Articles Posted in Hospital Falls

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Information About Sepsis Dangers and Sepsis-Associated Deaths in Hospital Settings 

When a person’s immune system becomes compromised, the body can respond in deadly ways, such as septicemia, a lethal condition more commonly known as – sepsis. A 2019 Critical Care Medicine investigative report confirmed that sepsis is highly present in hospitals and that it contributes significantly to patient deaths, some preventable. About one-third of people who develop sepsis will die from it, and as many as 65 percent of those people were being treated for another issue in a hospital setting at the time of their sepsis diagnosis.

Sepsis occurs when a person develops a bacterial infection in their bloodstream. It can happen to any patient, at any age. For those who survive, many will be left in a life-altering state and battle conditions such as post-traumatic stress disorder (PTSD), chronic pain and fatigue, organ dysfunction, brain and heart conditions, and disabling amputations. Family members and caregivers may also become exhausted and depressed due to the difficult recovery and therapies their loved one now requires. 

The Center for Investigative Journalism reports that in the decade following 9/11 the Department of Veterans Affairs paid $200 million to nearly 1,000 families in wrongful death cases. The median payment for each family was $150,000. Thirty-nine of the veterans died due to malpractice at the clinics in Danville, Marion, and Hines, Illinois alone.

Delayed diagnosis, delay in treatment, and improper performance repeatedly appear as the type of malpractice in these cases. The report includes a Shreveport, Louisiana veteran who overdosed on morphine in a locked psychiatric unit and a delusional Portland, Oregon veteran who jumped off the roof of a VA hospital. It also includes Iraq War heroes who committed suicide after being turned away for mental health treatment and Vietnam veterans who died from known cancerous tumors that were allowed to grow. The Seattle Times reports that the 1,000 families includes the family of a veteran who bled to death after knee replacement surgery and the family of another who died after being sent home with fractured ribs and a fractured spine.

Nursing Home Fall

There are many dangers hidden in the very places where we are supposed to heal. For example, many hospital rooms have bed with rails on the side. These bed rails are familiar to everyone. They are usually made of metal and run along the side of the sleeping space, presumably to prevent the sleeper from rolling off accidentally. While that general principle seems logical, those working on patient safety matters appreciate that bed rails usually cause far more harm then they prevent.

That is why many are leading efforts to get these bed rails off the market for good with the hopes of protecting hospital patients, nursing home residents, and other who sleep in spaces with the rails.

National attention was brought to the issue late last year with one of the leading anti-bed rail activists, Gloria Black, was profiled in a comprehensive New York Times article. Black began fighting in 2006 after her mother’s untimely death. The senior died in a nursing home after her neck became trapped in a bed rail and no one was around to help. It was a shocking tragedy, but, as Black soon found out, not all that rare.

The Agency for Healthcare Research and Quality is a component of the U.S. Department of Health and Human Services focused on improving medical care across the country. The entity runs the Patient Safety Network which often provides helpful information about efforts to minimize errors and provide better patient care.

For example, PSNET includes a very helpful primer on “never events”–the medical errors that are virtually always preventable with basic safety steps. There is simply no excuse for them ever occurring. The primer explains how the term “never event” was first coined in 2001 and has been used widely in the following decade. Throughout that time the term has expanded in meaning. While initially it referred to truly shocking events (i.e. amputating the wrong body part), it now refers to all errors which are clearly definable, serious, and usually preventable.

Today, the National Quality Forum (NQF)–the entity which coined the phrase–lists 29 different errors as never events. That group is further subdivided into 6 categories including surgical errors, environmental problems, care management mistakes, and more.

Patient safety is not an isolated topic–it permeates everything about medical care–from the first contact with a patient through a discharge and including follow-up care. In addition, a complete focus on preventing harm in medical settings also looks beyond the actual care provided by staff members. That is because the physical design and maintenance of the locations also factor into safety. It is critical that all those working in the field take a holistic approach so that these spaces are always those of healing and not the site of preventable accidents and injuries.

A recent article from Fierce Healthcare explored the topic, noting how important the physical space itself factors into error-free healthcare.

