By Wendy Ruderman, The Philidelphia Inquirer, Nov. 15, 2023.

Six years ago, a nurse at a Tennessee hospital accidentally gave a patient a powerful muscle-paralyzing drug. The patient stopped breathing and later died.

The nurse, RaDonda Vaught, was convicted of negligent homicide and sentenced last year to three years’ probation. Criminal charges over medical errors are rare, and the prosecution evoked fear in nurses nationwide. Patient safety advocates argued it sent the wrong message and would deter hospitals from admitting mistakes, which would not protect patients from medication errors.

Four years after Vaught’s deadly error, a similar mistake at Mercy Fitzgerald Hospital in Darby, nearly killed patient Didier Epopa and left him with irreversible brain injuries.

Epopa, 55, recently filed a medical malpractice lawsuit against the hospital. His lawyer, Eric Zajac, said the suit is among a growing number of Pennsylvania cases related to serious medication errors that he’s filed in recent years.

Zajac noted the drug errors in his caseload share a common denominator: They’re preventable.

“The health-care provider, whether it’s a pharmacist, hospital or doctor, either doesn’t have safeguards in place — or, they have them in place, but they aren’t following them,” said Zajac, whose practice, Zajac & Padilla, is based in Ardmore.

Life-and-death drug errors

In both the Tennessee case and Epopa’s, the errors were made in the use of neuromuscular-blocking drugs, which hospitals classify as “high-alert medications” because mistakes in their use can cause catastrophic harm or death.

Vaught, then a nurse at Vanderbilt University Medical Center in Nashville, mistakenly withdrew a vial of the paralytic vecuronium from a computerized medication cabinet. She typed “VE” into the search function, intending to take out Versed, a sedative to calm the 75-year-old patient who was about to be scanned in an MRI-like machine.

In the Philadelphia-area case, a lawyer for Mercy Fitzgerald revealed in a court filing that a pharmacy intern had mislabeled an IV bag. It was supposed to contain an antiviral but instead consisted of cisatracurium, a muscle-paralyzer similar to vecuronium.

Hospitals use these paralytics to keep patients still during surgery or to relax the throat when inserting a tube through the windpipe, known as endotracheal intubation. Even then, the drug is typically administered under the supervision of an anesthesiologist.

Cruel ‘air hunger’

Cisatracurium has also been at the center of controversy over lethal injections.

In 2018, Nevada prison officials intended to use it as part of a three-drug execution protocol, in conjunction with the sedative midazolam and the synthetic opioid fentanyl, to put a prisoner to death.

The pharmaceutical companies that make the medications sued Nevada because they didn’t want their products used in lethal injections.

A state judge ruled against the use of cisatracurium after hearing medical testimony that it could cause agonizing “air hunger” in fully alert prisoners — a violation of the U.S. Constitution, which prohibits “cruel and unusual punishments.”

Nevada’s cisatracurium supply expired in 2019. About a year later, as part of a legal settlement with the drug manufacturers, the state relinquished its unused cisatracurium and the other two medications.

Flawed systems fail patients

High-alert medications should come preformulated whenever possible, not in a powder or small vial that a hospital pharmacist needs to dilute and mix with saline in an IV bag. This is the recommendation of ECRI, a Plymouth Meeting-based national nonprofit that focuses on patient safety.

Additionally, hospitals should update computerized medication cabinets so practitioners must type in five letters instead of two or three to avoid retrieving medications that look and sound alike.

Vaught, who lost her nurse’s license and job in Tennessee, admitted her mistake. She told state authorities that she got “distracted” by a trainee while operating the automated drug dispenser and had become “complacent” in her job.

But she said the fault was not hers alone. The system failed, too.

During an interview with an investigator, Vaught said, “Ultimately, I can’t change what happened. … The best I can hope for is that something will come of this, so a mistake like that can’t be made again.”

ECRI president and CEO Marcus Schabacker agrees that system failures, not individuals, are at the root of medication errors.

“This is not about catching someone doing something wrong,” Schabacker said. “This is about understanding why a miss or near miss happens and then putting things in place to avoid a similar mistake.”

Schabacker noted that there hasn’t been a deadly accident in commercial air-safety traffic in the United States since 2009. Yet, each year, about 100,000 patients die of preventable medical errors in America. Like commercial aviation, health-care institutions should not only scrutinize errors, but near errors as well, so safety gaps can be closed tight, he said.

An anesthesiologist and intensive care specialist, Schabacker said hospitals must employ additional safeguards for cisatracurium and other high-alert medications, including limiting access and double verification by two qualified practitioners prior to dispensing and administering.

Hospital administrators who want to prevent errors must set the tone and atmosphere for staffers to come forward and report incidents in which a mistake occurred or nearly did, without fear of blame or discipline.

Until that happens, medical errors, particularly those related to medications, will continue, Schabacker said.

“We, as a medical profession, have just become too complacent,” he said.

Do you know what you need to know?

