrong level. Many patients tell me they choose their medical care based on parking. For an industry that represents one sixth of the U.S. economy, we can do better than that.”

See our blog, “Overtested, Overtreated, Overcharged.”

On Hospital Competency
“While patients are encouraged to think that the health-care system is competent and wise, it’s actually more like the Wild West. The shocking truth is that some prestigious hospitals participating in a national collaborative to measure surgical complications have four to five times more complications as other hospitals. And even within good hospitals, there are pockets of poorly performing services.”
…
“The wide disparity in the quality of medical care is no secret among hospital staff. In a study I conducted in 2006, we asked hospital employees, ‘Would you feel comfortable receiving medical care in the unit in which you work?’ While there were hospitals where 99 percent said yes, at more than half of the hospitals we surveyed, the majority of health-care workers said no. And to the question of whether their hospital gives priority to what’s best for the patient, again, in more than half of the hospitals surveyed, the majority of health-care workers said no.

“In other words, everyone who works in medicine knows about this problem but few talk about it. A cardiovascular anesthesiologist once described to me a colleague who was one of four heart surgeons at his well-known heart hospital. This surgeon had six consecutive deaths during routine bypass surgery. Half the operations of his last 10 surviving patients took several hours longer than the norm, often requiring the patient to be put back on the heart-lung bypass machine after having come off it. I asked my friend if he ever thought about reporting this surgeon to someone. He laughed and asked, “Like who?” The hospital administration loved this young doctor and was making a mint off his work. The senior partners were very protective of him—he covered their holiday shifts and happily tended to whatever the senior surgeons did not like to do. Whenever one of his complications was discussed at a peer-review conference, they cut him tremendous slack, attributing the death to some extenuating patient circumstance.”

See our blog, “An Insider Dishes About Hospital Ratings.”

On Hospital Transparency
“A new generation of doctors has been developing fair and simple ways to measure how well patients do at individual hospitals. In hospital-speak, we call the information “sensitive data”—data that would tell you which hospitals have much worse outcomes than others.

“It’s the kind of data that, if you had access to it, would help you know just where to find the best care. But you don’t. And that is precisely the problem with the entire system: because a hospital’s outcomes are hidden from the public, neither consumers nor payers have any way of measuring whether the medicine they provide is good, adequate, or even safe. Much as the financial crisis was incubated when bank executives turned a blind eye to the ugly details about their mortgage-backed securities, so too does medicine’s lack of accountability create an institutional culture that results in overtreatment, increased risk, and runaway costs.”

See our blog, “Rating Hospitals by Readmission Is Not Simple.”

On Dangerous Doctors
“Years ago, one of my favorite public-health professors, Harvard surgeon Dr. Lucian Leape, opened the keynote speech at a national surgeons’ conference by asking the thousands of doctors there to ‘raise your hand if you know of a physician you work with who should not be practicing because he or she is too dangerous.’ Every hand went up. Doing the math, I figured that each one of these dangerous doctors probably sees hundreds of patients each year, which would put the total number of patients who encounter the dangerous doctors known to this audience alone in the hundreds of thousands. If, say, only 2 percent of the nation’s 1 million doctors are seriously impaired or fraudulent (and most experts agree that 2 percent is a low estimate), that would mean 20,000 impaired or fraudulent doctors are practicing medicine. If each one of these doctors typically sees 500 patients each year, then 10 million people are seeing impaired or fraudulent doctors annually. Incredulous at the numbers, I took to asking the same question whenever I spoke at conferences. And the response was always the same.”
…
“[T]he National Practitioner Data Bank collected by the U.S. Department of Health and Human Services … is also known as the national “blacklist” of doctors. The public has absolutely no access to it. When I requested the list, I was given a version with the doctors’ names deleted; the only groups that can query the list are state medical boards or human-resources departments doing background checks. Ironically, sex offenders’ names are broadcast to the community when they move into town, but doctors who lose their license in one state because of sexual misconduct with a patient are shielded by name in the database if their license is later restored or if they continue to practice medicine in another state.”

See our blog, “Minnesota Tells Dangerous Doctors: We Won’t Punish You.”

On Preventable Medical Errors
A 2010 New England Journal of Medicine study concluded that as many as 25 percent of all hospitalized patients will experience a preventable medical error of some kind, and 100,000 will die annually because of errors. If medical error were a disease, it would be the sixth-leading cause of death in the country. My research partner lost his father due to a medical error. My medical partner lost his younger sister due to a medication error. My best friend’s mom had her breast removed unnecessarily because she was mistakenly told she had stage-III breast cancer. My grandfather died at age 60 from a preventable infection following a surgery he didn’t need. Andy Warhol died prematurely of a mistreated gallstone at 54; “Saturday Night Live’s” Dana Carvey had open-heart bypass surgery on the wrong vessel; and the singer Kanye West’s mother recently went to a surgery center for a routine plastic surgery, developed a rare complication, and died.”

See our blog, “Medical Mistakes That Led to a Greater Good.”

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.

Twelve years ago, Helen Haskell’s son died because of a series of medical errors. That sad episode prompted her to found Mothers Against Medical Error (MAME), which offers support and advice for people who share such tragedy.

Haskell’s ongoing effort to quantify medical errors and the harm they can cause are detailed in her story on Reporting on Health, an online community for people to share information that fosters better media coverage of health and medicine.

You can’t head off medical harm, Haskell contends, until you can identify its reach. Until 2010, she writes, the primary source cited for the frequency of medical harm in the U.S. was a 1999 report by the Institute of Medicine (IOM). As venerable an institution as it is, the IOM collected data for the report from the 1980s and 1990s--old numbers that didn’t fully offer even a sense of what was happening at the end of that decade, much less more than a decade later.

In addition, the IOM reported only on hospital admissions (see our article, “Hospital Errors” ); but medical harm, of course, occurs in outpatient clinics and surgery centers, in physicians’ offices and nursing home, in dialysis clinics and chemotherapy centers -- wherever medical care is rendered.

In short, while the IOM metrics were solid, they gave an incomplete picture of the impact of medical harm in the U.S.

In 2010 and 2011, Haskell says, new studies were published by the Health and Human Services Department in the New England Journal of Medicine (NEJM) and Health Affairs that advanced the body of harm knowledge.

Employing a system called the Global Trigger Tool developed by the IOM, the studies probe medical records for evidence of potential adverse events. To no one’s surprise, Haskell writes, the newer research found “exponentially greater levels of harm than had been reported earlier by the IOM.

Specifically:

• more than 1 in 4 hospitalized Medicare patients had suffered an adverse medical event resulting in harm;


• approximately 180,000 Medicare beneficiaries died every year from their medical care;


• 1 in 3 patients admitted to three large teaching hospitals suffered medical harm, often more than once;


• nearly 1 in 5 patients in 10 North Carolina hospitals experienced at least one adverse medical event;


• a commonly used adverse event detection method—voluntary reporting and the Agency for Healthcare Research and Quality’s Patient Safety Indicators--was poor; it missed 9 in 10 of the events (Global Trigger Tool found at least 10 times as many confirmed, serious events).

The researchers concluded, “Though disappointing, the absence of apparent improvement is not entirely surprising. Despite substantial resource allocation and efforts to draw attention to the patient-safety epidemic on the part of government agencies, health-care regulators and private organizations, the penetration of evidence-based safety practices has been quite modest.”

This “modesty” was quantified:

• only slightly more than 1 in 100 U.S. hospitals have implemented a comprehensive system of electronic medical records;


• only 9 in 100 have even basic electronic record-keeping;


• physicians-in-training and nurses routinely work hours in excess of what’s proved to be safe;


• compliance with even simple interventions such as hand washing is poor in many centers.

In the intervening years, medicine has become more corporate and more consolidated. Bottom-line pressure has intensified. The incidence of medical encounters has increased, but most occur outside of hospitals, where safety isn’t tracked.

In summary, our collective attention about medical errors and the harm they do has been piqued. But that’s only half the job of actually addressing and minimizing them.

In his article “Ten Medical Mistakes That Changed the Standard of Care,” Dr. Barry Bialek offered a lemons-to-lemonade account on CoverMd.com. In reviewing these sad tales, Bialek demonstrates how medical errors -- and the resolve to right a wrong -- can advance science and the notion of best practice.

Bialek provides some historical perspective as well. Western standards of care, he notes, date to Hippocrates more than 2,400 years ago. The origins of our contemporary understanding of best practices date only to 1910, with publication of the Flexner Report, a seminal document in which Abraham Flexner surveyed the state of medical education in the U.S. and Canada. At that time, only 16 of the 155 medical schools required more than a high school education for admission.

“The practice of medicine across the U.S.,” Bialek writes, “is much more standardized, thanks in large part to changes made by medical schools in response to the Flexner Report.” Among those changes are rigorous medical school admissions and clinician licensing. In addition, standards of care are (mostly) based on science.

Here are Bialek’s 10 tales of teachable mistakes.

1. In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a Nebraska cornfield. His wife was killed and he sustained serious injuries, as did three of their children. The local hospital’s care was inadequate, even by the standards in those days. Later, Styner stated, "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed."

Their tragic adventure spawned Advanced Trauma Life Support (ATLS) and changed the standard of care in the first hour after trauma.

2. Judy, 39, underwent a supposedly routine hysterectomy. But she died on the operating table, and an autopsy revealed that the anesthesiologist had placed a breathing tube not in her trachea, but in her esophagus.

Such a grave, simple anatomical mistake today is avoided because an anesthesiologist measures the patient’s carbon dioxide levels, which are much higher from the trachea than from the esophagus, with a CO2 monitor.

3. Sally’s labor for her first child was long, so her obstetrician administered Pitocin, a synthetic version of the hormone oxytocin, to speed things up. Unfortunately for the baby, the Pitocin prompted fetal distress that went unrecognized, and she suffered severe brain injury and cerebral palsy.

