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Entries in Errors (3)

Saturday
Jan072012

80 Percent of Hospital Errors Go Unreported

Getty(WASHINGTON) -- Martine Ehrenclou felt sidelined when her mother was admitted to the hospital for acute pancreatitis.

"I didn't know what I was supposed to do and what my role was in her care," said Ehrenclou, 51, of Los Angeles. "I just thought I needed to comfort my mother and just talk to the doctors."

But what was explained to Ehrenclou as a common procedure for the condition turned fatal. While in the hospital, Ehrenclou's mother, who was 71, acquired a host of complications including pneumonia and a staph infection.

Within five months, Ehrenclou's mother died.  

Hospital staff members could have made some mistakes with her mother's care, but Ehrenclou would never know.

A new report released Friday by the inspector general of the U.S. Department of Health and Human Services found that more than 80 percent of hospital errors go unreported by hospital employees.

The report, which looked at data from hospitalized Medicare patients, also found that most hospitals where errors were reported rarely changed their policies and practices to prevent repeat errors, saying the event did not reveal any "systemic quality problems."

The errors included overused or wrong medications, severe bedsores, hospital-based infections and even patient death.

In order to be paid by Medicare, hospitals are required to track and analyze medical errors. But organizations that inspect hospitals loosely regulate hospital tracking records, the study said.

Also, many hospital employees may not recognize "what constitutes patient harm," or they may not realize that particular events harmed patients and should be reported, according to the report.

The national report looked at nearly 300 adverse patient events acquired from medical records and traced the records back to its respective hospitals to see whether the hospitals had identified medical error. The report found very few hospitals did.

Sixty-one percent of unreported cases were not perceived as errors by hospital staff. The remaining 25 percent of unreported cases were situations that were typically reported by the staff, but happened not to be reported.

"We're always going to make mistakes," said Dr. Peter Pronovost, medical director at the Center for Innovation in Quality Patient Care at Johns Hopkins University Medical School of Medicine. "What we need to do is reduce harm."

The more serious events, like hospital-acquired infections and patient deaths, were no more likely to be reported than the smaller cases, like allergic reactions to medications.

Pronovost created a standard patient safety checklist for commonly performed procedures that are implemented in hospitals nationwide.  

The Center for Medicare Services also plans to develop and distribute a list of adverse events that should be reported, said Ruth Ann Dorrill, deputy regional inspector general for the Department of Health and Human Services.

Staff members may have feared retribution or may have not wanted to report their own colleagues said Dorrill.

The study is one of many finding similar results. In April 2011, a study released in the journal Health Affairs found that one third of hospital visits will lead to hospital related injuries, and as many as 90 percent of hospital errors are missed by current surveillance systems.

Forty-four percent of the errors identified were preventable, Dorrill said.

But beyond staff education, family members and patients themselves should be educated too, said Ehrenclou, who authored the book, "Critical Conditions: The Essential Hospital Guide to Get Your Loved One Out Alive."

Ehrenclou promised herself she would never again feel uncertain about her role at the hospital as she felt about her mother. Three years later, when her godmother was admitted to a different hospital for complications because of her diabetes, Ehrenclou felt better prepared.

The hospital staff informed her that her godmother received twice the dose of the sedative benzodiazepine, and her body wasn't capable of clearing the medication.

Her godmother also endured bed sores during her seven-month stay. Although her godmother also passed away, Ehrenclou said she became more involved in her godmother's hospital care by asking questions to understand her condition.

"I would've done so many things differently with my mother. I would've gotten a second opinion from a specialist. I would've done research on her disease," said Ehrenclou. "I would've been on top of all of her medications. I would've communicated all of that to her doctors."

Copyright 2012 ABC News Radio

Wednesday
Nov232011

Pharmacy Errors: Swallowing the Wrong Pill

Comstock/Jupiterimages/Thinkstock(WASHINGTON) -- Have you ever left the doctor’s office not remembering exactly which medication your doctor prescribed and later, whether the pharmacist got it right?

Names like Darvan and Diovan can sound the same. But one is a pain reliever while another is used to treat high blood pressure. And when a pharmacy gives one of the medications to a patient who really needs the other, it could lead to some serious consequences.

Anecdotal evidence suggests that this problem is more common than believed, especially since there are various ways to fill prescriptions, including in-store and online. But there’s no formal method used to track pharmacy errors, according to Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality.

Besides medications that may sound or look alike, other factors can contribute to the wrong prescription getting filled.

Reading a doctor’s handwriting may be just as difficult for some pharmacists as it is for patients. And because some prescriptions are filled with the cheaper generic alternative of a prescribed brand name drug, it’s difficult for many patients to tell whether they’re receiving the correct substitute.

Most pharmacies don’t report prescription errors because they’re not required to. Neither the federal government nor most states in the U.S. have laws requiring that drugstores report prescription errors, even if the cases lead to serious complications or death.

“Pharmacies consider even one prescription error to be one too many,” said Chrissy Kopple, spokeswoman for the National Association of Chain Drug Stores. “Recognizing that human error is a possibility in any profession, pharmacies constantly pursue opportunities to improve safety.”

Scanning technology is used in some instances to verify that the medication that has been prescribed matches the medication that’s dispensed. Also, the use of electronic prescribing is on the rise, which can potentially reduce the risk of errors from prescribers’ handwriting and from incorrectly entering prescription information.

But until these technologies catch on, both pharmacists and patients should create their own checks and balances to make sure the right medication gets into the right hands, said Kopple.

The Agency for Healthcare Quality and Research offers a few tips that consumers can use to lower the chance of  pharmacy errors:

When your doctor writes a prescription for you, make sure you can read it.

When you pick up your medicine from the pharmacy, ask the  pharmacist if this is the medicine that your doctor prescribed.

Open the bag containing your medication container and make sure the medicine matches your prescription, and your name is on the container.

Make sure you understand how to properly take the medication -- ask your pharmacist about how much medication to take, when, and whether you should expect to experience any side effects.

Copyright 2011 ABC News Radio

Thursday
Apr072011

Hospital Errors Common and Underreported, Study Says

Ryan McVay/Photodisc/Thinkstock(SALT LAKE CITY) -- Hospital errors are common.  In fact, as many as one-third of hospital visits leads to hospital-related injuries, according to a report published Thursday in Health Affairs.

"We know these types of injuries can increase the risk of other complications -- even death," said Dr. David Classen, the study's lead author and an associate professor of medicine at the University of Utah in Salt Lake City.  "They also increase the risk of readmissions and long-term disability."

Using the "global trigger tool" -- a checklist executed by a third party reviewing medical records -- Classen and colleagues showed that as many as 90 percent of hospital errors are missed by current surveillance systems.

"Clearly, we've made improvements, because hospitals have shown a reduction in mortality and the rate of some infections," Classen said.  "But this study suggests there's a whole lot more work to do."

The study revealed that current methods for tracking hospital errors may be inadequate and may be skewing data on the effectiveness efforts to improve patient safety.

"I think the next step is to push policy makers to develop much better tools for measuring hospital safety and get them into hospitals," Classen said.

Copyright 2011 ABC News Radio







ABC News Radio