Most people, it turns out, have no idea what to do when one of their family members (or themselves) lands in the hospital. Do you know what to do? Ask yourself the following questions:

•       Do you know what care activities should happen, when and why? 
•       Do you know what to ask of the nurses and doctors?
•       Do you know what you can and can’t ‘know?’
•       Do you know what is ‘standard’ to ask versus, what is considered ‘pushy?’
•       Do you know what is the ‘important’ information to share with the doctors or nurses?
•       Do you know how to tell if all the right things are taking place?

To have the most successful hospital admission, it is important to understand how hospitals operate, and what to do, if you are placed in the role of the caregiver. First off, let’s discuss how people become patients!

Common route to being admitted

The most common ‘route’ into the hospital usually starts in the emergency room, or ER: Someone feels really terrible or has an accident, and they go (or are taken) to the ER. For example, last week an older aunt started to feel sick—she was losing strength in her arms and legs, she stopped eating or drinking and she was warm to the touch. One of her children thought it best to take her to the ER, where, hours later, she was admitted to the hospital.

Ok. The person has become a patient…Now What?

Hospitals are a chaotic patchwork of part-time workers 

First off, it is important to know a few things about the state of hospital care. Hospital care may seem organized but they are not. The hospital setting is actually a patchwork of independent workers who come together in the patient’s room to treat a patient: The doctors most often are not employed by the hospital and might not know each other. Multiple doctors will probably be involved in the patient’s care.  So for example, if you have an infection like pneumonia, the hospital-based doctor will prescribe antibiotics and fluids. But if you also have a heart condition, then the patient will be treated by another doctor who specializes in the heart, called a cardiologist, who will order additional tests and medications.

These doctors and nurses also don’t usually know the patient so they don’t know all the unique or ‘weird’ things about the patient that the family member knows: they don’t know the patient’s medical history, if they have allergies to medications, if they’ve been put on new medications or if the patient might have a new, yet-to-be diagnosed condition. Which was the case with my aunt.

Job of the Nurse as the Super-Duper Project Manager

So, don’t expect that everyone in the hospital knows everything about the patient. However, don’t worry just yet—the job of the nurses is to make sense of all the medications, treatments and overall care plans and to help ‘course correct’ when different doctors say contradictory things. Think of nurses as super-duper project managers and the project is the patient’s care while in the hospital.

The job of the ‘Hospital Care Giver’

Given all that, the patient needs their own ‘staff’ of helpers or ‘care givers’ who are usually family members or close friends.

The role of the caregiver is challenging too. A caregiver must be patient since that person will be spending hours in the hospital waiting to talk to doctors or nurses.

The caregiver should also know the patient well enough to share important information with the doctors and nurses, like which medications the patient is on and know about the patient’s conditions.

The caregiver should also know what has been troubling the patient and for how long, such as a loss of appetite, new onset of weakness and the like.

Armed with all of this information, below are a few of the key things to know when you or your loved one gets admitted into the hospital.

Ten Things To Know And Ask:

1. Assume doctors and nurses do not know everything about the patient.

2. Assume that information you shared with one doctor or nurse is NOT communicated to the other doctors and nurses. Corollary: Assume you will have to repeat yourself.
3. Know that it is your right to ask to talk with ‘the doctor in charge.’ It is the doctor in charge that will be overseeing the patient’s care.
4. Ask to see this doctor every day. Why? Because every day new information is being generated about the patient so you can learn what is going on with your loved one. Corollary: It is normal to ask what the reasons are for the patient staying in the hospital and what is being done to improve those problems.
5. It is normal to ask why these problems (like getting an infection) happened in the first place. It is normal to ask if the patient is doing as well as they’d hope.
6. It is normal to ask what the plan of care is for the following day.
7. It is normal to ask for another opinion (outside of the hospital) if a big surgery is being recommended. It is normal to wait on big decisions if the patient and family need time to think.
8. It is normal to ask that things are explained in a way you can understand.
9. It is normal to ask for a social worker to discuss home care and discharge planning.
10. It is normal to express concerns like, if you think the nurse forget to administer a medication, or if one of the tubes going into the patient appears blocked or leaking. Corollary: It is normal and “OK” to ask any question.

A Reminder that Patients Are People Too

Sadly, it is not normal for doctors and nurses to have a lot of time to spend with the patient or care giver. They are squeezed for time, which is why care givers need to be organized and have some patience.

Sometimes they get busy and forget that patients are people and that every single patient is a very different person from the person they just saw in the previous hospital bed.

Compassion Goes A Long Way—Still

It is a curse of the work—doctors and nurses get hardened and critical. Doctors and nurses get focused on their ‘job,’ and getting their work ‘done,’ so they can get onto the next patient. It is not an excuse for rudeness or hard-heartedness. It is an explanation.

The most helpful things patients and care givers can do is to view themselves as part of the ‘care team’ by being organized, engaged, assertive and pro-active. Then, to top it all off, sprinkle in some kindness and compassion for everyone who works in hospitals.

Patient Advocacy Sources include: The National Patient Safety Foundation, Patients Like Me.

By Brett Kelman, KHN, Apr 29, 2022.