Today, fetal monitoring to test both uterine contractions and fetal heart rate is the standard. If fetal distress registers, it takes only 30 minutes for the baby to be delivered.

4. Bill was driving when he suffered a seizure and crashed his car into a tree, crushing both legs. Arteriography, an X-ray mapping of the arteries depicting the progress of an injected fluid, revealed that his right leg was salvageable, but his left leg was not. But the X-ray technician mislabeled the films and the orthopedic surgeon amputated Bill’s right leg.

Today, the surgical site is marked and multiple health-care providers interview each patient before he or she undergoes surgery.

5. Tom was 12 when his appendix burst. Three days after his appendectomy at a local pediatric hospital, his fever spiked anew. After one week, the surgeon performed a second procedure and found the cause—a surgical sponge had been left inside the wound.

Today, post-operative sponge and instrument counts are routine. In addition, threads visible on X-ray are woven into surgical sponges, so that such tools are readily apparent in post-operative X-rays.

6. As a young child, Betty had been given penicillin, turned blue and was rushed to the hospital. At 15, she contracted Strep throat, was given penicillin and died. No one had asked her about medication allergies.

Today, medical questionnaires always include a high-profile space for allergies.

7. Linda was in her first trimester of pregnancy, and not doing well. Nausea and vomiting had left her severely dehydrated and low on potassium. She was seen in a busy emergency department where the nurse made a simple mistake in arithmetic and added too much potassium to her IV. Within an hour, Linda was dead.

Today, clinical personnel don’t compound this medicine on the fly—potassium is added to IVs by the manufacturer and labeled.

8. Frank, 72, broke his right leg in a car accident. He recovered for a few weeks in a rehab facility in which the nurses didn’t know they were supposed to move him periodically, and he developed deep pressure wounds. They became infected, and Frank’s leg had to be amputated.

Today, caregivers know that pressure wounds are mostly preventable by regularly repositioning at-risk patients every two hours to enable blood flow to the skin.

9. Lillian was 68 and weighed 250 pounds when she underwent surgery to remove her gall bladder. The second day after surgery, she needed help walking to the bathroom. Her nurse, Millie, couldn’t bear the load, and they both fell, breaking Millie’s right arm and Lillian’s left leg.

Today, clinical personnel are taught proper lifting techniques, and they practice them.

10. Christy was 42 when her doctor discovered a large lump in her left breast. It would have been evident during Christy’s two previous annual exams, had those physical exams been complete. By the time it was diagnosed, the cancer had progressed beyond cure.

Today, breast self-exams are taught widely, and are routine in physical examinations. Mammograms are also standard care.

Bialek concludes his malpractice roundup by noting that the federal government and medical schools, acknowledging that all of the mistakes he recounted could have been prevented, have developed guidelines for prevention and treatment of many diseases. Chief among them is the Agency for Healthcare Research and Quality (AHRQ) from the Department of Health and Human Services. The website offers guidance to medical consumers as well as practitioners, including how to locate good quality medical care and reduce medical errors; how to compare medical treatments; how to navigate the health-care system; and how to assess insurance coverage.

We’ve discussed several of these topics in our monthly newsletters. If you think you or a loved one might have been the victim of medical malpractice, link to our Medical Malpractice A-Z page for guidance how to proceed.

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.

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.

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.

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?

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.

No surgical patient wants to experience, or remember, the details of their operation, and the drugs given to put patients to sleep generally work nicely to create a blank slate in the mind for anything that happened after the anesthesiologist told the patient to start counting backward. But not always.

As many as 1 in 100 patients reports afterward that he or she was awake during the surgery, and can recount details of what was heard that make it clear it wasn't a dream. The psychic injury is worse because the paralysis that accompanies anesthesia usually means that aware patients can do nothing to signal to the doctor that they can hear what is going on.

Sometimes these patients are psychologically traumatized enough (with post-traumatic stress disorder) that they end up in the office of a malpractice lawyer like me, asking if they have a legitimate claim against the anesthesiologist or the surgeon.

The answer to that question is "Probably not," according to the latest research.

The problem is that while anesthesiologists have a rough idea of which patients are at high risk, nobody knows how to guarantee, or even improve the odds, that "intra-operative awareness" will not occur.

A study published this week in the New England Journal of Medicine assessed two possible ways of cutting the risk of intra-op awareness. One involved monitoring brain waves. The other involved measuring the concentration of anesthetic gases being exhaled by the patient. The study found that neither clearly worked, although there were fewer reports of intra-op awareness in the patients whose anesthetic gas levels were monitored.

You would think that if someone is awake by mistake during surgery, it means they weren't given enough anesthesia. But you would be wrong, according to the experts. Despite decades of research, we don't know that much about consciousness and memory, and their relationship to general anesthesia. And the ability to figure out during surgery who might still be awake when they look asleep is surprisingly rudimentary.

Here's the conclusion of an editorial on the subject that was also published in the NEJM, written by Gregory Crosby, M.D., an anesthesiologist at Brigham & Women's Hospital in Boston:

Monitors are meant to supplement, not supplant, clinical decision making, and depth-of-anesthesia monitors that reduce complex neurobiology to simple numbers are no exception. It is unreasonable to expect any such monitor to unfailingly detect conscious awareness — a specific and still mysterious property of the brain and mind — and neither patients nor physicians should think otherwise. Notwithstanding this and other weaknesses of current devices, a window into the anesthetized brain, albeit a foggy one, may still be useful, in conjunction with information from other monitors ... as a generic, all-purpose index of the brain's response to powerfully sedating drugs. Whether these devices add value in this way remains to be seen, but when minding the mind during sedation and general anesthesia, a little insight into how the brain is reacting is apt to be better than none, especially if it challenges historical ways of gauging anesthetic depth and catalyzes the search for something better.

Article first published as Awake by Mistake During Surgery: A Patient's Nightmare on Technorati.

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.

Another episode in the if-you-build-it-they-will-come (and pay) story of medical technology has been written recently by hospital emergency rooms. In 1996, about 3 in 100 ER patients were given a CT scan; by 2007, the figure had grown nearly fivefold, to 1 in 7 ER patients, according to a new study in the Annals of Emergency Medicine.

Does this greater diagnostic investment result in fewer people being admitted to the hospital — which is a good thing — or are CTs being overused, and padding the health-care bill without much payoff?

The hospitalization rate following a CT scan was 26% in 1996, and 12% percent in 2007. During that period, the overall hospitalization rate of ER patients rose from about 11% to about 13%.

The cost-benefit issue was examined recently by Kaiser Health News, not only in the context of cost, but because CT scans — which render a three-dimensional image by coordinating a series of X-rays taken from multiple angles — can subject patients to excess radiation.

The researchers, from the University of Michigan Health System, said the radiation risk could be higher for children, patients receiving multiple scans and those who develop complications from the intravenous dyes the imaging often requires.

The American College of Emergency Physicians claimed that fewer patients being admitted to the hospital can be attributed partly to the diagnostic tool.

Hard to argue with a technology that appears to help cut hospital admissions by half, but the study also finds that this positive effect of CT scanning “appeared to diminish after 2003” when the rate “flattened and stabilized” as CT use continued to rise.

Dr. Keith Kocher, the study’s lead author, said, “There are risks to overuse of CT scans … so if they’re done for marginal reasons you have to question why. For example, patients who complained of flank pain (pain in the side) had an almost 1 in 2 chance of getting a CT scan by the end of the study period. Usually most physicians are doing that to look for a kidney stone, but it’s not clear if it’s necessary to use a CT scan for that purpose.”

“Also, during the study period, [emergency department] visits increased by about 30 percent,” Kocher said, “while CT use increased 330 percent, meaning the rate of CT use grew 11 times faster than the rate of ED visits.”

Several factors contribute to the increased use of CT scans:

• the greater availability of the equipment;


• doctors’ fear of being sued for malpractice;


• a perception that patients want the test; and


• financial pressure to make use of the machine.

A handful of symptoms accounted for a disproportionate use of CT scans in the ER — impairments of nerve, spinal cord or brain function; flank pain; convulsions; vertigo; headache; abdominal pain; and general weakness. Approximately 1 in 4 CT scans performed in the U.S. is done in an emergency department, the study found.

If CT scans are overused, figuring out how to reduce their use is tricky, noted Dr. Robert Wears, an emergency medicine doctor who wrote an editorial accompanying the study. Such decisions, he said, are made on a case-by-case basis.

“What is acceptable and appropriate use or nonuse of CT imaging is not an entirely objective question that can be neatly resolved by empirical data and formal analysis,” he wrote, “but rather a tangled, socially constructed issue involving competing views of risk, benefit and obligation, and the elusive question of how much certainty we must have.”

The last thing an injured or ill person wants to do is engage in a protracted discussion about the suitability of care — he just wants to stop hurting. Still, when a CT scan is prescribed, Kocher advises patients to ask if it’s truly necessary. Or ask this: If the CT comes out one way, how will the care be different from how it would be if it comes out another way? Here's where the doctor may hem and haw. The doctor will probably still want to do the scan, and maybe she’s right. But the greater the awareness of the issue, the sooner a reasonable and appropriate standard of care can be determined.

Article first published as Why is Use of CT Scans Soaring in Emergency Rooms? on Technorati.

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.

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.

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

Making physicians aware of the cost of regular lab tests cuts the daily bill for those tests by as much as 27%, according to a new study.

The study, published in the May issue of Archives of Surgery, first monitored the baseline daily per-patient cost for two common lab tests - complete blood count and total chemistry panel – among surgical patients at Rhode Island Hospital in Providence. Once the baseline was established, researchers made weekly scripted announcements to the physicians-in-training who order most of the tests and to their attending physicians about the cost of those tests, but doctors were never told when or when not to order a particular test.

When the program began, the daily cost per non-intensive care patient was $147.73. Over the 11 weeks of the study, that dipped as low as $108.11 in the eighth week. There were a couple of weeks where the cost of tests went up from the previous week, but those corresponded with a new influx of intern physicians who were hearing the announcement for the first time.

