medication errors

Study: Single rooms should become standard for new hospitals

Anne Zieger — Wed, 27 Aug 2008 12:01:07 -0400

Have you noticed, lately, that when hospitals and health systems announce a new facility, it usually comes with private rooms? That's not a coincidence. Increasingly, hospital planners are reaching a consensus that the benefits to single-patient rooms far outweigh the costs, argue the authors of a new paper appearing in the Journal of the American Medical Association.

The authors note that studies have shown single rooms to reduce infections, particularly important in the age of MRSA and other "superbugs," and that they may also cut medication errors. Also, with single rooms, physicians can talk with patients privately, and families can be there. What's more, since they're quieter, single rooms help lower patient blood pressure, heart rate and respiratory rates, as well as improving the quality of sleep and helping with pain management.

While the authors admit that single-room hospitals increase construction costs, with added expenses of $182 to $400 per patient for a new single-room ward versus $122 to $500 for a ward with double rooms, many of these expenses are capital costs that will be recouped comparatively quickly, researchers suggest.

To learn more about this study:
- read this HealthDay News piece

Related Articles:
Hospital construction costs skyrocket
Trend: Evidence-based hospital design increasingly popular
Design changes improve hospital safety
Study: Hospitals' design impacts employee turnover

CA hospitals fined for dangerous deficiencies

Anne Zieger — Mon, 18 Aug 2008 17:04:31 -0400

The California Public Health Department has announced that it has fined 18 hospitals $25,000 per violation for deficiencies in their performance, citing them for administrative problems that could have led to patient harm if unchecked. The hospitals were fined for failing to protect patients. Incidents that triggered citations included five leading to patient deaths, one wrong-patient surgery and two cases in which objects were left in the body after surgery. The Department also found medication errors, as well as processes that didn't meet the hospitals' requirements for licensure. Most hospitals received one citation, but four hospitals got two, including Anaheim General Hospital, Doctors Medical Center in San Pablo, UCLA Medical Center in Torrance and San Gorgonio Memorial Hospital in Banning.

To learn more about the fines:
- read this Modern Healthcare piece (reg. req.)

Related Articles:
CA fines nine hospitals for putting patients at risk
CA law would ban patient dumping

Study: Accidental drug overdose rates hit new high

Anne Zieger — Tue, 29 Jul 2008 11:22:13 -0400

A new study suggests that deaths from medical mistakes at home have gone up substantially over the last two decades, driven largely by growing home use of prescription painkillers and other drugs that were once used largely in hospitals. According to the study, which appears in the Archives of Internal Medicine, such deaths have climbed from 1,132 in 1983 to 12,426 in 2004, while medication errors away from home increased only five percent during the same period. (Researchers drew this conclusion based on studies of almost 50 million U.S. death certificates.) Causes for these deaths include abuse of prescription drugs, valid prescriptions taken in error--especially narcotics--and multiple prescription drugs taken at once.

Despite the large data set they had, researchers couldn't determine what proportion of the deaths was attributable to these various causes. However, they suspect that mistakes with valid prescriptions are on the rise. Such mistakes appear to have led to the recent death of 25-year-old actor Heath Ledger.

To learn more about this study:
- read this Associated Press article

Related Articles:
TN makes doctor shopping a felony
CT Attorney General sues FDA over OxyContin

Babies given heparin overdoses at TX hospital

Anne Zieger — Thu, 10 Jul 2008 12:56:16 -0400

Yet another incident of heparin overdose to babies has occurred, pointing to the difficulty in controlling this problem despite massive national attention to the issue.

Up to 17 babies in a Texas hospital's neonatal intensive care unit may have gotten heparin overdoses, and one of the babies has died. The overdoses that occurred at Christus Spohn Hospital South of Corpus Christi, TX, were discovered on Sunday, two days after the medication is believed to have been first administered. While the hospital has mounted a full-scale investigation of the incident, their preliminary conclusion is that the error occurred during the mixing process within the hospital pharmacy, according to the hospital's CEO.

Of the group of infants that got the overdose, 12 of the other 16 babies remain in stable condition in the NICU, while three have been discharged. One remains in critical and unstable condition as the baby has since admission to the NICU. The baby that died was already seriously ill, and doctors at the hospital have yet to determine what role the heparin overdose played in his death.

To learn more about the incident:
- read this CNN.com item

Related Articles:
Heparin scare leads to new dosing issue
Number of heparin-related deaths reported triples
Baxter provides update on heparin reactions
Post-heparin, no oversight excuses

CA hospitals disclose more than 1000 medical harm cases

Anne Zieger — Mon, 30 Jun 2008 10:18:33 -0400

California hospitals have made their first official disclosures of never events occurring in their facilities, a step required under a state law enacted in 2006. The disclosures, which cover the period between July 2007 and May 2008, address 28 never events specified in the legislation. The state's hospitals reported a total of 1,002 cases of serious medical harm, including wrong-organ surgeries, administration of incorrect drugs and neglect of serious medical conditions. This is a small percentage when weighed against the 4 million hospital admissions that occur in California each year, but still serious, observers note.

As in other states, California has considered legislation which would bar hospitals from charging patients for care that led to medical harm. Originally, such legislation would have covered all 28 conditions tracked by the state, but at the urging of hospital and physician lobbies, the legislator behind the proposed ban has cut back on what errors would be barred from charges.

