Preventable Medical Errors Include Infections and Defective Devices

U.S. News and World Report is revisiting a topic that needs to be revisited – the huge number of medical errors that harm and kill patients. The in-depth news report starts with a lesson presented to students at the University of Buffalo, New York, about an 88-year-old woman who was admitted to the hospital with a mild case of gout, or swelling of the joints caused by excessive uric acid in the blood.

Her daughter told the class that her mother was the life of the party and probably had another ten years to live. Instead, she was given a muscle relaxant, the label of which says it should not be used in the elderly, causing her to fall and lose the ability to walk. Then she acquired a hospital infection, in fact a series of infections which proved hard to treat.

On August 29, 2009, she died of sepsis, or an intense infection that had travelled through her bloodstream. She had been in the hospital just 48 hours.

Mary Brennan-Taylor, the daughter, has since been on a crusade to cut back on the number of medical errors. Lecturing to students, she has also testified to the federal government. But this is not a new problem.

Back in 1999, the Institute of Medicine issued a report, “To Err is Human: Building a Safer Health System.” It concluded that at least 44,000 patients were killed by hospital errors every year and that was a conservative estimate. Back in 1999, the problem of hospital-acquired infections and antibiotic-resistant bacteria was not as profound as today.

That 44,000 number is equal to a jumbo jetliner crashing every day in this country. If that was occurring within the airline industry, the industry would be shut down.

The problems include – surgery on the wrong body part, medication errors, incorrect or diagnosis diagnosis, foreign objects left inside the body, and hospital infections, among other problems.

In 2010, an analysis of Medicare beneficiaries found 134,000 suffered adverse effects, another word for complications, every month, many of them preventable. A New England Journal of Medicine report in November 2010 reviewed five-years of hospital admissions in North Carolina to find 25 percent of patients had been harmed by their medical care. And a Health Affairs report, April 2011, found the methods hospitals used to find and prevent medical errors failed more than 90 percent of the time.

The Nationwide Children’s Hospital in Columbus, Ohio is trying to make preventable hospital errors nonexistent at its facility. How? By making a list of hospital acquired infections, cardiac arrests, adverse drug reactions, complications from surgery, hospital-acquired pressure ulcers, and serious falls. Everyone is encouraged to report bad outcomes, which in itself is a start. They called the campaign “Zero Heroes” and so far it’s working. The number of preventable errors has been cut in half.

A cooperative partnership between the Michigan Health and Hospital Association and Johns Hopkins, known as the ‘Keystone Project’ has reduced infection from catheters. That alone has saved more than 1,500 lives and an estimated $100 million. Hand washing, the wearing of gloves, gowns, and masks have all helped. The Keystone program will be extended to more than 1,400 Intensive Care Units in 48 states.

It doesn’t hurt for patients to speak up and for a patient to have an advocate bedside. Ask them to wash their hands. You can say, “I don’t mind if you take an extra minute to wash your hands.” Check on medications and ask a lot of questions.

Though this article doesn’t mention it, to save serious Medicare money and reduce preventable medical errors, there needs to be a crackdown on medical devices that are entering the market with no clinical trials. Even devices that are supposed to be permanently implanted are making it to market this way, including transvaginal mesh, metal-on-metal hips, catheters and defibrillators.

In fact, every year about 3,000 medical devices make it to market under essentially no Food and Drug Administration review for safety and efficacy. That means we must trust the medical device manufacturer that they’ve done their homework concerning patient harm.

After repeated stories of failed devices and the companies that knew or should have known they were faulty, it is crystal clear that the honor system extended to medical device makers is not working.