Over 11 weeks, the official total saved was $54,967. (In practice, of course, the true amount saved would be less, as the official savings is based on the sticker price of the tests, not the amounts actually paid by Medicare or negotiated with third-party insurers.)

Study co-author Elizabeth Stuebing says the results show what can happen merely by giving physicians information they don’t usually get. “We never see the dollar amount of anything," she says. "The first week I stood up and said that in the previous week we’d charged $30,000 of routine blood work and I could hear gasps from the audience.”

Source: The Wall Street Journal

You can read an abstract of the study here.

Ask any nurse for stories about dealing with doctors, and you will hear that American hospitals and other health care institutions have a long way to go before civility and teamwork rule the day. Why is that a malpractice prevention issue?

Nurses have a vital role as a check and balance to catch mistakes and oversights by doctors that could lead to tragic malpractice injuries. But a typical example, when a nurse quietly questions a doctor's order for a medication that the nurse doesn't think appropriate, is to hear the doctor say: "When you get an MD after your name, you can question what I order."

Stamping out the attitude of doctor superiority is important for everyone in the health care system, especially patients. That message came through loud and clear in letters to the editor of the New York Times responding to a nurse's frustrated column about being humiliated one too many times by a doctor in front of a patient.

The CEO of one of New York City's top hospitals: Herbert Pardes of New York-Presbyterian Hospital, wrote:

The best doctors I know consider themselves part of a team and use the team’s knowledge to the advantage of the patient. They think “patient first” and draw on the experience of nurses, laboratory technicians and other medical professionals. The patient receives the doctor’s best treatment advice based on the collective knowledge of the team.

Doctors who accept only their own counsel are putting ego before medicine, possibly at the expense of the patient. Hospital care should be based on collective wisdom to reach the best treatment plan. Nurses, doctors and all highly trained medical professionals each have a role to play, each of which is invaluable to the patient.

And another letter writer, Donna Nickitas, a nursing professor at Hunter College, said:

As a nurse, I would not want my family member or my nursing students in a hospital where physicians demean and insult their nurse colleagues, thus hampering their ability to care. A culture of civility and a climate of respect and dignity not only win the day but also ensure patient safety and quality care.

So when you're in a hospital and you see doctors acting arrogantly, know that it's not just a personality quirk, but something that could be bad for the health of any patient, including you and your loved ones.

“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

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.

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.

A new study from the Office of Inspector General of the US Health and Human Services Department estimates that one in seven Medicare patients in hospitals -- or some 134,000 patients per month -- are hurt by "adverse events" in hospitals.

Nearly half of those events are preventable, based on reviews by doctors, the report says.

Read the summary of the report here.

And here is a USA Today story about the report.

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.

St. Joseph Medical Center in Towson, Maryland will pay $22 million to the federal government to settle claims that it engaged in a decade-long, illegal kickback scheme with the cardiology group MidAtlantic Cardiovascular Associates, which was co-founded by Mark G. Midei - the cardiologist accused of performing hundreds of unnecessary heart procedures.

More than 100 patients have filed malpractice lawsuits against the hospital and Midei. He was taken off duty in May 2009 under suspicion that he had falsified patient records to justify unneeded stent procedures.

Dr. Midei filed a suit against St. Joseph last month in which he said that officials there ruined his reputation by warning nearly 600 patients about his work. He denies all allegations against him.

Read more in the Washington Post article here.

Ambulatory surgery centers (ASCs) that specialize and have high case volumes have better patient outcomes, according to a study by researchers at four U.S. universities.

The researchers found that the more a facility specialized in its services –and the higher its case volume for those services, the higher its patient quality scores. The researchers defined quality performance as the likelihood that an ASC patient undergoing surgery would avoid unplanned hospitalization within 30 days after the procedure.

To perform the study, which examined potential associations among ASCs organizational strategy, structure and quality performance, the researchers obtained claims data for arthroscopy and colonoscopy procedures performed from 1997 to 2004. “Quality performance” was determined by the likelihood that an ASC patient undergoing surgery would avoid unplanned hospitalization within 30 days after the procedure.

Ambulatory surgery, or outpatient surgery, is provided for patients requiring less than a 24-hour stay. ASCs have become more common across the country because (a) advances in surgical technology and anesthesia have made surgery easier on patients and so consequently more in demand; and (b) the cost of providing the same procedure in an ASC is often considerably less than hospital outpatient surgery.

According to a KNG study, the specialties with the highest percentage of Medicare-certified ASCs in 2007 were ophthalmology (19%) and gastroenterology (18%), followed by pain management (8%), orthopedics (7%) and dermatology (4%). Multiple specialty ASCs comprised 35% of the total.

Source: Medical Care Research and Review

You can view the KNG study here.

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.

Hospitals that want to reduce their exposure to malpractice lawsuits from patients might want to take a hard look at a new study about a radically new strategy: Being honest with patients when errors have happened.

The usual hospital strategy in the face of a malpractice event is to deny everything and hope the patient and the family go away quietly, then when a lawsuit is filed, defend it to the hilt. But they do things differently at the University of Michigan Health System (UMHS), and it's a win-win for both patients and the hospital.

Since 2001, the University of Michigan Health System (UMHS) has fully disclosed and offered compensation to patients for medical errors. Under this model, UMHS has claimed to proactively look for medical errors, fully disclose found errors to patients and offer compensation when at fault.

The study -- newly published in the Annals of Internal Medicine -- compared liability claims before and after the “disclosure-with-offer” program was implemented between 1995 and 1997 and assessed the number of new claims for compensation, number of claims compensated, time- to-claim resolution and claims-related costs.

After full implementation of a disclosure-with-offer program, the study found that the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters. Likewise, the average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters.

Median time from claim reporting to resolution decreased from 1.36 to 0.95 years, wrote the authors, who also reported that the average monthly cost rates decreased for total liability (rate ratio, 0.41), patient compensation (rate ratio, 0.41) and non-compensation-related legal costs (rate ratio, 0.39).

However, the researchers acknowledged that the study “design cannot establish causality” and noted that malpractice claims generally declined in Michigan during the latter part of the study period. As a result, “the findings might not apply to other health systems, given that UMHS has a closed staff model covered by a captive insurance company and often assumes legal responsibility,” the researchers said.

Source: Annals of Internal Medicine
You can view the full text of the study here.

When is a radiation overdose not an overdose? When the facility giving the CT scans says so. At least that's what the Food and Drug Administration concluded when it dropped a safety investigation of the Huntsville, Alabama Hospital.

Now the FDA, which monitors radiation safety for the medical industry, is considering re-starting its investigation, once a New York Times reporting team found that the doses of radiation given to patients at the Huntsville Hospital were 13 times the normal dose for this type of scan, called a CT brain perfusion scan. The scan is used to test patients for stroke.

Even a properly done CT brain perfusion scan delivers about 200 times more radiation to a patient's head than a skull X-ray.

According to the Times, the hospital claims it used higher doses to get sharper images.

A quotable quote from the article, the latest in a series about medical radiation overdoses:

“It is absolutely shocking and mind-boggling that this facility would say the doses are acceptable,” said Dr. Rebecca Smith-Bindman, a radiology professor who has testified before Congress about the need for more controls over CT scans.

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.

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.

A tragic death in Albany, New York proves the power of the civil justice system to spur safety improvements to prevent injury to other patients.

In settling out of court a lawsuit for the death of 32-year-old Diane McCabe, who bled to death after a Cesarean section delivery, the Albany Medical Center agreed to fund for the next 20 years a Diane McCabe Memorial Quality Lecture series focusing on enhancing patient safety. The settlement also requires the hospital to buy a maternal and neonatal simulator to be used in staff training on the labor and delivery unit and to change procedures on the use of a machine that monitors a patient's vital signs during childbirth.

The attorney for Ms. McCabe's family, John Powers, said:

"It was never about the money with the family. It came down to the non-monetary aspects involved with the settlement. They wanted to do something to make certain this doesn't happen to someone else and to create a memorial to Diane for the children as they grow up that they'll know that their mother is being remembered in this way."

Read more in the Albany Times Union here.

Unfortunately the medical industry continues to push for "reforms" that would curb the right of patients and their families to seek legal redress for tragic incidents of malpractice. The industry actually argues that hospitals would work harder to improve patient safety if they were freed from the risk of lawsuits when they fail to live up to their promises. Joanne Doroshow, the author of the Pop Tort blog, has a one word response to this notion: "Pul-leze!" Read more from her column here.

Deaths of mothers in childbirth are fortunately rare. But injuries to the newborn baby are not so uncommon. My law firm's website has more about birth injuries here and here.

A new website has tools for learning how to speak up effectively when you've had a bad health care experience. That can be anything from being on the wrong end of someone's rudeness to being the victim of a serious malpractice event. The website is called The Assertive Patient. Click here for the link. It comes out of Massachusetts but has good resources for patients everywhere.

The website has a good diagram here that shows the steps involved in getting resolution to a bad experience, especially if it's in a hospital. You start with talking with the providers involved and if they are non-responsive, the hospital will have some sort of patient advocate or ombudsman or quality assurance officer or "risk manager" (many different terms cover the same thing). If this doesn't work, formal complaints to regulatory bodies are the next step, or talking to a lawyer.

The final chapter in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, also gives a step-by-step approach to getting to the bottom of poor quality care. And you can get the same information at my law firm's website, by filling out the form to download our free Injury Fact Kit.

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.”

It sure is. Work by Peter Pronovost and other pioneers in the patient safety movement has shown over and over that medicine's culture of "doctor knows best" can be dangerous to patient safety and can cause episodes of medical malpractice. That's because nurses (still mostly female) often see errors in the making and yet feel it is not their place to criticize or correct the (usually male) physician.

Pronovost, a Johns Hopkins critical care doctor, has a new book: Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

Changing the culture of medicine, to encourage nurses to speak up as valued members of the medical team, is critical to improving patient safety, Dr. Pronovost says.