More than four years ago, Tennessee nurse RaDonda Vaught typed two letters into a hospital’s computerized medication cabinet, selected the wrong drug from the search results, and gave a patient a fatal dose.

Vaught was prosecuted this year in an extremely rare criminal trial for a medical mistake, but the drug mix-up at the center of her case is anything but rare. Computerized cabinets have become nearly ubiquitous in modern health care, and the technological vulnerability that made Vaught’s error possible persists in many U.S. hospitals.

Since Vaught’s arrest in 2019, there have been at least seven other incidents of hospital staffers searching medication cabinets with three or fewer letters and then administering or nearly administering the wrong drug, according to a KHN review of reports provided by the Institute for Safe Medication Practices, or ISMP. Hospitals are not required to report most drug mix-ups, so the seven incidents are undoubtedly a small sampling of a much larger total.

Safety advocates say errors like these could be prevented by requiring nurses to type in at least five letters of a drug’s name when searching hospital cabinets. The two biggest cabinet companies, Omnicell and BD, agreed to update their machines in line with these recommendations, but the only safeguard that has taken effect so far is turned off by default.

“One letter, two letters, or three letters is just not enough,” said Michael Cohen, the president emeritus of ISMP, a nonprofit that collects error reports directly from medical professionals.

“For example, [if you type] M-E-T. Is that metronidazole? Or metformin?” Cohen added. “One is an antibiotic. The other is a drug for diabetes. That’s a pretty big mix-up. But when you see M-E-T on the screen, it’s easy to select the wrong drug.”

A Five-Letter Fix: Making It Stick

Omnicell added a five-letter search with a software update in 2020. But customers must opt in to the feature, so it is likely unused in many hospitals. BD, which makes Pyxis cabinets, said it intends to make five-letter searches standard on Pyxis machines through a software update later this year — more than 2½ years after it first told safety advocates the upgrade was coming.

That update will be felt in thousands of hospitals: It will be much more difficult to withdraw the wrong drug from Pyxis cabinets but also slightly more difficult to pull the right one. Nurses will need to correctly spell perplexing drug names, sometimes in chaotic medical emergencies.

Robert Wells, a Detroit emergency room nurse, said the hospital system in which he works activated the safeguard on its Omnicell cabinets about a year ago and now requires at least five letters. Wells struggled to spell some drug names at first, but that challenge is fading over time. “For me, it’s become a bigger hassle to pull drugs, but I understand why they went there,” Wells said. “It seems inherently safer.”

Computerized medication cabinets, also known as automated dispensing cabinets, are the way almost every U.S. hospital manages, tracks, and distributes dozens to hundreds of drugs. Pyxis and Omnicell account for almost all the cabinet industry, so once the Pyxis update is rolled out later this year, a five-letter search feature should be within reach of most hospitals in the nation. The feature may not be available on older cabinets that are not compatible with new software or if hospitals don’t regularly update their cabinet software.

Hospital medication cabinets are primarily accessed by nurses, who can search them in two ways. One is by patient name, at which point the cabinet presents a menu of available prescriptions to be filled or renewed. In more urgent situations, nurses can search cabinets for a specific drug, even if a prescription hasn’t been filed yet. With each additional letter typed into the search bar, the cabinet refines the search results, reducing the chance the user will select the wrong drug.

The seven drug mix-ups identified by KHN, each of which involved hospital staff members who withdrew the wrong drug after typing in three or fewer letters, were confidentially reported by front-line health care workers to ISMP, which has crowdsourced error reports since the 1990s.

Cohen allowed KHN to review error reports after redacting information that identified the hospitals involved. Those reports revealed mix-ups of anesthetics, antibiotics, blood pressure medicine, hormones, muscle relaxers, and a drug used to reverse the effects of sedatives.

In a 2019 mix-up, a patient had to be treated for bleeding after being given ketorolac, a pain reliever that can cause blood thinning and intestinal bleeding, instead of ketamine, a drug used in anesthesia. A nurse withdrew the wrong drug from a cabinet after typing in just three letters. The error would not have occurred if she had been required to search with four.

In another error, reported mere weeks after Vaught’s arrest, a hospital employee mixed up the same drugs as Vaught did — Versed, a sedative, and vecuronium, a dangerous paralytic.

Cohen said ISMP research suggests requiring five letters will almost entirely eliminate such errors because few cabinets contain two or more drugs with the same first five letters.

Erin Sparnon, an expert on medical device failures at ECRI, a nonprofit focused on improving health care, said that although many hospital drug errors are unrelated to medication cabinets, a five-letter search would lead to an “exponential increase in safety” when pulling drugs from cabinets.

“The goal is to add as many layers of safety as possible,” Sparnon said. “I’ve seen it called the Swiss cheese model: You line up enough pieces of cheese and eventually you can’t see a hole through it.”

And the five-letter search, she said, “is a darn good piece of cheese.”

Vaught, a former nurse at Vanderbilt University Medical Center in Nashville, was arrested in 2019 and convicted of criminally negligent homicide and gross neglect of an impaired adult during a controversial trial in March. She could serve as much as eight years in prison. Her sentencing May 13 is expected to draw hundreds of protesters who feel her medical error should not have been prosecuted as a crime.

