Last week, the US Senate Finance Committee investigated the diabetes drug Avandia and its safety issues as it is associated with an increased risk of heart attacks. This week, the powerful committee has focused on long term care hospitals and their allegedly substandard medical care. The issue was the subject of an article in the NY Times today. The Times headline read, "Senate Panel to Investigate Deaths at Long-Term Care Facilities".
The Senate committee has focused its investigation on one particular long-term care company which runs 89 such facilities across the country. On Monday of this week, two members of the committee sent Select Medical Corporation a letter demanding answers concerning staffing levels and quality of medical care at its facilities. An earlier NY Times article focused attention on these hospitals that treat 200,000 seriously ill patients each year. According to the Times, the facilities rarely have full-time physicians on staff. The Times cited one example of a dying patient whose heart monitor beeped for 77 minutes before a nurse responded.
According to today's Times' article, "The letter also requests that Select disclose information about its discharge policies. Former employees have also said that the company presses to keep patients for 25 days and then discharge them almost immediately, because patients are most profitable if they stay exactly 25 days under government reimbursement rules. At some Select hospitals, the 25th day is called the “magic day,” ex-employees say."
This is a particularly stark example of healthcare gone wrong in this country. It's an example, if the allegations are true, of healthcare companies placing profits over patients.
The California Department of Health began issuing fines to hospitals for preventable medical errors in 2007. The fines are based on self-reporting by hospitals of medical errors so the numbers reported may be lower than the medical errors that are actually occurring. In the last six months, 13 California hospitals were fined for such preventable medical errors as leaving surgical instruments in patients, wrong site surgeries, and medication errors. The report was published by www.clinicaladvisor.com. Among the notable preventable medical errors were the following:
- The Los Angeles Community Hospital in Norwalk, where a patient who was supposed to have been restrained pulled out a tracheotomy tube and subsequently died.
- California Hospital Medical Center, where an emergency room resident misdiagnosed a woman with an ectopic pregnancy (she was not pregnant) and administered methotrexate, which caused immunosuppression and major adverse effects.
- Marina Del Rey Hospital, where intensive care nurses failed to monitor a patient's oxygen levels, resulting in the patient passing out and having to be put on a ventilator.
- St. Jude Medical Center, where a patient died in the emergency room after nurses failed to notice that the heart monitor was disconnected.
- Kaiser Foundation Hospital, where a 90-year-old patient was given medication intended for another patient, resulting in his being intubated and on a ventilator.
- Sharp Memorial Hospital in San Diego, where a surgical team left a sponge in the pleural cavity of a patient during surgery, necessitating a second surgery.
- San Francisco General Hospital, where surgeons left a gauze sponge in a patient which went unnoticed for three months until the patient returned to the hospital.
- John F. Kennedy Memorial Hospital, which received four fines for incidents involving the use of untrained and non-certified nurses in the emergency room, resulting in the death of a two-year-old child.
- Hoag Memorial Hospital, where a patient was injured when a metal gurney that she was lying on was placed in a room with an MRI machine. When the MRI was turned on, the gurney was pulled by magnetic force into the machine, crushing the patient's leg.
These are just some of the medical errors reported in a six month period by a state that requires such reporting. It would be beneficial if our own state of New Hampshire had such reporting requirements.
Dr. Peter Pronovost, a Johns Hopkins anesthesiologist, is waging a war on what he calls "the secrecy, shame and lack of communication within health care". According to Pronovost, the war must be waged to protect patients from unsafe hospital practices that lead to dangerous medical errors. Pronovost has already designed a checklist to reduce catheter-related infections in ICU's.
Now, he's published a book entitled, "Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out." Pronovost's two-pronged approach involves creating safe practice checklists as well creating hospital cultures in which nurses and other healthcare workers are unafraid to challenge doctors who are making errors.
Dr. Pronovost decided to act after witnessing a toddler, 18 month old Josie King, who had been brought to Johns Hopkins Hospital for burn treatment. Josie died from substandard care resulting from a medical error.
In the book, Pronovost writes, doctors "think they are infallible, communication between nurses and doctors is poor and accountability is virtually non-existent. . . Medicine operates like a private club of self-styled deities where the entrance requirement is an M.D."
In her February 16, 2010 book review of Dr. Pronovost's work, Wall St. Journal writer Laura Landro mentions two scenes which Dr. Pronovost cites as examples of this egregious behavior.
"In the course of advancing his argument, Dr. Pronovost offers glimpses into the harrowing world of intensive care, such as a patient accidentally left to overdose on narcotics—saved, ironically, because he was a heroin addict and could tolerate the excess of drugs. In one heart-stopping scene, Dr. Pronovost faces off with a surgeon who refuses to admit that the patient on the operating table is having a deadly allergic reaction to the latex gloves that the surgeon is wearing."
I salute this young doctor's courage and willingness to stand up for patient safety. Medical errors and patient safety are intimately related to the institutional culture as well as a profession's willingness to change and adopt safe practices of medicine.
The Society for Pediatric Radiology is launching a nationwide campaign to highlight the CT scan risks for children as well as suggesting safety measures. Of the 70 million CT scans performed each year, it is estimated that between 5% and 10% of those are performed on children. The risk of radiation exposure is greater in children because of their smaller size and their longer life expectancy.
The "Image Gently" campaign is intended to urge radiologists to administer the lowest dose of radiation to children as well as suggest certain safety measures. Safety measures include covering reproductive organs during a CT scan as well as considering other tests such as an ultrasound.
The Center for Disease Control has estimated that 435,000 children under 14 visit emergency rooms for head trauma each year. Most of these children are administered a CT scan when ER doctors at University of California Davis Children’s Hospital determined most don't need a CT scan for minor injuries. In response to their findings, these doctors have developed guidelines for doctors to determine who actually needs a CT scan. Part of this determination includes an assessment of the severity of the head injury in relation to the risk of exposure cancer-causing radiation.
