Why Can’t Hospitals Clean Up Their Medical Errors?

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

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

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

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

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

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

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

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

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

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

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

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

  • Between 2002 and 2008, NYU Langone repeatedly was penalized by the New York State Department of Health for errors that led to patient deaths, including one delay in diagnosing an infant’s herniated bowel and deteriorating condition in the emergency room. The hospital also has a record of operating on the wrong body part.
  • Three times in 2007, surgeons at Rhode Island Hospital, the main teaching hospital of Brown University’s medical school, drilled into the wrong side of patients’ heads
  • In 2009 at the same hospital, a surgeon operated on the wrong side of the patient’s mouth during cleft palate surgery.
  • Also in 2009 at Rhode Island Hospital, a surgeon operated on the wrong finger of a patient.

After each of those incidents, the hospital said it was committed to patient care and would make needed changes. It was fined repeatedly, and has not performed a wrong-site surgery since. But in 2010, the state health department fined the hospital another $300,000 for leaving a broken drill bit inside a patient’s skull.

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

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

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

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

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

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

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

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

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