Preventing Hospital Falls

There is a hidden danger in many hospital rooms across the country that most patients and their families do not know about: bed rails. When someone is in the hospital with a medical ailment, the assumption, of course, is that the the professional who work their and the equipment provided exist to make the patient better. No one expects to suffer an injury as a result of staying in the facility.

Of course all cases of medical malpractice involve just that: a patient suffering more harm because of the conduct of medical professionals. That harm can result not only from the actions of the medical staff but also from the equipment that they use. That includes bed rails–the metal bars placed on the side of hospital beds presumably to prevent patients from rolling out and falling.

Hidden Dangers

If you are hurt by unreasoable conduct or mistakes in a hospital, then you will file a medical malpractice lawsuit, right? Not quite. While “medical malpractice” refers to professional negligence by medical cargivers, the actual setting of the mistake is not the critical distinction. Instead, when it comes to malpractice and negligence, the crucial issue is not where the error occurred but the conduct itself. These distinctions are also not just semantics, as different legal rules, evidentiary standards, and requirements, are often implicated depending on whether the case involves ordinary negligence or professional negligence.

In general, most hospital errors include professional negligence and most caregiving mistakes in other settings are traditional negligence. However, that is not always true. Medical malpractice can occur outside of the hospital and traditional neglgience can occur inside it. Sometimes it is necessary to parse details carefully to understand which might be implicated. For example, failing to properly read a medical chart and missing a diagnosis is malpractice. But failing to properly monitor a resident moving from the hosptial bed to the restroom, leading to a fall, it likely regular negligence.

On the other side, doctors an nurses sometimes work in settings outside of the hospital or medical clinic. The most common alternative, for example, is the skilled nursing facility or nursing home. The seniors and residents with disabilities in this facilities need basic day-to-day care as well as close medical support. When mistakes are made at these homes it is often regular negligence–wandering, elopement, etc.–but that is not always true. It is possible for a medical error to occur regarding the medical professional’s erroneous decision-making that might lead to an actual professional negligence claim.

A recent Las Vegas Sun investigation has found that patients in nearby hospitals suffered 969 preventable injuries caused by medical error in the last two years alone. The exhaustive and first of its kind study revealed that preventable harms, deadly infections, and neglect occurred at a rate about one a day in some hospitals.

Dr. John Santa, Director of the Health Ratings Center for Consumer Reports, explained the repeated examples of medical malpractice by admitting, “These are events that no one can be proud of. They aren’t inevitable. They’re preventable. It just involves attention to detail and a willingness to change the culture.”

Preventable injuries caused by medical error include foreign objects being left in bodies after surgery, advanced pressure sores, bloodstream infections, and postoperative falls. The one thing each of these complications has in common is that they can almost always be completely eliminated if proper medical care is provided. For example, the Institute on Healthcare Improvement suggests that bedsores are almost always preventable and occur only when a patient is not given close enough supervision and attention. Central-line infections would also be virtually non-existent with closer monitoring and removal of catheters

A county is paying $1.3 million to settle a medical malpractice lawsuit over the injuries suffered by a mentally disturbed patient. This patient injured himself when escaping out of a window of a county-owned mental hospital. Court documents say that in the 2004 incident, the 27-year-old mentally handicapped person was in a seclusion room on the hospital’s fifth floor when he climbed out a window and tried to jump 15 to 20 to a fire escape landing. He suffered multiple fractures in the fall. The family alleges he was not adequately monitored by staff at the hospital. The $1.3 million medical malpractice settlement was reached on December 23. To read more about the medical malpractice settlement, please click the link.

On Friday, December 18, a 44-year-old woman from Cerro Gordo, IL died after falling from a seventh floor window at Provena Covenant Medical Center in Urbana. An autopsy revealed that her death was a result of multiple injuries sustained in the fall. The article reports that the victim jumped from the window and landed on a roof five stories below. However, the article does not indicate if the victim was a patient, what led her to fall from the window, or if this was an incident of medical negligence. Read more about this Urbana hospital death.

In a case similar in nature, the medical malpractice attorneys of Levin & Perconti recently won a $1 million jury for the family of a nursing home resident who exited from a window at a Chicago area nursing home and fell to his death. The Cook County jury found the nursing home negligent in failing to prevent the resident from exiting through the window. To read about this jury verdict, follow the link.

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