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Investigation Finds Little Progress Correcting Medical Errors

Hearst Newspapers runs a series of articles called ” Dead by Mistake,” analyzing the causes and effects medical errors across the United States. In the lead article, Hearst Newspapers reported that “experts estimate that a staggering 98,000 people die from preventable medical errors each year,” and “federal analysts believe the rate of medical error is actually increasing.” Hearst’s “national investigation…found that the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in” a “highly publicized federal report” issued ten years ago which “called the death toll shocking and challenged the medical community to cut it in half.” Hearst noted a “secrecy built into the system,” but “a Hearst data analysis lifted a corner of that veil of secrecy to show that in five states served by Hearst newspapers — New York, California, Texas, Washington and Connecticut — only 20 percent of some 1,434 hospitals surveyed are participating in two national safety campaigns begun in recent years.”

California reports over 1000 serious errors. Hearst Newspapers reported on fatal medical errors in California which “moved state Sen. Elaine Alquist, D-San Jose, to write three related measures that have transformed California’s system for monitoring medical errors in hospitals – and toughened fines when egregious mistakes occur.” In all, “hospitals have reported more than 1,000 errors since the laws went into effect. Experts call them ‘never events’ because they are events with such serious consequences that experts say they should never happen.”

In another article, Hearst Newspapers reported, “The case of Diane Stewart, 70, who died of a bowel obstruction after knee replacement surgery [at Stanford University Medical Center in Palo Alto], shows that bad mistakes and worst-case outcomes are possible even at world-renowned hospitals, said her family’s lawyer, Christopher Dolan of San Francisco.” In 2008, “investigators from the state Department of Public Health found that ‘relevant’ portions of Diane Stewart’s computer file had been deleted after her death and that a supervisor instructed a nurse to make postmortem ‘late entries’ to describe her care.” The family is suing the hospital.

Connecticut medical error reporting system seen as opaque. Hearst Newspapers reported, “Although Connecticut has had a mandatory adverse-event reporting system in place for hospitals since 2002, the state’s health care industry has ensured that consumers can’t find out where medical errors most frequently occur. Since the Quality in Health Care program’s inception, all data about medical mistakes and resulting deaths have been listed in aggregated form, meaning no hospitals are identified within the annual reports.” In an effort “to run their own hospital-specific analysis of patient safety indicators using software issued by the Agency for Healthcare Research and Quality, Hearst reporters requested hospital discharge data from Connecticut’s Office of Health Care Access – data that 40 states, including Connecticut, voluntarily submit to AHRQ for quality and patient safety assessments.” Hearst’s team “found out, however, that although billing and discharge data is ostensibly available for “all interested parties and institutions,” OHCA’s regulations were crafted to make it effectively impossible for outsiders to obtain the patient-level data AHRQ’s software requires, while also identifying individual hospitals.”

NYPORTS error reporting system viewed as flawed. Hearst Newspapers reported, “Patient-safety advocates say, after years of insufficient staffing and chronic underreporting by hospitals, the once-groundbreaking New York Patient Occurrence Reporting and Tracking System is dysfunctional. ‘At the end of the day, there were simply not enough resources within the state to take the information that was coming in and do much with it, nor were there the resources or will within the state to enforce the reporting requirement,’ said Arthur Levin, director of the Center for Medical Consumers and a member of the working group that created NYPORTS.”

Texas lacks reporting system. The Houston Chronicle reported, “For the past six years, Texas has fumbled attempts to establish a medical error reporting system, often leaving patients to discover errors the hard way – when a mistake costs them their livelihood or the life of a loved one. A 2003 measure to report errors was so vaguely designed for the state’s 613 hospitals that even the Texas Hospital Association, which supported the measure, offered no resistance when lawmakers decided to eliminate it in 2007.” Starr West, the hospital association’s senior director for policy analysis, “concedes now that facilities underreported mistakes during the four years the law was in place. That’s small comfort for people like Geoff Schorr, a personal-injury attorney in Dallas who said he never got a straight story about what happened during a 2006 surgery that caused the death of his 7-year-old son, Porter.” This year, “a new law passed that requires hospitals to report more than two dozen types of errors by hospital. But important details, like how the system will be designed and maintained and how the results will be interpreted, have not been determined.”

Underreporting a problem at Washington hospitals. Hearst Newspapers reported, “Six years after the ‘To Err is Human’ report, the Washington state Legislature responded with a law mandating medical error reports.” But according to State Rep. Tom Campbell, a sponsor of the bill, the mandated steps have not been taken. A contractor “was supposed to create a Web site where medical errors could be reported, in confidence. That didn’t happen, though plans are afoot for a lesser Web site with program information and aggregated data. Reporting has been a trickle, at best.” The article focuses on underreporting, noting, “if national studies are any indication, there should be thousands, not hundreds, of reports from” Washington hospitals.

Hearst Newspapers reported, “Government tolerance policy poses a public-relations dilemma for health facilities every time there is an error to report.” Admit each error properly, “and a hospital can be flogged for its accumulated record. Don’t report, and there’s no risk of sanction. Washington’s law makes reporting mandatory, but a one-person office in the Health Department has no authority to enforce it, and more numerous hospital-licensing officials who could, admittedly don’t.” In Washington and other states, “with apparent widespread underreporting, health care consumers can only assume from the numbers that a hospital with a lot of error reports is a better facility, or at least more honest.”

