By Todd Ackerman, Houston Chronicle.
Another patient recently died at Ben Taub Hospital’s emergency center without receiving timely treatment, system officials revealed Friday, the fourth death in the Texas Medical Center in the last eight months because of an apparent miscue.
The Ben Taub patient was discovered unresponsive in a waiting room restroom, the same fate that befell a 66-year-old Hispanic man at the Houston safety-net hospital in April. That case was detailed in a government report released earlier this week.
“Incidents like this should never happen,” George Masi, president and CEO of the Harris Health System, said in a statement about the second death. “It is our responsibility to learn from them, and to constantly make improvements in our processes to ensure Harris Health fulfills our mission of caring for those most in need. We are fully committed to that effort, whatever it takes.”
The system, which operates Ben Taub, reported the death to the Texas Health and Human Services Commission and the Centers for Medicare and Medicaid Services July 19, the statement said. The death occurred July 16.
Ben Taub completed its review of the case and developed “additional risk reduction strategies” within those 72 hours, said Masi’s statement.
Ben Taub is already under increased oversight by CMS and HHSC because of key patient care and safety deficiencies found by investigators who inspected the hospital after the April death. Those investigators are expected to return later this summer to assess the progress the hospital has made.
CMS officials could not be reached for comment about the latest death.
Baylor St. Luke’s Medical Center and MD Anderson Cancer Center are under the same increased oversight because of patient care and safety issues that led to deaths. CMS earlier this year took that step — known as removing a hospital’s “deemed” status — following the death of a Baylor St. Luke’s ER patient who’d received the wrong blood type and the death of a MD Anderson patient who received contaminated blood.
Such mistakes are more common in hospitals than any of us would wish, said Leah Binder, CEO of the Leapfrog Group, which grades hospitals on safety. CMS annually places about 300 accredited hospitals under state and federal authority after adverse events reveal deficiencies that show the hospitals are out of compliance with the agency’s conditions of participation.
Vivian Ho, a Rice University health economist, suggested Ben Taub’s recent deaths shouldn’t come as a surprise.
“Harris Health is in a tough situation,” said Ho, director of the Center for Health and Biosciences at Rice’s Baker Institute for Public Policy.
“Because Texas didn’t take the Medicaid expansion under the Affordable Care Act, Ben Taub is forced to scrape together the resources to provide care for an extraordinary number of uninsured patients,” Ho said. “On top of that, it’s competing for trained health professionals in a tight labor market. With these financial pressures, it surprises me that care quality didn’t slip earlier.”
In a blog post last year, Ho cited recent studies showing financial struggles impair quality of care: one found hospitals “in worse financial condition” had significantly higher rates of adverse incidents, such as bedsores or hospital-acquired infections; another found patients undergoing major surgery faced significantly higher odds of suffering from medical errors when hospital margins decline over time.
But Binder said the issue “is about a hospital putting the needs of the patient first and foremost every minute of every day. That doesn’t cost more money, but it takes leadership.”
Ben Taub received a “C” grade from Leapfrog, which Binder said means patients are almost twice as likely to die from an error as they are in an A hospital.
The latest Ben Taub death involved a man who died nearly eight hours after he arrived at the emergency center, was clinically assessed and placed in the waiting area pending the availability of a treatment bed. In contrast, the man who died in April was found without a pulse in a restroom more than 28 hours after he was first seen.
In the latest case, the man received an electrocardiogram soon after he arrived at 12:46 p.m., according to the Harris Health statement. He was reassessed at 1:55 p.m. and 4:15 p.m., both times returned to the waiting area. At 7:15 p.m., the patient was escorted to the restroom by a family member, who waited outside.
Harris Health said there was no response to emergency center’s staff call out for the patient’s follow-up assessment at 7:29 p.m. and 7:47p.m.
The family member discovered the patient unresponsive in the restroom at 7:48 and called for help. The statement said staff immediately responded and moved the patient to a critical care room to attempt resuscitation, but the patient was pronounced dead at 8:27 p.m.
The statement provided no other specifics about the case “out of respect for the family’s privacy and in keeping with patient privacy laws.”
Ben Taub voluntarily disclosed news about the death to the Chronicle. In the statement, Masi said “Harris Health is committed to sharing the findings of these matters with its stakeholders and the residents of Harris County when the expected CMS survey and inspection is complete.”
July 26, 2019.
Ben Taub Latest TMC Hospital Sanctioned for Patient Death
By Todd Ackerman, Houston Chronicle, June 27, 2019.
