Articles Posted in Prevention Programs

Comprehensive patient safety efforts undoubtedly include addressing issues on a wide range of fronts. There is not a single type of error, and so many different solutions are needed to eliminate different mistakes–from medication problems to lapses during surgery. We’ve seen them all with our work in Chicago and the rest of Illinois on these cases.

One underappreciated facet to many of these problems, however, is relationships. How medical professionals and staff members treat each other and interact together in the workplace has a huge effect on the quality of the work they provide to patients. This is not all that surprising, considering work environment is a critical factor in all employment setting–an unhappy or disrespected worker is rarely a high-performing worker. But, in the medical setting the lives of others are on the line, and so the need to eliminate personnel problems is critical.

Respect & Hospital-Acquired Infections

On many occasions we have discussed the staggering cost of malpractice both on patient lives and healthcare costs. Estimates suggest that each year nearly 98,000 people die and around $55 billion is spent because medical mistakes. The toll has led many experts to spend time and effort working to better understand why the errors are made and what can be done to prevent them.

One of the easiest but most effective ways to provide better care involves the use of medical checklists. Reuters recently discussed new research which highlighted the benefits. The latest data indicates that almost a third of all malpractice claims would be eliminated if checklists were used in all cases. The improvement would specifically be seen in surgeries, as the vast majority of mistakes actually occur during those operations.

The checklists include reminders of obvious but occasionally overlooked processes that are vital to proper care. They list simple acts like proper scheduling, ensuring equipment availability, marking the correct operating location, and similar actions so that the professionals ensure that nothing is overlooked.

A surgeon who has written often on the issue explained, “This kind of evidence indicates that surgeons who do not use one of these checklists are endangering patients.”
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Official government efforts to ensure proper medical care for patients at the state level typically involves rules proscribing allowable conduct as well as clear procedures to ensure negligent doctors are prevented from harming more patients. Unfortunately, the second-prong of that approach is typically lacking.

St. Louis Today recently discussed that lax doctor disciplinary and oversight process in the state. For example, the story highlights the case of one doctor who botched eye procedures on a young infant girl. The child went in for surgery to fix a muscle in her left eye. But the doctor made a mistake and operated on the right eye. To cover up his error, the doctor lied to the family and claimed that another surgery was necessary. He then did the original procedure on the left eye. Afterwards, the doctor altered the girl’s charts to make it seem as if no mistake was made. The girl is now legally blind in one and has only minimal sight in the other.

After all of this was uncovered the doctor was reported to the state’s Board of Registration, but little to nothing was done to sanction the surgeon for his conduct. The doctor was allowed to keep seeing patients without missing a single day, and he received only a silent reprimand in his file.

As the newspaper uncovered, this lenient treatment for error-prone doctors seem to be a trend for the state’s regulatory body.
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The San Francisco Gate wrote a story today about one doctor’s call for improved safety measures following a medical error that affected him personally. Dr. Jose Gonzalez’s 18 month old niece was brought to a local hospital after a fall left a bump on her head. The facility conducted an MRI on the young girl to check for any problems. However, the girl’s breathing tube became dislodged during the procedure, resulting in severe brain damage.

As the doctor discovered afterwards, and our Chicago medical malpractice lawyers at Levin & Perconti are well aware, these sorts of preventable medical errors occur with startling frequency across the country. Nearly 100,000 patients are killed each year due to these medical mistakes.

However, even with these staggering numbers, little is done to stem the tide. In many states it is still not even required that hospitals report when errors occur. Because of the growing problem, Dr. Gonzalez and other patients’ safety advocates are working to raise awareness of the issue. Specifically, the doctor is trying to spread knowledge of safety systems that can be implemented at hospitals to improve patient well-being.

A recent study by the Center for Disease Control (CDC) found that ambulatory surgical centers failed to prevent hospital-borne infections in 46 of the 68 surgical centers that the study examined. Researchers reported lapses in infection control in hand hygiene, injection safety, medication and handling, equipment reprocessing, environmental cleaning, and handling of blood sugar monitoring equipment. The study found that 28% of the facilities used medications in single-dose vials for multiple patients and that 32% of the facilities performing blood glucose testing did not clean and disinfect the blood glucose meters after each use. Additionally, the study found that 6% of the facilities reused items that were packaged and labeled as single-use devices and 21% of the facilities used a single lancing penlet device for multiple patients in blood glucose testing.

