'It's never just one thing' that leads to serious harm in hospitals

A technician mistakes an "a" for an "o" in a drug name. A doctor misplaces a decimal point in a prescription order. A nurse reaches for a vial in a cabinet as she's done hundreds of times before, only this time the light is dim and she fails to notice that the powder-blue label is more of a sky blue. The slip-ups are often simple, and always human, and all have happened in U.S. hospitals.
Each simple mistake is supposed to be countered by a recommended backup, a second or third set of eyes -- in other words, guidelines to reduce human error. A lot has to be overlooked in the cascade of errors that result in serious patient harm.
"It's never just one thing that goes wrong when a serious event happens," says Michael Cohen, president of the Institute for Safe Medication Practices, an organization that tracks prescribing errors and is sometimes called in to examine a hospital's mistake. "We've detailed a situation where we found over 50 mistakes in the system before an infant was killed." The incident, he said, was a 1,000-fold overdose of the blood thinner heparin in an Indianapolis neonatal intensive care unit that resulted in the deaths of three infants in 2006.
Late last year, the infant twins of actor Dennis Quaid and his wife, Kimberly, were the victims of a nearly identical mistake, an overdose of heparin at Cedars-Sinai Medical Center. "It was the exact same situation in a hospital in Indianapolis that we investigated a year earlier," Cohen says. "The pharmacy dispensed the wrong dose to the nursing station."
The mistake calls attention to how far hospitals have to go in preventing medical errors and in learning from the mistakes of others, even though many have made progress in protecting patients within their own institutions. Despite a decade of rising public awareness of such mistakes and research into how to prevent them, even one of the country's premier institutions and a celebrity couple were not immune. Hospitals still have a long way to go to avoid mistakenly hurting their charges.
Hospitals are trying. In a program called the 100,000 Lives Campaign, some 3,000 of the nation's 5,000 acute care hospitals, including Cedars-Sinai, have voluntarily instituted up to six changes in practices aimed at reducing errors. The Joint Commission, a national organization that accredits hospitals and other healthcare facilities, now requires that patients be informed of "unanticipated outcomes."
A changing bottom line may spur the effort to change. After Oct. 1, 2008, Medicare rules will make it more worthwhile for hospitals to avoid mistakes. The federal insurance program will no longer pay for follow-up care for several preventable problems. For example, the government will not reimburse a hospital for retrieving scissors, scalpels or sponges left in a patient's body cavity following surgery. Nor will the federal insurer pay if a patient is transfused with the wrong blood type, or acquires a pressure ulcer while in the hospital. And, the new rules say, the hospital cannot pass the bill for a mistake on to the patient. Private insurers may follow suit and refuse to pay for preventable mistakes.
The first step in controlling errors is to know how many there are and where they occur. Reporting is becoming more stringent. "One of the interesting developments is that state after state has announced that hospitals have to report these serious, preventable adverse events," says Leape. California, since 2006, has required reporting of 27 serious medical errors listed by the National Quality Forum, a group of consumers, doctors, insurers and institutions promoting improved quality in healthcare.
If mistakes must be reported, then insurers can insist that hospitals eat the cost of the error, says Leape. "The next step is to say that we won't pay for preventable infections," he says. "If that sort of thing happens, we're going to move from doing the right thing simply because it's the right thing to doing it, because if we don't, we'll be out of business."
One impediment to admitting mistakes has been the fear that an apology would lead to a lawsuit. That, too, is changing. Mistakes, and their solutions, says Dr. Thomas Gallagher, professor of medical ethics at the University of Washington School of Medicine, are human. Wronged patients, and their families, want someone to sincerely say they are sorry, studies show. Gallagher, in a Feb. 26, 2003, report in the Journal of the American Medical Assn., talked with 52 patients and 46 doctors in 13 focus groups. He found that patients wanted full disclosure of harmful errors; an explanation for why it happened; information on what the institution was doing to prevent the mistake from happening again; and an apology.
The apology, a response long mangled and silenced by fear of malpractice litigation, is making a legally protected comeback. Thirty-six states, including California, have passed apology laws. They take different forms, but at the very least they mean a hospital's or a physician's apology cannot be used against them in court.
So far, technology is a poorly utilized partner in helping humans reduce errors. A 2005 study by the RAND Corp. found that computerizing medical records could save the healthcare system $81 billion -- and $4 billion of that savings would come from improved safety, largely by reducing prescription errors.
But computerized records and prescriptions are notoriously slow in coming to physicians' offices and hospitals. In the first comprehensive look at health Internet technology in the state, a Jan. 17 report by the California HealthCare Foundation found that only 13% of hospitals in the state use electronic health records, and only 11% use bar-code administration of drugs. Such bar codes, as those seen in supermarket checkout lines, would signal an alert if a healthcare worker grabbed, and scanned, the wrong drug or the wrong dose for the wrong patient.
Until more hospitals acquire the technological means to double-check providers' actions, nurses like those at Cedars will still reach for vials as they've done thousands of times. They may fail to notice a decimal point or a different colored label. "I can easily see how a nurse, especially an experienced one who has always done it right, can overlook the label," Cohen says. "Just like you and I do at the supermarket, reaching for what we've always known, not realizing it has changed.
"This same incident that affected the Quaids, it could happen again at another hospital in another place."
Source: Los Angeles Times, January 28, 2008