Ben Taub Hospital violated key federal patient care and safety requirements in a case that culminated in death, according to a new report, the third such event in recent months to result in the sanctioning of a Texas Medical Center hospital.
The Centers for Medicare and Medicaid Services notified the Harris Health System of the deficiencies and moved to place it under state and federal authority in a letter and report the system received Wednesday. The action applies to all components of Harris Health, the public safety-net hospital network that operates Ben Taub.
“These deficiencies have been determined to be of such a serious nature as to substantially limit your hospital’s capacity to render adequate care,” CMS wrote in the June 26 notification letter to Harris Health.
George Masi, CEO of Harris Health, disclosed the death and CMS action in an email to hospital staff Wednesday afternoon. He wrote that the death — in the Ben Taub Emergency Center in April — stemmed “from an ineffective process in patient monitoring and communication of critical lab values.”
Harris Health did not self-report the death to CMS, which instead learned of it in a complaint. The Texas Health and Human Services Commission investigated the complaint on June 4-5 and found deficiencies in patient rights and emergency services, according to the CMS letter.
Harris Health received the CMS letter two days after the agency released a report providing details about an MD Anderson Cancer Center patient who died after receiving contaminated blood; and a month and a half after its release of a report about a Baylor St. Luke’s ER patient who died after receiving the wrong blood type, given because of a labeling error.
The Centers for Medicare and Medicaid Services placed both those hospitals under state and federal authority after finding major deficiencies on their campuses.
The three hospitals are among the most esteemed institutions in the medical center. MD Anderson consistently ranks as the nation’s No. 1 provider of cancer care, St. Luke’s has long been regarded as a leader in heart care and the Ben Taub Emergency Center is renowned for its trauma care.
One expert warned about reading much significance into the prevalence of problems in a short period of time in the medical center, one of Houston’s most prized brands.
“What’s unusual here probably isn’t so much three hospitals in a city being involved in these sort of sanctions as it being publicly reported,” said Leah Binder, CEO of the Leapfrog Group, which grades hospitals on safety. “It’s very unusual for hospitals to self-disclose, wherever it’s coming from. They’ve never lived in the spotlight of transparency in the past.”
Binder attributed the greater transparency to President Donald Trump, whose administration’s hallmarks include holding hospitals more accountable, she said.
But CMS spokesman Bob Moos denied the agency is in any way stepping up efforts to scrutinize hospitals.
“We don’t target hospital enforcement either toward specific facilities or issues,” Moos emailed the Chronicle. “Aside from a small percentage of sample validation surveys, our oversight of accredited hospitals is primarily based on complaint investigations. Complaints can come from a variety of sources and allege a multitude of issues.”
Moos said CMS annually cites about 300 accredited hospitals for being out of compliance with the agency’s conditions of participation. When that happens, the hospital is put under state and federal authority. In his letter to staff, Masi wrote that Harris Health is working toward “a speedy resolution” of the matter.
“Harris Health’s leadership takes this matter very seriously,” Masi wrote. “Since the completion of the HHSC survey, Harris Health made substantial strides in achieving full compliance and will continue to work diligently to meet all of the applicable standards of care.”
Harris Health did not grant any interviews about the case. But in response to Chronicle questions about the death, the system cited its Emergency Services policy, which appears to have broken down. The policy refers to “an ongoing process that begins with triage and includes monitoring of the patient until qualified medical personnel determine whether an emergency medical condition exists.”
“The medical screening examination includes all services within the capabilities of Harris Health, which, in the judgment of the emergency physician or other treating or consulting physician are reasonably necessary to screen and/or stabilize an individual with an emergency medical condition,” the policy says.
Harris Health is currently working on its plan of corrective action, said a spokesman. It has 10 days to submit its plan, after which HHSC will conduct a follow-up investigation.
Masi’s email included a link to the CMS notification letter, which became public once Harris Health received it, according to the agency. The email didn’t include a link to the full CMS report, typically not released by the agency until after the hospital submits its corrective plan.
CMS’ notification letter did not mention a death or even an “adverse event.” That was disclosed by Masi in his email to staff.
Harris Health was placed under state and federal authority as a result of CMS lifting its “deemed status,” a component of Medicare and Medicaid participation. The system will remain under government authority — instead of DNV GL Healthcare, its accrediting agency — until it demonstrates it is in compliance with CMS’ “conditions of participation.” CMS took the same action against St. Luke’s and MD Anderson.
All three remain a participant in Medicare and Medicaid programs.