I interviewed Peter Pronovost last year for my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst. One of the things I wrote about then was how the simple culture change of having all members of the surgical team introduce themselves by name at the beginning of the operation has been found to have a big impact on improving safety. Why? Because when people know each other by name, and not just by "nurse," or "doctor," they communicate better with each other, and good communications are vital in preventing hospital errors.

Patient Safety And Sexism In Medicine

I've been thinking about sexism in medicine since the news last month about the west Texas nurse who was brought up on criminal charges for having the gumption to report a doctor she thought was endangering patients to the state licensing board. The nurse was ultimately acquitted, as reported on this blog, but of course the outrage was that she was investigated and indicted in the first place (and fired from her job at the hospital where she had watched this doctor).

It's no surprise that the nurse was female, the doctor was male, and the nurse's accusers in the sheriff's office and the local prosecutor were male too.

Of course, it's not just the gender of the people involved, but their power. Doctors admit patients to hospitals and thus are "cash cows" who are often coddled by hospital administrators for fear the doctor will take his business elsewhere.

After the Texas "not guilty" verdict, there were some interesting comments from nurses about their experiences. One posted on the San Antonio Express newspaper web site was revealing:

I am from the east coast. There, the relationship between doctors and nurses is collegial. We respect one another as licensed professionals. I was amazed that the difference here in Tx. One simple example - if a patient being admitted for chest pain, and their blood test that shows they probably had a heart attack is positive, then standard of care is that they should be admitted to a unit that can do constant heart monitoring (telemetry). Where I am from, if the doctor gave written or telephone orders for a standard unit (without telemetry), it is the DUTY of the nurse to remind him/her that the patient has a positive Troponin and needs a telemetry bed. If you did not do that, and the patient had a poor outcome, the review committee would point the finger to the nurse that took the telephone orders for admission on not taking it up the chain of command until that patient had a telemetry bed. She or he would then face a peer review and be potentially turned into their state licensing agency to determine if their license should be suspended or revoked for failure to follow appropriate patient standards of care.

I heard a nurse very politely say "doctor, would you like a telemetry bed for this patient with a high troponin level"?

His response? "Can you put a nurse on the phone that knows how to take orders"?

The issue was dropped, right then and there, and the decision to let it drop was supported by the ER and hospital nursing supervisor, because they didn't want to upset the physician. Now I have met very nice physicians here, but for the most part, this is the attitude of many physicians towards the nurses. Nurses hold a license, and have a duty to ensure quality and safety of care, in addition to taking care of the patient.This includes reporting even the SUSPICION of unsafe care. It is a shame when our ability to do so is threatened by situations like this.

The handsome silver-haired doctor in the long white coat, standing at the nurse's station in a photograph accompanying a New York Times story, is the national medical director for a chain of for-profit long-term care hospitals. But he puts in barely ten hours a week for Select Medical Corporation, which has no physicians in its top management. Or nurses for that matter.

The founders of the publicly traded company, a father and son team, have made about $200 million since they started Select in late 1996, according to the Times. They also own stock worth many millions more.

From barely a handful in the entire country in the 1980s, the number of long-term care hospitals now exceeds 400, with growth fueled by Medicare payment rules that penalize hospitals when patients languish too long with a particular condition but reward those same hospitals if they can transfer the patient to a long-term care facility. Many of the long-term care hospitals -- and nearly all in the Select chain -- actually consist of a wing or floor within another hospital, so patients can be transferred just a floor or two and for reimbursement purposes be tagged as located in a wholly different facility.

According to the Times report, many of the long-term care hospitals have no doctors in the building overnight as routine practice. They have heart monitors watched by untrained clerks, or not watched at all. Patients have died from lack of appropriate attention.

Here are government inspection reports obtained by the Times from a Freedom of Information request. Statistics show that bed for bed, Select hospitals have four times as many official findings of poor quality than the average hospital.

Medicare rules pay long-term care hospitals more if the patient is hospitalized at least 25 days, but then reimbursement declines drastically for patients who need longer treatment. It's no surprise that the average length of stay at Select hovers at 25 days.

What is the appropriate role of profit making in American health care? Money can certainly drive improvements in technology and medications, but we have to question the role of profits in routine medical care.

This question can be answered -- perhaps unscientifically but with arresting examples nonetheless -- by just one week's worth of news. Joanne Doroshow of the Center for Justice and Democracy did a roundup of the evidence and posted her findings on the Huffington Post.

Ms. Doroshow found lots of reports of terrible injuries to patients and little accountability for the wayward practitioners except through the painful but necessary process of lawsuits in court. As she concluded:

Fixing our health care insurance system is no easy job. But this is the wrong time to consider weakening the legal liability and accountability of incompetent or reckless health care providers.

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.

Time and again in U.S. health care, new technologies are hurried into wide use with little testing, scant training of their human operators, and lack of solid evidence that newer really is better. After the flush of optimism has faded, billions of dollars later, we learn how to judiciously use the new equipment, but only after patients have been hurt or killed by the rush to the new.

The latest example is the deployment of new radiation therapy machines on cancer patients with operators who are not properly trained or credentialed and equipment that has not been tested or calibrated. The New York Times' recent investigative series on the subject prompted one knowledgeable reader, Dr. Joseph Imperato, medical director of the Center for Advanced Radiation Medicine at Lake Forest (Ill.) Hospital. to write this:

To the Editor:

As a radiation oncologist practicing for 25 years, I believe that there is a crucial part of the story of radiation mishaps that has not been mentioned: the “nuclear arms race,” in which people want the newest technologies, without stopping to think about who is operating them.

In the past, academic medical centers were typically the first to obtain and use new technologies. The equipment would be thoroughly vetted and reported on in peer review articles before being accepted and used by the smaller community hospitals.

Now the reverse is true. Small community hospitals often far outpace academic medical centers. One example is the proliferation of proton centers run by for-profit companies. Often the staff has limited knowledge and experience with this extraordinarily complex equipment. And new technologies are often assumed by the public to be better, even though there is often little firm clinical data to support that.

As we struggle as a country to come to grips with health care costs, this is one area where there is great opportunity for savings. Clinical reviews can prevent the proliferation of needlessly expensive technology. What the public must come to grips with is that “new” is not automatically “better.”

See the Times' letters section for more.

In my book, "The Life You Save," I have several chapters that speak to this issue, particularly with new drugs. What patients need to understand is that whatever the technology, the early years of use are in essence a continuation of the testing phase. If you are comfortable with being a guinea pig, that's fine, but very often you can get better, safer care with the tried and true. And if the new technology looks enticing, go with an operator who has the most experience using it, because practice does make perfect.

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.

More evidence of the urgent need for "checklists" to protect patient safety in complex medical treatments comes with a long article in the New York Times about terrible injuries from malpractice episodes during radiation therapy. Yet readers have to dive deep into the article to find this key point.

Scott Jerome-Parks suffered terrible radiation burns to his neck, and lingered for two years in agony before dying, because he received a seven-fold overdose in the radiation that was supposed to treat his tongue cancer, on three separate occasions. Why did it happen? The hospital, St. Vincent's in New York, blamed a confluence of tragic coincidences. But I reached a different conclusion, as I wrote in a blog post to the Times' "Well" blog:

Deep in this tragic article is the following paragraph that exposes the reforms that are needed before medical care can become safe for all patients:

"It was customary — though not mandatory — that the physicist would run a test before the first treatment to make sure that the computer had been programmed correctly. Yet that was not done until after the third overdose."

So there you have it. If the physicist had been required to run the test -- better yet, if the equipment had been set so that it wouldn't work until the final test had been run -- Scott Jerome-Parks would not have suffered the hideous injuries so eloquently described in the article.

Medicine needs to adopt standard and mandatory - not merely "customary" -- checklist routines to ensure the safety of patients. This is the thesis of Atul Gawande's new book, "The Checklist Manifesto," and I have a chapter on how patients can enforce checklist protocols before surgery in my own book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Many medical commenters on the New York Times "Well" blog defensively say, "We're only human," to excuse these kinds of errors. Yes! That's exactly the point of the checklist. It recognizes that we're all only human and that when we are deploying potentially deadly treatments, a final check and double-check is needed, every time, before pressing the button.

The Times also found that the manufacturer of the software that ran the linear accelerator, which delivered the radiation, did not have in place until after the injury a simple "fail-safe" mechanism to prevent the kind of error that occurred.

The entire article by the brilliant reporter, Walt Bogdanich, is worth reading. Here is the Times' own summary of the article:

The Times found that while this new technology allows doctors to more accurately attack tumors and reduce certain mistakes, its complexity has created new avenues for error — through software flaws, faulty programming, poor safety procedures or inadequate staffing and training. When those errors occur, they can be crippling.

I also recommend that readers interested in patient safety issues go through some of the NYT "Well" blog posts on this article.

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.

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 recent news about the two Northwest Airlines pilots whose licenses were revoked, less than a week after they let their plane wander 150 miles off course, raises the question: Where are the firing offenses in medicine?

The pilots injured no passengers, and the event didn't even qualify as a "near miss." But because they egregiously violated safety rules by working on their flight schedules on a laptop in the cockpit, the aviation authorities did not hesitate to pull their licenses.

In the medical industry, by contrast, it is well known that a doctor will lose his or her license for only flagrant patterns of drug or alcohol abuse or other criminal behavior, with a trail of dead and injured patients usually lasting years before the practitioner is finally put out of business.

Read my entire post on this in the Huffington Post here.

One of the HuffPost comments on my blog post raised the fair point about what should be firing offenses for attorneys. Here's what I said in response:

A firing offense for an attorney should be any conduct that is unethical or negligent and hurts a client. (That's a short and probably incomplete answer to a complicated question.)

In most states, the highest court of appeals of the state has power to revoke attorney licenses. Some do a better job than others. But unlike medicine, everything happens out in the open, for the public to observe.