At trial, prosecutors argued Vaught made numerous mistakes and overlooked obvious warning signs while administering vecuronium instead of Versed. But Vaught’s first and foundational error, which made all other errors possible, was inadvertently withdrawing the vecuronium from a cabinet after typing just V-E. If the cabinet had required three letters, Vaught probably would not have pulled the wrong drug.

“Ultimately, I can’t change what happened,” Vaught said, describing the mix-up to investigators in a recorded interview that was played at her trial. “The best I can hope for is that something will come of this so a mistake like that can’t be made again.”

After the details of Vaught’s case became public, ISMP renewed its calls for safer searches and then held “multiple calls” with BD and Omnicell, Cohen said. ISMP said that, within a year, both companies confirmed plans to tweak their cabinets based on its guidance.

BD raised the default on Pyxis cabinets to a three-letter minimum in 2019 and intends to raise it to five in a software update expected “by the end of summer,” spokesperson Trey Hollern said. Cabinet owners will be able to turn off this feature because it’s “ultimately up to the health care system to configure safety settings,” Hollern said.

Omnicell added a “recommended” five-letter search through a software update in 2020 but left the feature deactivated, so its cabinets allow searches with a single letter by default, according to a company news release.

Perilous Typos: M-O-R-F-I-N-E

At least some hospitals must have activated the Omnicell safety feature because they’ve begun to alert ISMP to workflow problems — spelling errors or typos — made worse by requiring more letters. Omnicell declined to comment for this story.

Ballad Health, a chain of 21 hospitals in Tennessee and Virginia, activated the five-letter search while installing new Omnicell cabinets this year.

CEO Alan Levine said it was an easy choice to engage the safety feature after the Vaught case but that the transition has laid bare an unflattering truth: Lots of people, even highly trained professionals, are bad spellers. “We have people that try to spell morphine as M-O-R-F-I-N-E,” Levine said.

Ballad Health officials said one of the most common issues arose in emergency rooms and operating rooms where patients need tranexamic acid, a drug used to promote blood clotting. So many nurses were delayed at cabinets by misspelling the drug by adding an S or a Z that Ballad posted reminders of the proper spelling.

Even so, Levine said Ballad would not deactivate the five-letter search. Because of the pandemic and widespread staffing shortages, nurses are “stretched” and more likely to make a mistake, so the feature is needed more than ever, he said.

“I think, given what happened to the nurse at Vanderbilt, a lot of [nurses] have a better appreciation of why we are doing it,” Levine said. “Because we’re trying to protect them as we are the patient.”

Some nurses remain unconvinced.

Michelle Lehner, a nurse at a suburban Atlanta hospital that activated the five-letter search last year, said she believed hospitals would be better served by isolating dangerous medications like vecuronium, instead of complicating the search for all other drugs. Five-letter search, while well-intentioned, might slow nurses down so much that it causes more harm than good, she said.

As an example, Lehner said that about three months ago, she went to retrieve an anti-inflammatory drug, Solu-Medrol, from a cabinet with the safety feature. Lehner typed in the first five letters of the drug name but couldn’t find it. She searched for the generic name, methylprednisolone, but still couldn’t find it. She called the hospital pharmacy for help, but it couldn’t find the medication either, she said.

After almost 20 minutes, Lehner abandoned the dispensing cabinet and pulled the drug from a non-powered, “old school” medication cart the hospital normally reserves for power outages.

Then she realized her mistake: She forgot the hyphen.

“If this had been a situation where we needed to give the drug emergently,” Lehner said, “that would have been unacceptable.”

Article link: https://khn.org/news/article/medication-cabinet-hospital-drug-errors/

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By Andrew Jacobs, New York Times, Aug. 21, 2021.

Cyndy O’Brien, an emergency room nurse at Ocean Springs Hospital on the Gulf Coast of Mississippi, could not believe her eyes as she arrived for work. There were people sprawled out in their cars gasping for air as three ambulances with gravely ill patients idled in the parking lot. Just inside the front doors, a crush of anxious people jostled to get the attention of an overwhelmed triage nurse.

“It’s like a war zone,” said Ms. O’Brien, who is the patient care coordinator at Singing River, a small health system near the Alabama border that includes Ocean Springs. “We are just barraged with patients and have nowhere to put them.”

The bottleneck, however, has little to do with a lack of space. Nearly 30 percent of Singing River’s 500 beds are empty. With 169 unfilled nursing positions, administrators must keep the beds empty.

Nursing shortages have long vexed hospitals. But in the year and half since its ferocious debut in the United States, the coronavirus pandemic has stretched the nation’s nurses as never before, testing their skills and stamina as desperately ill patients with a poorly understood malady flooded emergency rooms. They remained steadfast amid a calamitous shortage of personal protective equipment; spurred by a sense of duty, they flocked from across the country to the newest hot zones, sometimes working as volunteers. More than 1,200 of them have died from the virus.