To learn more about the error reports:
- read this Los Angeles Times piece

Related Articles:
NY Medicaid will stop paying for 'never events'
By 2008, Medicare won't pay for hospital errors
Businesses say: 'no pay' for major mistakes
PA hospitals won't charge for 'never events'

MA Blue plan, state ban payment for medical errors

Anne Zieger — Thu, 19 Jun 2008 13:09:02 -0400

In another major blow for this approach, the state of Massachusetts' Medicaid program and the largest health insurer there each announced that they won't pay for a list of "never events." This week, Blue Cross and Blue Shield of Massachusetts and the state's MassHealth both said that they won't pay for 28 types of surgical, medication and other errors compiled by the National Quality Forum. Collectively, the two insurers cover about 4 million people in the state, making their decision influential not only in the state, but nationally as well. This follows a round of voluntary commitments by hospital administrators in Massachusetts who have begun vowing not to charge any insurer for medical errors, and instead promise to absorb the costs on their own.

While it's not clear how this policy will affect the Medicaid program, the state, whose public health department recently began requiring that hospitals and doctors report such mistakes, had previously found that 70 such errors were reported during the five five months of the year. More in question is how MassHealth will implement and enforce its policy. Processing 6 million claims a month, it's not clear yet how MassHealth will scan claims to make sure that it's not paying for treatment related to medical mistakes.

To learn more about the insurers' decision:
- read this article from The Boston Globe

Related Articles:
PA hospitals won't charge for never events
MN hospitals won't charge for major errors
By 2008, Medicare won't pay for some hospital errors
Business say 'no pay' for major mistakes

NY Medicaid will stop paying for 'never events'

Fri, 06 Jun 2008 06:59:58 -0400

New York's Medicaid program has decided to stop reimbursing for avoidable hospital complications and medical errors it considers to be "never events." Starting in October, it won't pay for care related to 14 conditions, including wrong-site surgery; foreign objects left in the body; medication errors; blood incompatibility; contaminated drugs and patient disability from electric shock. Hospitals that want to receive Medicaid payments will have to prove that such conditions were present on admission to get paid for treating them. Meanwhile, the state expects to keep expanding this list.

To learn more about New York's decision:
- read this Modern Healthcare report (reg. req.)

Related Articles:
By 2008, Medicare won't pay for hospital errors
Business say 'no pay' for major mistakes
PA hospitals won't charge for 'never events'
CIGNA stops paying for its list of never events

Heparin scare leads to new dosing issue

Fri, 16 May 2008 06:59:55 -0400

While efforts to make dosing safer in the wake of recent heparin-related deaths make sense, such efforts have created a fresh set of safety concerns for providers who use it, observers say. For one thing, with providers turning to new suppliers, the drug is arriving in different quantities and strengths than many medical staffs are used to administering, raising the risk that the drug will be dosed incorrectly. Specifically, new packaging isn't coming in the single-dose form typically distributed by Baxter; instead, many vials contain larger or more potent quantities of the drug.

Heparin already is one of the five "high-alert" drugs most commonly associated with medication errors in hospitals, and this only raises the ante. As a result, some medical centers are having to establish extra precautions. For example, in some hospitals, pharmacists are reminding nurses to draw the drug from a vial instead of using a pre-filled syringe, and have asked the hospitals to remove the syringes so nurses won't make a mistake while switching between products.

To learn more about this issue:
- read this article from the Baltimore Sun

Related Articles:
Number of heparin-related deaths reported triples
Baxter provides update on heparin reactions
Post-heparin, no oversight excuses

Joint Commission issues warning on child med errors

Fri, 11 Apr 2008 06:59:55 -0400

As we reported earlier this week, a new study found that one of 15 hospitalized children is harmed, most often by medication errors. Now, following up on that study, the Commission has released an alert urging hospitals to take children's unique safety needs into account. The new alert asks hospitals to weigh children in kilograms when admitted, given that such weights routinely are used to calculate medication doses for children. Hospitals that weigh children in pounds increase the risk of giving the child a double dose, they noted. The Commission also reminded hospitals to clearly mark products that get repacked from adult formulations for use in children, keep adult meds away from pediatric units, and avoid storing adult and children's meds in the same dispensing machine or cabinet.

To learn more about the Joint Commission's recommendations:
- read this Associated Press article
- read this Joint Commission press release

Related Articles:
Study: One of 15 hospitalized children harmed
Quality studies proposed for children's healthcare
Babies infected at CA hospital
Study: Hospitalized kids get off-label drugs

Study: One of 15 hospitalized children harmed

Mon, 07 Apr 2008 06:59:55 -0400

A study using new methodology for detecting errors points up an alarming discrepancy between the level of potential harm children faced in hospitals, and what may actually be happening. The study, conducted by the National Initiative for Children's Healthcare Quality, concluded that medication errors and adverse drug reactions harm about one out of 15 hospitalized children. The study drew on randomly-selected charts for 960 children treated at 12 freestanding children's hospitals across the U.S. in 2002.

As part of the study, the group developed a new monitoring method which provides a list of 15 "triggers" on childrens' charts that might suggest drug-related harm, as well as specific antidotes for overdoses and side effects. The group did an in-depth review of any case where triggers were found. The group's researchers found 11 drug-related harmful events for every 100 hospitalized children, much higher than the estimated two per 100 estimated by prior methods.

To learn more about the study:
- read this Associated Press item

Related Articles:
Quality studies proposed for children's healthcare. Report
Babies infected at CA hospital. Report
Study: Hospitalized kids get off-label drugs. Report