For patient advocates like me, the frustrating part of the medical discipline system is its secrecy and unresponsiveness. I filed a formal licensing complaint about a Maryland plastic surgeon who put a healthy patient into a permanent coma with a gross overdose of local anesthetic; two years later, I received a one-paragraph response from the state board that he had received a "private reprimand." No details available, because, after all, it's "private."

In another recent case, I complained to the Florida nursing board about a nurse-midwife whose overuse of the uterine-stimulating drug oxytocin caused the uterus to rupture and the baby to suffer terrible cerebral palsy. More than a year later, I received a one-sentence reply that the board had "failed to find probable cause."

In the law world, comparable incidents would have received at least a detailed explanation of why the licensing body was or was not taking action. That's what we should demand of any professional disciplinary system that respects the public's right to know.

The current sorry state of medical discipline is one reason I warn readers of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," that patients need to go way beyond looking up medical licensing discipline to make sure they are picking the right doctor for themselves.

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.

Every hospital patient needs someone with them at all times to help prevent medical errors and keep them safe. That's a mantra I have advocated for years, and another example of why it's good advice comes with a riveting story in the Washington Post by health writer Sandra Boodman.

Ms. Boodman's article tells how a Washington area woman's advocacy in the emergency room and hospital helped lead to a correct diagnosis of baffling symptoms, and likely saved her sick daughter from harm. The article interviews Patricia Dawn about her 4-year-old daughter Brooke's illness, that was eventually discovered to be Kawasaki disease, an unusual heart condition.

Brooke got the right treatment in time, but only because of her mother's persistence. Mrs. Dawn refused the recommendation of the emergency room doctors to take her daughter home at 2 a.m. when she wasn't feeling any better but they had run out of things to do. At her insistence, her daughter was hospitalized, and an infectious disease specialist eventually figured out that the red lips, red eyes, fever longer than five days, and swollen lymph node in the neck all were signs of Kawasaki, which affects about 2,000 American children a year.

It was also at the family's suggestion that the infectious disease doctor was brought in who made the correct diagnosis.

The story underlines the importance of having a good advocate present at all times with a patient in the hospital. Even a lay advocate can see when symptoms aren't improving and can insist on action.

I discuss this subject in depth in Chapter 12 of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

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."

Several letters to the editor in the New York Times have good thoughts on the critical topic of reducing hospital-acquired infections. It's important not just to exhort hospital administrators to try harder, but to set up incentives that reward safety and punish harm. One incentive not discussed in these letters is a national mandatory disclosure system. That would require hospitals to measure and publicly report all their infections. Consumers would then be able to make intelligent decisions about which hospitals to seek care at.

As previously discussed in this blog, Consumers Union has been advocating such a disclosure system for several years and has made headway in various states, but a national system is needed.

Chapter 13 in my new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, talks about, as the chapter title says: "The Scandal of Infections in Hospitals and Other Health-Care Facilities, and What You Can Do." Patients and family members can do a lot to enforce hygiene rules and avoid infection.

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.

Stroke experts have widened the window for when the clot-busting drug tPA can be given intravenously. The previous U.S. guideline was to give the drug only if treatment could be started within three hours of the onset of symptoms. Many patients did not get the drug because they didn't get to the hospital in time or it took too long to do tests to make sure the drug could be helpful. (Everyone with stroke symptoms has to have a CT scan to make sure the stroke is not caused by bleeding in the brain, because if tPA is given on top of bleeding, it could worsen the hemorrhage or even kill the patient.)

The new guideline widens the effective time window to four and one-half hours after symptoms start. It comes from the American Heart Association/American Stroke Association and is based on European studies.

Stroke experts stress that just because there is more time now to administer this drug does not mean patients or doctors should think they can go slow. The faster treatment is begun, the more likely it is to help break up the clot and restore normal blood flow in the brain. Anyone with stroke symptoms needs to be rushed to a hospital with special expertise in stroke treatment.

In a study published this week in The Lancet, a British research team found that surgical stockings given to stroke patients for prevention of blood clots do not work, reports Sam Lister of UK’s Times.

The compression stockings provide graduated pressure and should reduce swelling in the legs. Studies have shown that, for patients immobilized after surgery, these stockings effectively reduce formation of blood clots, which can be deadly when the clots travel up to the heart or lungs and obstruct blood flow.

However, in the new Lancet paper, scientists followed 2,500 stroke patients in Britain, Italy and Australia, and found that the use of compression stockings made no significant difference in the occurrence of DVT (deep vein thrombosis, the blood clots in the deep veins of the legs that can travel to the heart or lungs). Patients who wore the stockings actually suffered additional symptoms that include skin breaks, ulcers and blisters.

The results of the study were also presented at the European Stroke Conference on May 27 in Stockholm. Researchers believe this study conclusively shows compression stockings should not be recommended to stroke patients.

Time was when you had to pay a lot extra to get a private room in a hospital, and the single room was thought to be a luxury for patients. But now research has been accumulating that the private room can play a big role in safety: cutting the risk of infection, helping the patient sleep better at night, reducing the risk of medication mixups, and to boot, making for the kind of real privacy that the Orwellian-termed "semi-private" room does not allow.

In most new hospital construction in the United States, the patient rooms are single-bed, and many of them have other features that promote safety and comfort: like having plenty of room for a family member to stay in the room (so they can act as a patient advocate), and placing a sink near the door to encourage caregivers to wash hands and reduce infections. The American Institute of Architects has called for single rooms in new hospital design since 2006.

These and other features of safety-oriented hospital design are discussed by Carol Ann Campbell in an article in the New York Times.

Another important feature of safe design is placing nurses stations within line of sight for the patient rooms.

Patients who have a choice of hospitals should look to these kinds of issues when deciding what hospital offers the best prospects of safe, high-quality care.

The importance of having an advocate with you at all times in the hospital, how to look for a quality hospital and how to take steps to reduce risk of infections in the hospital are discussed by Patrick Malone in his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst.

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

Strokes cause more disability than just about any other disease, but they don't have to. Effective treatments are known for the most common type of stroke; delivering them to the right patients has proven to be difficult. Now a group of researchers is proposing some changes in how stroke care is organized, with the hope of matching reality to the promise and greatly improving stroke outcomes.

In 1995, a landmark study was published showing that the impact of stroke on the human brain could be greatly diminished by using clot-busting drugs to dissolve the clots that kill brain cells in ischemic stroke. (Ischemic stroke is responsible for about four of five strokes. In ischemic stroke, brain tissue dies because blood clots or narrowed blood vessels block flow of oxygen-rich blood to brain tissue. In hemorrhagic stroke, which affects about one in five stroke patients, brain tissue dies because a burst blood vessel causes bleeding in the tissue.)

Today, though, it is estimated that fewer than one in ten victims of ischemic stroke are treated with either intravenous tPA, the main clot-dissolving drug, or other effective treatments, such as breaking up the clot with a mechanical device inserted inside the blood vessel.

The accepted convention is that tPA does not work unless the i.v. is started within three hours of the onset of stroke symptoms. Most patients don't get to the hospital that quickly, and even when they do, time is eaten up by the necessity to give everyone a CT scan to make sure they are not having a bleeding stroke, for which use of the clot-dissolving drugs could be a disaster.

A new article by Drs. Reza Hakimelahi and R. Gilberto González, "Neuroimaging of Ischemic Stroke With CT and MRI: Advancing Towards Physiology-Based Diagnosis and Therapy," advocates these changes to help deliver more of these proven treatments to more patients:

* Doctors need to recognize that the three-hour window for treatment sometimes is much longer in patients who have blockages of smaller vessels in the brain with some temporary compensation through "collateral" vessels. Better imaging studies can identify these patients who have an "ischemic penumbra" that would benefit from clot-dissolving drugs.

* Many patients can benefit, even after the three hours has expired, by direct intervention with mechanical devices to break up clots from the inside of the vessels. Because this requires expertise in interventional neuroradiology, a field with only a few hundred practitioners in the United States, the authors recommend cross-training for doctors in related fields who know how to use tiny tubes inside blood vessels to deliver treatments. These include interventional cardiologists.

* Hospitals that are recognized as expert in care of acute strokes could be divided between advanced and general levels of expertise. On the general level, any such hospital needs to have 24-hour CT scanning and the ability to give clot-busting drugs in the emergency department. To qualify as an advanced stroke center, the hospital would have to have the ability to do interventional treatments inside blood vessels ("endovascular therapy"), a neuro-intensive care unit, and a team of doctors from multiple specialties that work together to decide the best treatment for each patient.

(NOTE: To read this article, you have to sign up for a free membership at Medscape.com.)

As these ideas are debated in the medical industry, the best strategy for patients is to have some advance knowledge and basic planning. Knowing how common strokes are, and how urgent the timeline is ("Time Is Brain" in stroke treatment) once stroke symptoms start, here is what I advocate:

* Know the basic symptoms of stroke, and don't rationalize your way out of a trip to the hospital if the symptoms seem mild or go away after a few minutes. Here is a basic list from the American Stroke Association:
* Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
* Sudden confusion, trouble speaking or understanding
* Sudden trouble seeing in one or both eyes
* Sudden trouble walking, dizziness, loss of balance or coordination
* Sudden, severe headache with no known cause

* Know which hospital in your area has advanced stroke treatment staff and machines. Ask if they have a multi-disciplinary team. (It should include both neurosurgeons and endovascular therapists.) Ask if they have a neuro-intensive care unit (an ICU that treats only patients with brain or spinal cord problems).

* If a loved one suffers stroke symptoms, do not let the rescue squad take them to the nearest emergency room UNLESS the same hospital has advanced stroke treatment abilities.

* A multi-disciplinary team is important because conflicts of interest can drive doctors to advocate for therapy they can do when a safer, more effective treatment might be available from a doctor with different training. Having doctors work together to help the patient and family decide treatment is the best approach.