Now, as the highly contagious Delta variant pummels the United States, bedside nurses, the workhorse of a well-oiled hospital, are depleted and traumatized, their ranks thinned by early retirements or career shifts that traded the emergency room for less stressful nursing jobs at schools, summer camps and private doctor’s offices.

“We’re exhausted, both physically and emotionally,” Ms. O’Brien said, choking back tears.

Like hospital leaders across much of the South, Lee Bond, the chief executive of Singing River, has been struggling to stanch the loss of nurses over the past year. Burnout and poaching by financially flush health systems have hobbled hospitals during the worst public health crisis in living memory.

With just over a third of Mississippi residents fully vaccinated, Mr. Bond is terrified things will worsen in the coming weeks as schools reopen and Gov. Tate Reeves doubles down on his refusal to reinstate mask mandates. “Our nurses are at their wits’ end,” Mr. Bond said. “They are tired, overburdened, and they feel like forgotten soldiers.”

Across the country, the shortages are complicating efforts to treat hospitalized coronavirus patients, leading to longer emergency room waiting times and rushed or inadequate care as health workers struggle to treat to patients who often require exacting, round-the-clock attention, according to interviews with hospital executives, state health officials and medical workers who have spent the past 17 months in the trenches.

The staffing shortages have a hospital-wide domino effect. When hospitals lack nurses to treat those who need less intensive care, emergency rooms and I.C.U.s are unable to move out patients, creating a traffic jam that limits their ability to admit new ones. One in five I.C.U.s are at least 95 percent capacity, according to an analysis by The New York Times, a level experts say makes it difficult to maintain standards of care for the very sick.

“When hospitals are understaffed, people die,” said Patrica Pittman, director of the Health Workforce Research Center at George Washington University.

Oregon’s governor has ordered 1,500 National Guard troops to help tapped-out hospital staff. Officials in a Florida county where hospitals are over capacity are urging residents “to consider other options” before calling 911. And a Houston man with six gunshot wounds had to wait a week before Harris Health, one of the country’s largest hospital systems, could fit him in for surgery to repair a shattered shoulder.

“If it’s a broken ankle that needs a pin, it’s going to have to wait. Our nurses are working so hard, but they can only do so much,” said Maureen Padilla, who oversees nursing at Harris Health. The system has 400 openings for bedside nurses, including 17 that became vacant in the last three weeks.

In Mississippi, where coronavirus cases have doubled over the past two weeks, health officials are warning that the state’s hospital system is on the verge of collapse. The state has 2,000 fewer registered nurses than it did at the beginning of the year, according to the Mississippi Hospital Association. With neighboring states also in crisis and unable to take patient transfers, the University of Mississippi Medical Center in Jackson, the only Level 1 trauma unit in the state, has been setting up beds inside a parking garage.

“You want to be there in someone’s moment of need, but when you are in disaster mode and trying to keep your finger on the leak in the dike, you can’t give every patient the care they deserve,” said Dr. LouAnn Woodward, the medical center’s top executive. With staffing shortfalls plaguing hospitals coast to coast, bidding wars have pushed salaries for travel nurses to stratospheric levels, depleting staff at hospitals that can’t afford to compete. Many are in states flooded with coronavirus patients.

Texas Emergency Hospital, a small health system near Houston that employs 150 nurses and has 50 unfilled shifts each week, has been losing experienced nurses to recruiters who offer $20,000 signing bonuses and $140-an-hour wages. Texas Emergency, by contrast, pays its nurses $43 an hour with a $2 stipend for those on the night shift. “That’s ridiculous money, which gives you a sense of how desperate everyone is,” said Patti Foster, the chief operations officer of the system, which runs two emergency rooms in Cleveland, Texas, that are over capacity.

Ms. Foster sighed when asked whether the hospital offered signing bonuses. The best she can do is pass out goody bags filled with gum, bottled water and a letter of appreciation that includes online resources for those overwhelmed by the stress of the past few weeks.

Business has never been better for travel nurse recruiters. Aya Healthcare, one of the country’s biggest nurse recruitment agencies, has been booking 3,500 registered nurses a week, double its prepandemic levels, but it still has more than 40,000 unfilled jobs listed on its website, said April Hansen, the company’s president of work force solutions. “We’re barely making a dent in what’s needed out there,” she said.

There were more than three million nurses in the United States in 2019, according to the Bureau of Labor Statistics, which estimates 176,000 annual openings for registered nurses across the country in the next few years. But those projections were issued before the pandemic.

Peter Buerhaus, an expert on the economics of the nursing work force at Montana State University, is especially rattled by two data points: A third of the nation’s nurses were born during the baby boom years, with 640,000 nearing retirement; and the demographic bulge of aging boomers needing intensive medical care will only increase the demand for hospital nurses. “I’m raising the yellow flag because a sudden withdrawal of so many experienced nurses would be disastrous for hospitals,” he said.

Many experts fear the exodus will accelerate as the pandemic drags on and burnout intensifies. Multiple surveys suggest that nurses are feeling increasingly embattled: the unrelenting workloads, the moral injury caused by their inability to provide quality care, and dismay as emergency rooms fill with unvaccinated patients, some of whom brim with hostility stoked by misinformation. Nurses, too, are angry — that so many Americans have refused to get vaccinated. “They feel betrayed and disrespected,” Professor Buerhaus said.