Ambulatory surgical centers operate exclusively to provide surgical services to patients who do not require hospitalizations or admission lasting longer than 24 hours. Between 2001 and 2008, researchers found that there was a 50% increase in the number of Medicare certified ambulatory surgical centers in the United States. During that same period of time, researchers also found a significant rise in problems relating to hygiene and safety health procedures at the Centers.

Hospital-borne infections are a serious problem facing hospitals. When a patient suffers further injury or death because of a hospital’s failure to prevent infections, hospitals may be held liable. Hospitals can prevent infections among patients by making sure that both the hospital staff and visitors regularly clean their hands with an alcohol-based hand cleaner. Hospitals should also make sure that if a patient needs an IV that it is inserted and removed under clean conditions and changed every three to four days.

An Illinois woman has started a website designed to improve hospital safety entitled Campaign Zero. She began the website after Medicare discontinued reimbursing hospitals for preventable hospital hazards. The website focuses on preventing medical errors by zeroing in on what can be prevented with a little bit of knowledge. It also discusses ways in which everyone can help prevent medical error.

One area that can be improved is hospital acquired infections. Campaign Zero estimates that 2.2 million people are affected with hospital-acquired infections every year. More than 135,000 Americans wrongfully die from these hospital-acquired infections, most of which are preventable. The biggest culprit in the spread of this disease is unwashed, or poorly washed, hands. There is a simple way to prevent this medical error: to have employees simply wash their hands with soap and water. The website shows a video highlighting the easy way to wash hands and save lives.

Campaign Zero also highlights ways in which to prevent surgical error. The website’s study estimates that between 1,300 and 2,700 surgical errors occur every year in America. These include events when patients are mistaken for each other. Also, surgical tools and sponges are left behind in patients. In fact, 1 out of every 1,500 abdominal surgeries results in a left tool or sponge. The average cost of these types of surgical errors runs around $40,323. The website suggests showering before surgery and marking the part of your body that is to be operated on in order to prevent these errors. This website is a valuable tool for anyone that has a loved one in the hospital.

A detailed safety analysis conducted on behalf of Hearst Newspapers found that at least one in six of the studied facilities had preventable deaths. These occurred from common procedures, including cases in which medical instruments were left inside patients and transfusions were done incorrectly. Many hospitals have poor performance in the safety indicators developed in recent years by federal health researchers. The study found that doctors fudge death certificates, leaving out information that would point to medical errors as a prime cause of death. One woman was reported to have died of pneumonia on her death certificate. However hospital records show she initially went to the hospital for a shot of diuretic to treat leg swelling and then contracted an infection which caused the pneumonia. The CDC is aware of the inaccuracies in death certificates. They stated that medical error is “often not reported” because it gives doctors problems down the road. Some groups say that a nationwide reporting system is too expensive and too difficult to implement. However, it may decrease the amount of medical malpractice cases. To read more about the medical errors, please click the link.

Although a study conducted 10 years ago stated that a mandatory nationwide reporting system for medical errors was imperative, one still does not exist today. The AMA and the American Hospital Association vehemently opposed an attempt by President Clinton to create a mandatory reporting system for serious errors. The groups launched a multimillion-dollar advertising campaign that said mandatory reporting would drive medical errors underground. If medical errors and infections were better tracked, they would top the list of accidental deaths. The recent study by Hearst Newspapers state that approximately 99,000 patients a year die as a result medical error. To read more about the mandatory reporting system, please click the links.

An issue of Women’s Health this summer touched upon issues that concern a lot of Levin & Perconti blog readers – how to avoid medical mishaps. We wanted to share the startling statistics that the magazine provided. Each year, nearly 1.5 million Americans are injured by medication errors and up to 98,000 die in hospital due to medical errors. To avoid being a victim, Women’s Health suggested that you always check your prescriptions, find rested workers, and personalize your case file.

To read more about how to take control of your medical care.

A new Medicare study claims that too many people are dying needless deaths within hospitals and are carelessly turning out patients after short stays that end up back in the hospital within 30 days. John Rumsfeld of the Denver VA Medical Center and chief science officer for the American College of Cardiology’s National Data Registry, called this a “double failure” of our healthcare system. Death rates in hospitals below the national average tend to be in the nation’s smallest and poorest counties. Currently, organizations are trying to disseminate information to patients in order to educate them on health care and help them seek out higher standards of care. If you feel you have been a victim of medical malpractice or medical negligence, you should consider consulting a medical malpractice attorney.

Read more about Medicare’s hospital study here.

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