In his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, Patrick Malone discusses one tragic case in which a patient needed a teamwork approach to her neurological problem but didn't get it because the hospital had no effective team in place. The book discusses the questions to ask to make sure your doctors are working together and not as competitors for your health care business.

Getting a loved one home from the hospital is always a relief for both patient and family, but the weeks immediately after hospital discharge are fraught with peril, as many families don't discover until the patient has to be readmitted for a new problem. This is especially common with Medicare patients: an alarming one in five Medicare patients are back in the hospital within thirty days, and one in three are readmitted within ninety days. Fully half of the non-surgical patients who have to be readmitted in the first month after going home had no followup visit with any doctor during that same month. That means the patients were basically set adrift to fend for themselves. These numbers come from an analysis published in the New England Journal of Medicine, as reported in an editorial in the New York Times.

Leaders in the health care field freely admit that hospital readmissions come about from poor discharge planning and inadequate communication with family members about what they need to do to keep the patient healthy. The president of the American Hospital Association said in a letter to The Times about the editorial: "Most unplanned readmissions can be traced back to our fragmented delivery system, and to the lack of social support programs for many elderly and sick patients."

What is the answer?

Family members who are assigned by hospitals to take care of a loved one at home need to be very clear on what they are supposed to do. Do not let a family member be dumped on your lap without a clear, written list of everything they need, including medications, therapies, and appointments for return visits. Family members need a lifeline they can call on when things don't seem to be going right.

The leaders of our health care system are talking about extending Medicare benefits so that nurse managers can coordinate the transition from hospital to home, or teams of caregivers can conduct house calls on recently discharged patients. These are promising ideas, but what is needed right now is for anyone who has a family member coming home from the hospital to speak up and insist on clear instructions and advice. Being forceful and clear can help the caregivers help you to make sure there is a well thought out plan and that you can realistically carry it out.

Patrick Malone's new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, has a chapter on how family members can become effective patient advocates when they have someone in the hospital. The chapter includes a list of key checkoff points that you need to understand when a loved one is discharged to your care. You need to have at a minimum:

* A written set of discharge instructions.

* A specific appointment with the doctor in charge for a followup visit.

* A list of bad things to watch out for, and the contact person to relay this information to.

* Written lists of all medications that need to be taken, when and how; plus all therapies that need to be done with similar detailed instructions.

An international research team has shown that death and complication rates from surgery can be dramatically improved by using simple checklists to make sure that safety measures are taken before, during and after each operation.

The research project, involving nearly 8,000 patients at eight hospitals around the world, was done as part of the World Health Organization's program called Safe Surgery Saves Lives. The results were published in January 2009 in the New England Journal of Medicine.

When the surgical teams at the hospitals used the checklists, they found that death rates were cut in half and non-fatal complications by one-third.

The nineteen items on the surgical safety checklist include basic items like verifying that the team has the correct patient and the correct surgical site, making sure the pulse oximeter (which measures oxygen in the blood) is working, making sure antibiotics have been given within one hour before the start of the surgery to prevent infection, and confirming that x-rays needed for the case are on display in the operating room. One other item on the checklist is to have all members of the surgical team introduce themselves by name and role; this is intended to give permission to lower-status team members to speak up at a later time if they notice something wrong. Click here for the entire checklist from the WHO (which is part of the United Nations).

The Patrick Malone law firm has prosecuted many lawsuits against hospitals where these basic preventive steps were not done and their absence led to tragedy. Examples include non-functioning pulse oximeters, surgery done on the wrong body part, and failing to prepare for known possible risks like heavy bleeding.

Patrick Malone discusses steps that patients can take to make sure their surgeons follow safe practices in his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, available at Amazon.

Hospitals have long used color-coded bracelets as shorthand to communicate patients' needs to doctors and nurses. For instance, a purple bracelet might indicate that a terminally ill patient does not wish to be resuscitated in the event of heart failure.

Now there is a movement to standardize bracelets, preventing confusion when a health care worker moves from one hospital where (for instance) yellow bracelets mean "do not resuscitate" to another where they indicate an allergy to peanuts.

Bracelets have other pitfalls--for instance, a patient might not wish to advertise a certain desire or condition to visiting loved ones. And children have a tendency to take them off and trade them with each other.

The important thing, if you or a loved one is staying in a hospital, is to know what the colors of your bracelets mean and be prepared to tell doctors and nurses about it. If a doctor or nurse comes up to you or your loved one and begins doing something you don't understand, do not hesitate to ask about it--not only is it good for you to know these things in general, but they may be acting on a misinterpretation of the colored bracelet.

Forbes Magazine has an informative article on the frequency of hospitals making mistakes while caring for patients, pointing out that 1.5 million Americans fall victim to such errors every single year.

Some of these errors occur through sheer carelessness: for example, 100,000 people a year die from "superbugs," bacteria that are resistant to available antibiotics. Infections from these superbugs can frequently be prevented by hand-washing. Yet other errors are the system's fault and not the fault of any individual. They occur because of overcrowding and the consequent inability of doctors and nurses to spend sufficient time with each patient.

The article also cites an Auburn University study showing that hospitals administer the wrong drug one time out of five. The dosage of the drug is another common source of error. A famous recent example of a drug error is from last November when actor Dennis Quaid's newborn twins were given 1,000 times the intended dose of the blood-thinner heparin. Luckily the hospital detected the error before permanent damage was done.

What is the bottom line? There are no magical solutions, especially since most of these problems are systemic. As a doctor quoted in the article says: "If you're sick, the best way to avoid getting sicker is to take charge of your care." Asking questions and being unafraid to make demands is the most any individual patient, or their loved ones, can do to reduce risk of error.

USA Today has published the government's best estimates of death rates due to heart attack, heart failure and pneumonia for every American hospital for the past two years. The article has links to the pages where the death rates are published. As USA Today points out, this information was previously inaccessible to most patients.

From the article:

Now anyone with access to a computer can directly compare a local hospital with the one across town to see how it stacks up against the biggest medical institutions nationwide.

Death rates from heart attack, heart failure and pneumonia are widely viewed as yardsticks of a hospital's overall performance.

Using this resource is one good way that people can get the information they need to make sure their health is in the best hands.

Tara Parker-Pope recently had an article on how fewer and fewer patients trust their doctors.

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.

The distrust and animosity between doctors and patients has shown up in a variety of places. In bookstores, there is now a genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease.

What are the reasons for this new distrust? Several factors appear to be involved:

(1) Patients often don't understand what is going on with their health care because doctors and nurses are too rushed to explain things to them. Dr. Sandeep Jauhar, cardiologist and author of Intern: A Doctor's Initiation, is quoted in the article with a story of a patient who was transferred from one hospital to another with no explanation for why. He blamed a "broken system" for such failures to communicate.

(2) There has been greater coverage in the news of medical error, the power of the drug industry and the flaws in health care administration.

(3) The Internet makes information much more available, so patients can be informed skeptics. Drug companies also market directly to patients, so they come into the doctor's office with their own desires and opinions on what medications they should take. The upside to this is that patients have the information to challenge a doctor's errors. The downside is that many end up taking a drug commercial, for instance, at face value and will not listen to a doctor's reservations about the efficacy of a drug.

Again, from the article:

“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

The whole article is worth reading. In addition, the article's page also has an embedded video clip of interviews with people discussing their attitudes to their doctors.

Starting October 1, 2008, Medicare will no longer pay for eight hospital-acquired conditions that could be prevented if hospitals followed the proper guidelines.

Those eight conditions are bed sores, objects left inside the patient during surgery, falls that occur when the patient is in the hospital, blood incompatibility, air embolism, mediastinitis (infection of the area between the lungs, which can happen after a heart bypass surgery), catheter-associated urinary tract infections, and certain bloodstream infections. In addition, several other conditions have been proposed as additions to the list.

The purpose of this change is to provide an incentive for hospitals and health care providers to avoid errors and prevent neglect of patients. If both Medicare and the patient refuse to pay for treatment of a hospital-acquired condition, then the hospital is stuck with the costs, and most hospitals would obviously wish to avoid that.

This is a long-overdue incentive for hospitals to reduce the incidence of these events and injuries which should never happen.

Senior citizens who bring company to their doctor or hospital visits receive better medical care, according to a new study published in the Archives of Internal Medicine. Of the 38.6% of elderly patients who brought a companion along on their medical visits, the most common person to bring along was a spouse or an adult child, followed by other relatives and friends and neighbors.

The effects of bringing along a companion are clear and beneficial:

The parts that these companions played varied. Primarily, they aided communication in the visit, with 63.8% of companions filling this role. Of these, 44.1% reported recording physician comments and instructions, 41.5% communicating information related to the patient's medical conditions to a health professional, 41% asking questions, 29.7% explaining the instructions given by the physician, and 3.3% who translated the English language. Companions filled other roles as well, with 28.4% of all companions present for moral support and to provide company, 16.6% to help schedule appointments, and 8.4% to provide physical assistance.

Additionally, the elderly patients who regularly brought companions were more satisfied with their physicians' services, including technical skills, information dissemination, and interpersonal skills. If their companions actively assisted with communications, the patients rated their physicians' informational and interpersonal skills more highly. This trend became stronger in patients who reported themselves to be in worse health.

Not only is an elderly person more likely to feel better during the visit if he or she brings along a supportive person, but it will also lead to better communication with the doctor.

Larry Ragan, a man who spent a great deal of time around doctors before dying of Lou Gehrig's disease, made a list of suggestions for hospital workers, regarding how they can improve their treatment of patients.

Much of the advice centers around basic respect. Don't condescend to a patient by using their first name without permission, for instance. Don't put patients in skimpy and revealing robes: that puts the convenience of the nurse or doctor above the comfort of the patient.

The entire article is worth reading, including the comments from readers at the bottom.

A new study from the American College of Emergency Physicians shows that scarcity of beds and a decrease in the number of hospitals with mental health units has led to long emergency room waits for psychiatric patients.