Increasing the nation’s nursing workforce is no easy task. The United States is producing about 170,000 nurses a year, but 80,000 qualified applicants were rejected in 2019 because of a lack of teaching staff, according to the American Association of Colleges of Nursing.

“We can’t graduate nurses fast enough, but even when they do graduate, they are often not prepared to provide the level of care that’s most needed right now,” said Dr. Katie Boston-Leary, director of nursing programs at the American Nurses Association. Newly minted nurses, she added, require on-the-job education from more seasoned ones, placing additional strains on hospital resources.

Some of the proposed remedies include federal policies that can stabilize the profession, including financial assistance to help nursing schools hire more instructors and staffing-ratio mandates that limit the number of patients under a nurse’s care.

“This simplistic notion that the labor market will just produce the number of nurses we need just isn’t true for health care,” said Professor Pittman of George Washington University. “Nursing is in crisis, and maybe the pandemic is the straw that will break the camel’s back.”

The crisis is on full display at Texas Emergency Hospital, which has been treating patients in hallways and tapping administrators to run specimens to the lab. In recent days, 90 percent of those admitted to the hospital have tested positive for the coronavirus. Short on ventilators, and with hospitals in Houston no longer able to take their most critically ill patients, officials have been contemplating the unthinkable: how to ration care.

On Friday, Cassie Kavanaugh, the chief nursing officer for the hospital’s network, was dealing with additional challenges: Ten nurses were out sick with Covid. She had no luck renting ventilators or other breathing machines for her Covid patients. Many of the new arrivals are in their 30s and 40s and far sicker than those she saw during previous surges. “This is a whole different ballgame,” she said.

Ms. Kavanaugh, too, was running on fumes, having worked 60 hours as a staff nurse over the previous week on top of her administrative duties. She was also emotionally wrought after seeing co-workers and relatives admitted to her hospital. And her anguish only mounted after she stopped at the grocery store: Almost no one, she said, was wearing masks.

“I don’t know how much more we can take,” she said. “But one thing that hit me hard today is a realization: If things keep going the way they are, we’re going to lose people for sure, and as a nurse, that’s almost too much to bear.”

By: Adrianna Rodriguez, USA Today, May 04, 2021.

During the height of the pandemic, many health care providers were forced to temporarily halt elective procedures in an attempt to slow down virus transmission and relieve hospitals overwhelmed by COVID-19 patients.

But before the pandemic, a new report shows U.S. hospitals may have unnecessarily performed too many elective procedures and tests, particularly among older adults.

The Lown Institute, a health care think tank, found more than a million tests and procedures performed in hospitals on Medicare patients from 2016-2018 met established criteria for overuse.

“These results are if anything the low end of the estimate,” said Dr. Vikas Saini, president of the Lown Institute. “It speaks to the power of habit, weak penetration of actual science and certainly a lot of prominent financial incentives for hospitals and doctors without any counter-balancing information that patients could use to push back.”

The report looks at 12 low-value services including hysterectomies for benign disease, coronary stents for a stable heart and diagnostic tests like head imaging for fainting. Researchers found more than 90% of hospitals overused these tests or procedures.

The institute released a ranking of more than 3,100 hospitals examining success at avoiding the use of tests and procedures that offer little to no clinical benefit.

Out of the 50 top performing hospitals, nine are located in New England and 10 in the Pacific Northwest. Forty-one of the 50 lowest-performing hospitals are in the South.

“It seems like in medicine and health care, there’s similar kind of forces that are more active in the South than elsewhere,” Saini said. “If we want to improve our health care system, it’s important to understand what about the South may be different.”

A separate report published last week by The Leapfrog Group, a watchdog organization focused on health care safety and quality, found a similar trend when looking at hospital safety across the country. For the ninth year in a row, more than 2,700 hospitals were assigned a letter grade based on its ability to protect patients from preventable errors, accidents, injuries and infections.

Only two out of the 27 hospitals that achieved “A” grades for the 19th time in a row are located in the South, specifically in North Carolina and Virginia, said Leah Binder, president and CEO of The Leapfrog Group.

But unlike the Lown Institute report, Binder said Leapfrog’s straight “A” hospitals are more widespread across the rest of the nation, and include many community hospitals as well as academic institutions.

She also said hospitals with a consistent pattern of protecting patients from errors accidents and injuries seem to have been more prepared when the pandemic hit.

“First step is safety because it doesn’t matter how good the surgery is if you get the wrong medication or they make a big mistake in post-op, then it doesn’t matter anymore because your life is at stake or you can suffer terribly,” she said.

By releasing these reports, Saini and Binder hope to sound an alarm and encourage hospitals to reduce unnecessary procedures and tests, and increase patient safety.

“We’re not publishing the rankings because we think patients can use this information to pick hospitals,” Saini said. “Our incentive is more about changing the conversation and putting it out in the town square to say ‘Look, this is a problem.’”

