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Entries in Hospital Care (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

Tuesday
Aug022011

Five Year Old Dies from Lethal Dose of Local Anesthesia

Pixland/Thinkstock(ATLANTA) -- Five-year-old Kensley Kirby was taken to an Atlanta urgent care center to get treated for a broken arm, but died from a lethal dose of local anesthesia given to her at the clinic, an Atlanta coroner confirmed.

In June, Kensley's parents brought her to Family Medical Clinic in Atlanta, Ga. after she fell. When doctors administered the local anesthesia lidocaine while setting Kensley's arm, her parents "went from picking the color of the cast with their daughter to basically being with her as she died," explained Pete Law, the Kirby family's attorney.

A hospital spokesperson refused to comment on the case, and the family's attorney did not return several requests for comment.

"Dying from a local anesthesia is extremely rare," said Dr. Elliot Krane, professor of pediatrics and anesthesia at Stanford University. "But there is a maximum allowable dose of lidocaine, and as with any drug, it has toxicity associations with it."

Lidocaine is a common local anesthesia used topically to relieve itching and burning from skin irritations; it is injected during dental work and other minor surgeries. The drug blocks nerves and in turn, numbs pain, during surgical procedures.

Allergic reactions to the drug are rare, but excessive doses of the anesthesia can cause unconsciousness, seizures, low blood pressure and even cardiac arrest. Drug dosage is determined by a patient's weight and whether it will be injected into tissue mass or directly into the bloodstream.
It is unclear which way Kensley received the anesthesia after breaking her arm.

"It's possible that the doctor might have been accustomed to taking care of adults all the time, which would have been a larger dose than necessary," said Krane, who was quick to note that he did not know the details of the case. "And with broken bones, there's an opening of vascular channels, so it's possible that it absorbed very rapidly into the bloodstream."

If parents are concerned, Dr. Mark Singleton, chair of the committee of pediatric anesthesia at the American Society of Anesthesiologists, encouraged them to speak with their child's anesthesiologist prior to surgery.

Copyright 2011 ABC News Radio

Wednesday
Feb022011

Quality Care Program Decreases Deaths in Mich. ICU Patients

Photo Courtesy - Getty Images(BALTIMORE, Md.) - A new quality improvement program in Michigan intensive care units has decreased the likeliness of patients dying while in care, reports MedPage Today.

The Keystone ICU project, designed by researchers at John Hopkins University, was implemented in 95 Michigan hospitals in 2004 to help reduce deaths caused by infection and to improve other safety standards.

During an evaluation 13 to 22 months after the program started, it was found that patients admitted to Michigan intensive care units were 24 percent less likely to die compared to before the program was initiated.

"These results strongly support governments', hospitals', and healthcare payers' investment in similar successful, large scale, robust, quality improvement initiatives to maximize patient benefits," wrote Allison Lipitz-Snyderman and colleagues.

The length of stays for patients in the ICU in Michigan hospitals also dropped after the program began.

Copyright 2011 ABC News Radio







ABC News Radio