As the article points out, almost eighty percent of hospitals have a four-hour wait for mentally ill patients. By contrast, for non-psychiatric ailments, only thirty percent of hospitals have a four-hour wait.

From the article:

Only half of the hospitals surveyed had psychiatric units. The rest transferred patients, sometimes far from homes and families. Hospitals are closing their units because of inadequate payments from government and insurers, unpaid costs for the uninsured and too few psychiatrists willing to work in hospitals, says James Bentley of the American Hospital Association.

Patients with mental illness "are the ones we hold the longest because there are so few psychiatric services available, and the ones that are available are overwhelmed," says David Mendelson, of the physicians group.

If you or someone you know has a psychiatric problem, you should be aware of this issue and be prepared for a lack of support in the event of an emergency.

Researchers at Dartmouth University have found striking regional differences in quality of health care. In addition, within any given region, black people are less likely to receive the appropriate health care than white people.

But region was the strongest factor that affected quality of health care. From the article:

For instance, the widest racial gaps in mammogram rates within a state were in California and Illinois, with a difference of 12 percentage points between the white rate and the black rate. But the country’s lowest rate for blacks — 48 percent in California — was 24 percentage points below the highest rate — 72 percent in Massachusetts. The statistics were for women ages 65 to 69 who received screening in 2004 or 2005.

In all but two states, black diabetics were less likely than whites to receive annual hemoglobin testing. But blacks in Colorado (66 percent) were far less likely to be screened than those in Massachusetts (88 percent).

What causes these differences? The researchers suggest that multiple factors are at work:

Such variations may be partly explained by regional differences in education and poverty levels, but researchers increasingly believe that variations in medical practice and spending also are factors.

The most extreme disparities, as the article notes, concern some important and even life-altering procedures. For instance, people in Louisiana, Mississippi and South Carolina are much more likely to have their legs amputated (usually as a result of diabetes or vascular disease) than those in Colorado or Nevada, and black people in those regions are much more likely to undergo amputation than whites. Also, access to mammograms sharply varies according to region.

The U.S. government is launching an ad campaign to promote a website where consumers can check to see how good their hospitals are, measured by such things as patient satisfaction and cooperation with recommended care guidelines. The website, called Hospital Compare, can be found here.

But the federal government is not the only such purveyor of such information: Zagat Survey (the same people who publish the restaurant guide) also rates doctors, for example.

These efforts are limited, however, by the lack of common standards. From the article:

While ratings efforts can be useful, they also can be confusing and limited in scope, says Robert Berenson, a senior fellow with the Urban Institute, a Washington, D.C., think tank that studies policy issues.

"If I were a consumer looking at these reports, I would be bewildered by the variations that show up across different rating systems," says Berenson, who says there is not enough information available to shop for health care the way people shop for cars or televisions.

However, some organizations are making efforts to address this problem:

Last month, the Consumer-Purchaser Disclosure Project, a coalition of groups representing consumers, employers and unions, agreed to develop a national set of standards to measure doctor performance.

There is a growing industry of hired patient advocates. Patients are hiring people to defend their interests when they go to the hospital.

The impetus from this comes from the huge number of patients who die because of medical error, and the growing consensus that going into a hospital as a patient alone is one of the most dangerous things you could do.

From the article:

It is a trend emerging here and across the country, though it's not without controversy — and a hefty price tag. But it may be offering a vital, even lifesaving service in a severely overburdened medical system plagued by a shortage of nurses, doctors and hospital beds. Arizona — with the nation's longest ER wait time and an extreme shortage of doctors and nurses — should prove fertile for the fledgling business. "We have seen so many patients — including my own father and mother — nearly die in the hospital because of mistakes or neglect, we realized somebody had to do something," said Alice Milton, a Tucson attorney now working for Patient Care Advocates, a company launched two years ago in Tucson — first to provide home care services, expanding to hospital patient advocacy in recent months. "This idea was born of personal trauma, of seeing firsthand what kind of fight you have to wage to get decent care for someone you love. And of seeing patients who are absolutely terrified to go to the hospital, because they are certain they will die there," Milton said. "The need for this is huge — great enough to actually earn a living doing it."

Of course, savvy family members and other loved ones can also serve as your "advocate," with the added benefit that they will probably do it for free. But the idea is essentially the same: when you go to a hospital, it is comforting and may even be life-saving to have back-up with you.

Tara Parker-Pope in the New York Times reports on a study by British researchers investigating what questions patients felt comfortable asking their doctors.

Questions that did not imply anything about the doctor's preparation or experience or authority were easy to ask--for example, questions about length of stay, or details about how a procedure worked. However, other questions were tougher:

But questions aimed at improving patient safety and reducing medical errors were far more difficult for patients to ask, receiving an average score of just 2.4 points. Questions that received low marks included:

* “Who are you, and what is your job?”
* “I don’t think that is the medication I am on. Can you check please?”
* “Have you washed your hands?”
* “How many times have you done this operation?”

The abstract of the study, published in the journal Quality and Safety in Health Care, can be found here: How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study

It is clear that, as hand-washing and double-checking medications are important safety protocols, patients need to become more assertive and doctors and nurses need to become less defensive and more open to these kinds of questions.

A new survey on patients' opinions on their hospital stays has some disturbing results:

Many patients reported that they had not been treated with courtesy and respect by doctors and nurses; that they had not received adequate pain medication after surgery; and that they did not understand the instructions they received when discharged from the hospital.

Nationwide, in the average hospital, 67 percent of patients said they would definitely recommend the institution where they had been treated to friends and relatives. Sixty-three percent gave their hospitals a score of 9 or 10 on a scale of 0 to 10.

At the average hospital, more than 25 percent of patients said nurses had not always communicated well with them.

There is more at stake here than the patients' feelings, as Dr. Carolyn Clancy notes:

“Poor communication is a major source of medical errors,” Dr. Clancy said. “If doctors are not listening carefully, patients may not bring up important information. Patients who do not understand discharge instructions are more likely to be readmitted to the hospital or end up in the emergency room.”

In a previous entry, we discussed the phenomenon of a form elder abuse in nursing homes wherein staff give anti-psychotics elderly patients without psychotic disorders in order to make them easier to deal with.

Earlier this month, a study was released following up on that, showing which states have the highest rate of this form of abuse. Louisiana and Connecticut head the list, with Florida, Pennsylvania and New Jersey below the average.

Two recent events highlight the need for easy access to information about a hospital's record of mistakes and violation of standards.

The Florida Supreme Court ruled on Thursday March 6th that patients have a right to see records on past mistakes made by hospitals and health care providers, including very old records, and that laws limiting access to such records are unconstitutional.

In more disturbing news, the Endoscopy Center of Southern Nevada violated hygiene protocols and, consequently, six cases of hepatitis C have been traced back to them. The linked editorial argues that detailed, publicly available information on medical centers and health care providers--standards, inspection results, past errors--is necessary for public trust in medical institutions.

Unfortunately, the Centers for Disease Control and Prevention has issued a warning that the Nevada incident may not be an isolated incident. It is likely that these safety problems exist in other clinics all over the country.

When AIDS was first discovered and little was known about it, that ignorance resulted in a great deal of paranoia, ostracism and cruelty towards AIDS patients.

Now, more than two decades after we have known about AIDS and during which the disease has been studied and treated if not cured, we might be tempted to say that AIDS no longer carries its stigma. But we would be mistaken. A new study shows that AIDS patients continue to be insulted and demeaned by doctors, nurses and other health care professionals who ought to know better. From the article:

Examples include doctors who would not visit a patient's hospital room, neurologists who avoid looking patients in the eye, and ambulance personnel who madly threw bloodied gloves into the street after learning the injured patient carried the virus.

These instances of stigmatic events are described in the study conducted by Lance S Rintamaki of the University at Buffalo and colleagues. The study participants report several of these events, which include a wide variety of health-care personnel. "Clinicians should have the training and common sense to avoid a lot of these behaviors, but perhaps we shouldn't be surprised when hearing about nonclinical staff caught up in these events. They're likely relying on the same stereotypes and misinformation about HIV that are commonplace among the general public, which may lead them to act in fearful and stigmatizing ways toward HIV-positive patients," says Rintamaki.

This is discouraging news in the year 2008. AIDS patients and their loved ones should be prepared for these reactions and should take special care to insist on proper treatment.

Bedsores, a common hospital problem, are not just ugly nuisances. They can turn into deep and extremely painful wounds that go clear to the bone, and can be fatal when infected.

That is why it is encouraging to find that hospitals and nursing homes are beginning to take a highly effective collaborative approach towards preventing bedsores. From the article:

New research is suggesting that the battle against bedsores requires a team approach, enlisting everyone from nurses and nursing assistants to laundry workers, nutritionists, maintenance workers and even in-house beauticians.

For instance, laundry workers can be in a position to notice when patients' garments are restrictive and ill-fitting, which increases the likelihood of bedsores. All staff can help by repositioning patients during waits for food and other services. Proper nutrition goes a long way towards helping this problem as well, research suggests.

As this blog has discussed in the past, collaborative efforts can be helpful to all kinds of medical problems. Evidently such approaches are useful in dealing with this painful issue as well.

The Centers for Disease Control and Prevention (CDC) has an article on hand hygiene. Much of it is somewhat technical, categorizing different types and levels of sterilization precautions and measurements of efficacy.

If you scroll down, however, there are quite a few practical details that may be helpful. Much of it is common sense: fingernails that are long or artificial, for instance, have been linked to outbreaks of infections and the presence of pathogens. If you wear a ring, the skin under the ring is more likely to be colonized with bacteria than the rest of your hand. And, of course, wearing gloves play an important role in maintaining good hygiene.

If you scroll down even further, you'll get to Part II of the report, which is the CDC's recommendations about how to maintain hygiene in various professional contexts.