“We wish we could give every hospital in this country an ‘A,’ but we can’t yet,” Binder said. “We have to make it clear to hospitals that this needs to be their priority, that nothing else matters as much as the safety of the patients in their bed.”

Article link: https://www.usatoday.com/story/news/health/2021/05/04/hospitals-overuse-elective-procedures-before-pandemic-report-finds/4921660001/

Medical Error Statistics: When Healthcare Can Kill You

What They Can Cause

Medical errors have a huge cost. They cost about $20 billion per year annually since they lead to more expenses to correct or treat more issues. These payments often fall on outside parties, such as Medicare. One in seven Medicare patients face a medical mistake, so these costs do occur frequently.

But the cost is more than financial; they can cause prolonged illness, permanent disability, or even death.

These issues aren’t new; the first major report on medical errors in the US is from over two decades ago. In 1999, The Err is Human from the Institution of Medicine estimated 98,000 deaths due to error. At the time, this would be the sixth leading cause of death in the country.

A study in 2010 found that this number had almost doubled to 180,000 deaths. And by 2013, the estimate ranged from 210,000 to 440,000 deaths per year. This landed medical errors as the third leading cause of death trailing heart disease and cancer.

via CDC.

Following the same pattern, it would still be the third leading cause of death today.

Researchers used four separate studies from 2000 to 2008 and hospital admissions rates from 2013 to analyze this problem. Based on extrapolated data of 35,416,020 hospitalizations, medical errors cause 251,454 deaths per year. This translated to 9.5% of all deaths per year.

Issues With Reporting

Despite mistakes affecting so many patients, it goes unreported more often than it should. NORC at the University of Chicago conducted a 2017 survey about patients’ experiences with medical errors.

This survey from adults found that in 32% of cases where a patient experienced an error, the health facility informed the person of it. Sixty-seven percent said they were not informed.

Because patients aren’t always informed of an incident, they end up reporting it to the hospital on their own. Of those who personally experience errors, 31% report it themselves and 10% have someone else report it on their behalf. Fifty-six percent of patients who don’t report the mistakes said they didn’t think it would do any good. And four in ten didn’t even know how to report it.

So why aren’t mistakes reported? Despite the previous statistics of how many deaths occur, the reality is that the true numbers are unclear. This is for several reasons. There’s disagreement about how to measure adverse effects, if it’s possible to pinpoint accurate numbers, or if reporting is necessary for enhancing patient safety.

On a larger scale, the CDC fails to classify errors separately on a death certificate when collecting health statistics. This makes it even harder to know real data about how often these issues occur.

Even if hospitals do report mistakes, it doesn’t mean anything will change. A study looked at hospitals that reported total medical mistakes. Researchers studied 25 Pennsylvania hospitals that implemented a MEDMARX Medication Error reporting system.

Throughout the year, reports increased significantly over each quarter. During the same time, the proportion of hospital corrective actions stayed relatively constant. So even though they were tracking how much harm there was, they weren’t managing it.

Why Errors Occur

The term “error” is negative and might sound malicious, but it doesn’t mean there was intentional harm. There are situations where doctors intentionally disrespect or don’t value their patients, but more often than not, this isn’t the cause.

Most are due to systematic problems. Just like how there are system issues with reporting, there are also system issues that cause preventable problems:

• Communication problems

• Organizational transfer of knowledge

• Inadequate information flow

• Patient-related issues

• Staffing patterns and workflow

• Technical failure

• Inadequate policies

All of these are controllable factors, which go to show that many mistakes are preventable.

Common Types

There are thousands of types of mistakes, but let’s look at some of the most frequent.

The most common type relates to diagnoses. Of those who experience mistakes, 59% said that it was due to an incorrect diagnosis, late diagnosis, or a problem that wasn’t diagnosed at all.

Diagnostic mistakes lead to the death or injury of 40,000 to 80,000 patients annually. The misdiagnosis rate is 10% to 15%. These problems are a challenge regardless of medical specialty.

Surgical errors are another common problem with at least 4,000 occurring each year in the US. What’s interesting is that many are a result of systematic issues, as I mentioned earlier. Some are a result of medical equipment during surgery, which leads me to the third common type.

While medical devices advance and improve the health industry, they still aren’t perfect. There are over 5,000 kinds of medical devices used in healthcare, so mistakes are inevitable. Sometimes these devices end up getting recalled because of their risks.

But unfortunately, the flaws aren’t always caught before it’s too late. Across all devices, the FDA reported more than 1.7 million injuries and around 83,000 deaths in the last ten years.

Health-associated Infections

You’d think that you’ll be least likely to get sick at a medical facility. After all, it should be clean so patients can heal. But a health-associated infection (HAI) is one adverse effect that results from medical care. According to the CDC, one in 31 patients has an HAI on any given day.

In 2013, 99,000 people died from this effect. Thankfully this number dropped within a few years, but not by much. In 2015, there were still about 72,000 patients who died from HAIs during their hospital stay. But patients were 16% less likely to have one of these infections in 2015 versus 2011.

