Hospital mistakes go public

By Jordan Rau

June 30, 2008 12 AM PT

Times Staff Writer

SACRAMENTO — Last October, a technician at the children’s hospital at Stanford University improperly connected a ventilator hose, accidentally pumping too little oxygen into a 9-day-old infant’s lungs.

A month later, technicians at Dominican Hospital in Santa Cruz unintentionally placed a CT scan of one patient into the electronic file of another, leading physicians to remove the wrong person’s appendix.

Last March, Virginia Fahres, 76, died at Pomona Valley Hospital Medical Center in Pomona after a nurse gave her two drugs, neither of which her doctor had prescribed.

Those incidents were among 1,002 cases of serious medical harm disclosed by California hospitals between July 2007 and May of this year. The disclosures are the first under a state law that requires hospitals to inform health regulators of all substantial injuries to their patients.

Officially called “adverse events,” those accidents are also known as “never events” because they are considered preventable, and many safety experts say they should never happen. California patients are being injured at a rate of about 100 a month, according to data compiled by the state Department of Public Health.

“I think the never events are a wake-up call to everyone about the safety of California hospitals,” said Beth Capell, a lobbyist for Health Access California, a consumer group.

Revelations of such errors have led lawmakers and hospital associations in at least seven states to protect patients from having to pay for the cost of care that went awry. In Sacramento, an assemblyman proposed a ban on reimbursing hospitals for the types of injuries tracked by the state. But when lobbyists for doctors and hospitals objected, he scaled it back to cover far fewer errors.

Four million people were admitted to California hospitals last year. State investigators found some errors occurred because hospitals failed to follow safeguards designed specifically to prevent harm.

Last July at UC San Diego Medical Center, a patient died after a nurse incorrectly programmed a medicine pump that then delivered more than twice the appropriate dose of a specialized blood pressure drug. Regulators found that the hospital’s administration had been warned earlier by its own safety committee that “errors continue to occur” with that type of pump but had not taken sufficient corrective action, according to a state probe.

UC San Diego officials said they have since held repeat drills with staffers who treat patients with Flolan and examined every step in the process.

Dr. Angela Scioscia, the center’s senior medical director, said the public reporting requirement is “a great opportunity to make rapid improvements” because hospitals can learn from one another’s problems. “We don’t want people to be afraid when they come into hospitals, because they are becoming safer and safer all the time,” Scioscia said.

Under the 2006 disclosure law by state Sen. Elaine Alquist (D-Santa Clara), hospitals must inform state regulators of every occurrence of 28 different types of dangerous mistakes. Those include deaths during labor, medication errors, suicide attempts and sexual assaults.

The public health department has until 2015 to begin posting the information on the Internet, although officials said they hope to begin publishing it earlier. The most recent figures available cover the 10 months since July 2007. In that time, 466 patients developed bedsores so severe that the dead skin formed a crater or rotted through to the muscle or bone.

Another 145 patients had foreign objects such as surgical equipment left in their bodies. Thirty-four died while under anesthesia. In 41 surgeries, doctors performed the wrong procedure or operated on the wrong body part or on the wrong patient.

So far, the state Department of Public Health has levied $25,000 fines against 10 hospitals that reported adverse events. Officials said other investigations are still under way.

One hospital, Scripps Memorial in La Jolla, was fined twice for two errors that occurred last November with the same patient. First, as the patient was recovering from surgery, she was given a painkiller that is not supposed to be used after operations. When she went into respiratory arrest, the pharmacist provided a corrective medication at a dose 10 times too weak to be effective.

The patient survived. State investigators discovered that the hospital’s pharmacists had not been properly instructed in the use of 10 medications, including the corrective drug, that the hospital stocked for emergencies.

The ventilator error at Stanford’s Lucile Packard Children’s Hospital occurred because a therapist had assembled the machine by following a diagram that had been drawn backward. Dr. Christy Sandborg, the hospital’s chief of staff, said the medical team quickly noticed that the ventilator wasn’t working correctly and stopped using it. The child recovered, she said, and the hospital has made changes to prevent future occurrences.

Overcrowded emergency rooms are another factor behind patient injuries. A 2006 study found that California had fewer emergency rooms per resident than any other state.

At Kaiser Foundation Hospital San Jose in March, staffers left a patient waiting in the emergency room for more than an hour after a test showed that his blood sugar was higher than the maximum measurable with a glucometer. The medics determined that he needed immediate care, but all 25 treatment bays were full. He passed out in the waiting room and died from heart failure.

Kaiser officials said that since his death, patients who need immediate care have been kept in the triage area under nursing supervision. The hospital said it also established a system to call in extra medical help when its emergency room is overwhelmed.

Doctors and hospitals warned against equating all adverse events with mistakes.

Debby Rogers, the vice president for quality and emergency services at the California Hospital Assn, said someone with a fractured neck might develop a pressure sore while resting on a backboard awaiting surgery. Treating the sore would require moving the patient, potentially paralyzing them by exacerbating the fracture, she said.

“We would like to think we can prevent all of them, but we can’t,” Rogers said.

Kathleen Billingsley, the deputy public health director in charge of regulating healthcare facilities in California, said that overall, “the hospitals are very responsive” about reporting injuries.

Dr. Donald Berwick, the president of the Institute for Healthcare Improvement, a Massachusetts nonprofit, said the number of mistakes is certainly much higher than what California hospitals have disclosed. His institute has estimated that as many as 15 million patients nationwide are harmed each year in hospitals.

“It will always be true that the vast majority of incidents are never reported,” Berwick said.

Maine, Massachusetts, Pennsylvania and New York have restricted payments for avoidable medical errors. Hospital associations in Minnesota, Washington and Vermont have pledged never to bill patients for the costs of botched care, according to the National Conference of State Legislatures.

Starting in October, the federal Centers for Medicaid and Medicare Services will stop reimbursing hospitals for eight kinds of mistakes, including bedsores, objects left in patients, and infections acquired during surgery or from catheters.

In April, Assemblyman Mike Feuer (D-Los Angeles) introduced legislation to bar medical providers from seeking payment in cases involving any of the adverse events that California hospitals must report.

But the hospitals’ and doctors’ associations objected that the bill, AB 2146, could result in denial of payment even when the damage was not their fault, or occurred when they were repairing an injury caused by another medical provider.

Last week, Feuer rewrote the bill so that the state MediCal program would no longer reimburse hospitals for the same preventable errors that Medicare refuses to pay for.

Feuer said he hopes that cutting payments will prod hospitals to be more careful.

“There’s a widespread recognition,” he said, “that the ‘never’ list is too long.”

jordan.rau@latimes.com

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Hospital errors

California’s 518 hospitals reported 1,002 incidents of serious harm to patients in the first 10 months* of a law requiring such disclosure. A sample:

Advanced skin ulcer (bedsore)

466

Object left in patient after surgery

145

Death/disability from restraints

Sexual assault on patient