If the number of emergency rooms go down and the number of medical emergencies rise, it stands to reason that the average waiting time in emergency rooms would get longer, resulting in more problems and even deaths. That is exactly what is happening right now in the U.S, as a new study from Harvard Medical School demonstrates.

In 1997, half of all patients waited for 22 minutes or more in the emergency room. Today, they wait for 30 minutes or more.

Most disturbing is the fact that even patients with the most dire and urgent problems are subjected to greatly increased waits. From the linked article:

Even those experiencing a heart attack are not assured speedy treatment, with half waiting 20 minutes or more to be examined in 2004, up from eight minutes in 1997, the study found. The same was true for those with other serious health problems: By 2004, patients whose conditions warranted treatment within 15 minutes were waiting 14 minutes or more to see a doctor, up from 10 minutes in 1997, the study found.

These longer waits are due to a number of factors: shortage of doctors and nurses, an aging population, and the fact that for uninsured Americans the emergency room is the only method of accessing healthcare. So not only do more people go to the emergency room for non-urgent problems, but many Americans also do not have access to the preventative care that would reduce the risk of serious emergencies that need to be dealt with right away.

Out of nineteen industrialized nations, the U.S. has the most deaths that could have been prevented by access to timely, effective medical care.

Ellen Nolte and Martin McKee of the London School of Hygiene and Tropical Medicine performed the study, looking at deaths before the age of seventy-five caused by numerous diseases and complications. They found that France performed the best by this measure--though France, and other countries that ranked higher than the U.S., spends less money on health care than the U.S. does.

Not only was the U.S. the worst in these rankings, but we Americans are also ranked four places lower than we were in the last study (which covered 1997 and 1998). We are getting worse and spending more money.

By January 1st of this year, Illinois was to have established a system for reporting and reviewing egregious hospital errors--e.g. sponges left inside patients after surgery. But it has not done so. Illinois has also failed to fulfill other elements of the hospital safety legislation the state passed four years ago. For instance, the Illinois Hospital Report Card was supposed to have been published, but is nowhere to be seen. Illinois officials are now predicting that it will be released in October.

Officials blame this failure on everything from poor leadership to lack of funding to unrealistic expectations. Whatever the cause, the failure is disappointing because--as the Consumers Union health-care expert Lisa McGiffert points out--Illinois was regarded as a role model for other states in this area.

It is safer to have a heart attack in an airport or casino than in a hospital.

Why? One reason is that many hospitals still rely on old-fashioned defibrillators rather than the newer ones found in public places. The new ones are fully automated, faster and easy to use.

Chances of surviving a heart attack are nearly 40 percent if you are defibrillated within two minutes of the attack--but fall to 22 percent if it takes longer. Hospital staffs in the study took longer than two minutes in nearly one third of all cases.

What happens when a hospital makes a mistake in medical care, and the harm to the patient results in the need for another medical treatment? It used to be that the patient was charged for this subsequent treatment, which would have been unnecessary but for the hospital's error. An article in the Journal of the American Medical Association (JAMA), cited in the New York Times discusses the economics of this system. Indeed, the system is set up so hospitals are financially rewarded for their mistakes.

But as the NY Times article points out, Medicare has changed its rules so that it will no longer compensate hospitals for the following mistakes: objects left in patients during surgery, incompatible blood transfusions, infections from vascular catheters and other hospital-acquired problems. This does bring up the potential problem of hospitals not having financial incentive to provide good care for these medical problems, but there are laws in place mandating that hospitals provide such care, so that may not be as much of a problem as some would fear.

Shockingly, nursing homes having been giving elderly residents anti-psychotic drugs--not to combat actual psychosis, but rather to quiet symptoms of Alzheimer's or other forms of dementia and make the patients more docile and controllable.

This overuse of anti-psychotics is so rampant that it accounts for why Medicaid has recently spent more money on anti-psychotics than on any other type of pharmaceuticals.

This is not wholly due to malicious intent on the part of the nursing homes, but also on the fact that federal insurance programs are more willing to give money for drugs rather than for the extra staff that are needed to care for elderly patients with dementia.

This report highlights how medical institutions can harm the most vulnerable patients by giving them medications they do not require in order to meet economic or administrative goals.

An article in the New Yorker by Atul Gawande highlights the simple ways in which hospitals can be made less dangerous places for their patients. A checklist to make sure intensive care doctors and nurses handle catheters correctly has been proven to dramatically reduce the risk of deadly infections. Gawande focuses on the work of Peter Pronovost, MD, an intensive care specialist at Johns Hopkins Hospital who consults with hospitals around the country to spread his gospel of routinizing simple procedures. For example, on catheter infections, Pronovost's work was first published in December 2006 in the New England Journal of Medicine. In 108 ICU's across Michigan, they were able to virtually wipe out catheter-based infection by enforcing a required checklist of five interventions: hand-washing before handling a catheter, full-body draping when inserting a central venous catheter, scrubbing the skin with chlorhexidine, avoiding catheters in the groin, and removing unneeded catheters as soon as possible. All hospitals should implement these simple ideas which can prevent deadly infections and save lives. Dr. Pronovost is a pioneer in patient safety research.

Hospitals have been getting some negative attention recently as a result of their high rates of infection. That is why it is good to hear that they are stepping up efforts to fight MRSA, one of the worst "superbugs" that infect patients in hospitals.

Their efforts can be boiled down to two categories: testing and hygiene. They are trying to make it a common practice to test surfaces and equipment and patients for the presence of these bugs. They are also encouraging hygiene by placing alcohol sanitizer dispensers in hallways and outside patient rooms, and by placing secret observers to watch if their doctors and nurses are washing their hands as often as they are supposed to.

Patients cannot do very much to ascertain whether or not their hospital is testing for MRSA, but hygiene is often much more obvious. A careful patient or family member should watch and see if there are sanitizer dispensers in their hospital's hallways, and if the healthcare providers are taking advantage of these dispensers. You should not hesitate to ask if the doctor or nurse has washed their hands, or to complain if you know that they have not. Such basic measures can prevent deadly infections.

Rhode Island Hospital has, for the third time this year, done a brain surgery on the wrong side of the patient's head.

The hospital has been fined $50,000 and has received a reprimand from the state Department of Health. In this most recent instance, the patient was 82 years old. Fortunately, the patient was unhurt by the mistake. However, in one of the previous instances of this mistake at this hospital, the patient died as a result.

Rhode Island Hospital has said that it will be conducting a review of its procedures and implementing reforms. One such reform would be to allow nurses greater power in ensuring that procedures are followed correctly. Another would be to mandate better verification of surgery plans, which would require better communication between surgeons and other doctors. These reforms highlight a major factor in averting medical errors: teamwork. The multiple healthcare professionals involved in taking care of a patient need to be empowered to speak up if they see something going wrong. They also need to know what the others are doing, and to make sure that they are not acting contrary to the recommendations and instructions of other healthcare providers. Performing a surgery on the wrong side of the head is only one possible thing that could go wrong in the absence of communication. Another example would be giving a patient medications that, combined with medicine the patient is already taking, could cause problems. Such errors can be minimized through proper communication between healthcare professionals.

For more information: When Surgeons Cut the Wrong Body Part

Going to a hospital and getting even sicker is an all-too-common occurrence for many in the U.S.A., thanks to the high hospital infection rates.

Indiana University School of Medicine researcher Dr. Bradley Doebbeling is using a $400,000 grant to study this problem and come up with solutions. The study will take eighteen months and will require participating hospitals to come up with better hand hygiene policies and screen patients for MRSA (methicillin-resistant Staphylococcus aureus). MRSA is the most common example of what is known as a “superbug,” a strain of bacteria resistant to antibiotics.

Participating hospitals will also have to record the number of patients who get MRSA—something federal and state governments do not require hospitals to do.

The hospitals in the study say that they are already noticing results. This is unsurprising considering how straightforward the study’s experimental policies are: hand-washing and screening. Learning that such basic measures help prevent sickness is hardly a massive discovery.

Infections contracted in hospitals can be a serious threat to patients' health. The CDC estimates that roughly two million patients per year develop infections in hospitals, out of which approximately 90,000 per year die. The Consumers' Union discusses how many states have adopted laws requiring hospitals to disclose rates of patient infection, and how more states are considering such measures.

Disclosing infection rates will hopefully lead to better patient safety and stronger compliance with prevention protocols. It is a good idea for people to remain aware of the infection rates at local hospitals.

Thankfully, some hospitals are beginning to fight the problem more aggressively. Although many people who work in large U.S. hospitals view infections as either a non-issue or as inevitable, hospitals are beginning to take more severe measures to curb them.

As described in the July 27th, 2007 issue of the New York TImes, three state legislatures have passed bills requiring hospitals to routinely test high-risk patients. The article also notes that that CDC projections estimate that one out of 22 patients would become infected while hospitalized, and that some European countries have had success in aggressively fighting infections.

This is a late response to a problem that has existed for a long time, as an earlier Times article documented on the Veterans Affairs website indicates.

Infection is often caused by carelessness about hygiene, and can lead to tragedy—for instance, the article refers to a woman who lost her mother because of an infection that was probably contracted because a caregiver had unwashed hands. Patients ought to be aware of this issue. If possible, it is a good idea to seek out hospitals where some anti-infection measures are taken.

The July 24th, 2007 issue of the New York Times Health Section discusses recent findings indicating that a lower nurse-to-patient ratio leads to more patients on respirators getting pneumonia.

One of the Swiss researchers who performed the study (involving 936 patients) said that with fewer nurses, each nurse has a larger workload to shoulder and therefore has less ability to properly follow all hygiene-related rules. Patients should be aware how staffing problems can affect their standard of care.

This issue has drawn the attention of legislators. For instance, California has passed a law mandating a minimum nurse-to-patient ratio, with the support of the nurses' union. It has also received attention on a national scale, including from Congress--for example, Congresswoman Jan Schakowsky of Illinois introduced a bill to set minimum nurse-to-patient ratios in hospitals.