Patient remained unaware about concerns surrounding doctor. Hearst Newspapers reported, “Sharon Moore didn’t realize her cocktail of painkillers was killing her. … Doctors, a cop and pharmacists in her Eastern Washington farming town were concerned that her doctor was overprescribing narcotics, according to documents and interviews, but she and her daughters didn’t know that.” None of the cases associated with Dr. David T. Earl of Moses Lake was reported to the state at the time of death. “By state law, hospitals must report only their cases they have ‘confirmed.'”

MRSA deaths reported. Hearst Newspapers reported, “When Hartford Hospital in Connecticut marked the death of former president Dr. T. Stewart Hamilton in a 2002 employee newsletter, the obituary stated Hamilton ‘died peacefully on July 29, with his family at his side.’ Left unsaid was that Hamilton died at Hartford Hospital from complications brought about by MRSA, a form of bacteria spread through skin contact or an infected open wound, which he may have contracted after being admitted for treatment of a minor head laceration.” His daughter, Jeanne Hamilton, said that “she is not angry with Hartford Hospital, specifically, but is angry at the prevalence of MRSA in health care settings.”

Hearst Newspapers reported, “On Nov. 10, 2008, Norine Zazzara entered St. Joseph’s Hospital in Syracuse, N.Y., for a routine procedure for heart patients: She got a shot of a diuretic to treat swollen legs.” While at the hospital, she contracted MRSA and died. “When Betsy Zazzara received her mother’s death certificate, MRSA was not mentioned. Instead, the cause of death was listed as pneumonia.”

Connecticut man brain-damaged after routine surgery. Hearst Newspapers reported, “Michael Guigliano broke his left leg when he took a 15-foot tumble at work. He went to Danbury Hospital [in Connecticut] on Feb. 7, 2001, to undergo minor surgery but, after what his family alleges was a series of preventable medical mistakes and procedural oversights, he left the hospital severely brain damaged, quadriplegic, ventilator-dependent and semi-comatose.” In a case “that settled for an undisclosed amount just before going to trial, Joseph Lanni, attorney for the Guigliano family, detailed what the suit claimed were opportunities that Danbury Hospital staff had to prevent serious complications, and the avoidable medical errors that put Michael Guigliano’s life in jeopardy.”

Producer dies after receiving “potentially deadly” mix of drugs. Hearst Newspapers reported on CBS producer Trevor Nelson, who died in Massachusetts General Hospital after receiving “a potentially deadly mix of prescription-strength drugs – given with dangerous frequency.” Mass General’s staff “then attempted to cover up the mistake, according to the lawsuit now being brought by Nelson’s family, by not referring the case to an independent medical examiner and by wrongfully attributing Nelson’s death to viral meningitis.” The article notes that Massachusetts hospitals last year reported a “surprisingly low” number of medical errors.

Lawsuit alleged errors in mother’s death during childbirth. Hearst Newspapers reported on Diane Rizk McCabe, who died at Albany Medical Center in New York “after her uterine arteries were cut or torn during the surgery that delivered her daughter, Jenna, according to allegations in a lawsuit. Her obstetrician and the attending physician at Albany Med’s intensive-care unit disagreed over how to treat her, and she bled to death, according to testimony.”

Patient dies after feeding tube inserted into lung. Hearst Newspapers reported, “Elbert Eugene ‘Gene’ Riggs Jr. went into Brooke Army Medical Center in San Antonio for a stomachache. He ended up dying there – after a feeding tube was inserted into his right lung.” Government lawyers representing BAMC, in their written response to a lawsuit brought by Riggs’ family, “admit the feeding tube was misplaced, but they deny it caused Riggs’ death.” Riggs’ case “illustrates how murky medical error cases can be, even when a hospital admits a mistake.”

Texas tort law caps damages for paralyzed engineer. The Houston Chronicle reported on Bashar Ashkar of Texas, who became paralyzed when a “steroid injection into his spine for arm and back pain resulted in a cerebral hemorrhage.” In December, “the family settled its lawsuit against one of Bashar Ashkar’s doctors, after the other parties had been dismissed from the suit. Because of 2003 tort reform in Texas, most of the $1.9 million settlement went to legal fees; to continue Bashar Ashkar’s life insurance policies; and to pay back his health insurance companies, which consider what happened to him an unusual event not foreseen as a part of his coverage. Tort reform resulted in a $250,000 cap on ‘noneconomic,’ or pain and suffering, damages in Texas.”

From the American Association for Justice news release.

Bob Kraft

I am a Dallas, Texas lawyer who has had the privilege of helping thousands of clients since 1971 in the areas of Personal Injury law and Social Security Disability.

About This Blog

The title of this blog reflects my attitude toward those government agencies and insurance companies that routinely mistreat injured or disabled people. As a Dallas, Texas lawyer, I've spent more than 45 years trying to help those poor folk, and I have been frustrated daily by the actions of the people on the other side of their claims. (Sorry if I offended you...)

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