Are hospitals growing numb to medical errors?


Despite all the talk of efforts to enhance patient safety and improve quality of care, hospitals still have a long way to go. And what I've discovered since joining FierceHealthcare is that just about everyone I talk to has a hospital horror story that suggests we've got a long road ahead where patient safety is concerned. Here's one account I heard recently.

On Oct. 15, Yolanda Robles' 95-year-old grandmother was admitted to a New York hospital for observation after a fall. But what should have been a 24-hour observation turned into a seven-day long stay that ended with discharge to a hospice.

Early on, a nurse failed to correctly identify her and gave her a drug prescribed to the patient in the room next door. The nurse later discovered she had the wrong patient after she told Robles' grandmother that her blood sugar was high and that they would need to give her insulin. Robles' aunt, who was staying with her grandmother, protested that her mother wasn't a diabetic. Luckily, they were able to catch the mistake within an hour. Otherwise, the case of mistaken identities could have been fatal.

It gets worse.

Because Robles' grandmother had developed an arrhythmia, the residents managing her care decided that it would be best to install a pacemaker. But the family said no. Apparently that didn't make a difference. The next morning, a surgery crew came to prep her for surgery. But no informed consent had been signed. "It was insane," Robles told FierceHealthcare.

Robles, who is president of CulturaLink, a company that, among other things, helps healthcare organizations improve patient care by enhancing cultural competency, coached her aunt by phone on how to become a healthcare proxy.

Now in a hospice, Robles' grandmother may have a few weeks left before she goes into that good night.

The situation at the hospital was probably compounded by limited English proficiency. Although Robles' grandmother was listed as non-English speaking, no interpreter ever showed up during her stay.

The hospital's reaction to the whole situation didn't help, Robles said. It was matter-of-fact and no one expressed any real concern for what the family was going through. Robles filed a complaint with patient relations, only to learn that the hospital's policy is not to divulge information about a root cause analysis to the family involved. She plans to file more complaints on up the chain of command.

This set me to wondering: Could it be that the hospital had become immune to the aftershocks of patient safety errors, because they are so common?

Eleven years have passed since the landmark 1999 Institute of Medicine report, "To Err is Human," came out with a guesstimate that up to 98,000 people are killed by hospital errors each year. That number is low compared to an estimate in a report issued this week by the Office of the Inspector General. According to that analysis, hospitals kill 180,000 people with medical errors each year.

To be specific, that number is conservative because it represents Medicare beneficiaries only. Even so, the death toll is the equivalent of one sardine-packed Boeing 747 crashing every day. If that happened, we'd hear about it for sure. It would be all over the news. When a metal can falls out of the sky, it gets our attention.

But these hospital-related deaths barely register. What goes on behind the doors of the hospital usually stays hidden. So-called "never" events or horrible mistakes like the one where a surgeon performed the wrong surgery on a person are rarely publicized. Yet more transparency might help us tackle adverse events--especially the preventable ones.

But if you can't talk about medical errors openly, how do you address the problem? - Sandra

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