Patients who end up with an HAI after surgery spend an extra 6.5 days in the hospital on average. They’re also five times more likely to return after hospital discharge and twice as likely to die.

How They Affect Women and Infants

There are disparities across different demographics when it comes to medical errors. Let’s take a look at women and infants. It’s worth mentioning that the maternal mortality rate (MMR) in the US is higher than those in other wealthy countries.

Of course, this can be for a variety of reasons. But one contributing factor to this rate is preventable problems. About 700 US women die from pregnancy-related complications each year. But around 60% of these are preventable.

For maternal mortalities, a revised coding method and death certificate have improved the quality of data. This can help with determining if the cause of death was preventable, thus enhancing reporting.

Newborns experience preventable complications, too. There are nearly 28,000 birth injuries per year and many are preventable. This is about three babies each hour that experience these injuries. About 134 of 100,000 babies will die from birth injuries. While one-quarter are due to poor prenatal care, many are a result of medical negligence or malpractice.

Is Anyone Else to Blame?

Pointing fingers doesn’t help because anyone can make mistakes. It isn’t always the fault of the hospital, which is why you shouldn’t avoid receiving care if you need it.

Other parties come into play when mistakes occur. I mentioned that medical equipment can cause harm to patients. Sure, this could fall on the hospital for not assessing vendors or providing equipment training. But it may simply come down to the device manufacturer.

We see product malfunctions all the time whether it be with cars, cell phones, or other technology. The same can happen with medical equipment, but unfortunately, this can have more tragic impacts since lives are at risk.

Medication errors occur outside of the hospital. They can happen from a doctor giving out the wrong prescription or a nurse administering the wrong drug. But pharmacists also fill wrong prescriptions.

These medication mistakes cause injuries for around 1.5 million people each year. Out of three health settings that these occur most frequently, hospitals of the least. Each year, about 400,000 occur in hospitals compared to 800,000 in long-term care settings and 530,000 in outpatient clinics.

OK, at this point you might be afraid to trust health professionals when receiving a prescription. But in many cases, the patient has power when it comes to reducing medication mistakes.

Yes, even patients can be the cause of their own adverse health effects. People use half of all prescriptions incorrectly, which causes up to a quarter of hospital and nursing home admissions. And around 125,000 people die each year because they didn’t follow their medications properly.

Like other mistakes, this is also preventable. Patients should ask questions, confirm their medication directions, and consult their doctor with any concerns.

Conclusion

Medical errors have serious costs associated with it. The health industry loses out on billions each year because of them. But patients have more to lose.

These can cost people their health and, in the worst cases, their lives. Since most of these mistakes aren’t intentional or malicious, it seems negative to refer to them as “errors.”

But it draws attention to the idea that something needs to change. For example, hospitals don’t always disclose them to patients or don’t have a good system for reporting data.

They must hold staff accountable, improve reporting methods, use secured devices, and keep facilities clean. They can also improve education for patients so that they don’t cause any issues on their own. If they improve in just some of these areas, they can start seeing changes in numbers. And more people may be willing to visit.

We should rely on hospitals as premier authorities on protecting people from health hazards like infections and injuries. After all, they hire exceptionally smart and credentialed staff to care for the most vulnerable people in our communities. But statistics suggest otherwise. Preventable errors, accidents, and infections at hospitals are so common they rank as the third leading cause of death in the U.S., with an estimated 20,000 avoidable deaths a month. At least one in six people admitted to an American hospital suffered a hospital-acquired infection—long before we heard of SARS-CoV-19.

Sadly, after a tumultuous year of pandemic, it appears many hospitals are emerging worse, not better, at keeping patients safe.

According to a new white paper by Press Ganey, one of the country’s largest and most influential health care quality companies, “safety culture” scores declined significantly among a sample of 54 hospitals across the country. Assessed through an anonymous survey at each hospital, safety culture describes whether the norms and habits of staff and clinicians keep the focus on patient safety. Questions on the survey are extensively tested and validated by researchers, and studies show the results correlate closely with actual rates of avoidable harms, errors, and infections. A separate examination of 160 hospitals by the Agency for Healthcare Research and Quality (AHRQ) found similar results, including an alarming 40% reduction from 2018 to 2020 in staff perceptions that management made safety a priority.

Press Ganey found that safety culture declined last year in two of three categories measured. First, they found decline in the category “Prevention and Reporting,” which explores whether staff believe the hospital actively attempts to improve patient safety and whether they feel free to raise concerns.

“Given that everything was in crisis mode, it appears people didn’t feel that safety concerns were being addressed or they weren’t comfortable speaking up,” said Tejal Gandhi, MD, MPH, CPPS, Press Ganey’s chief safety and transformation officer. She finds this “disappointing, but not surprising” given the challenges organizations were facing. “It shows that all of the work on safety culture has not become hard coded or habit and that it could deteriorate under stress, which is exactly when you need that culture to be strongest.”

The category of safety culture Press Ganey found most in decline is “Resources and Teamwork,” which covers communication and collaboration between physicians, nurses, and others, as well as overall staffing levels and job stress. Gandhi says this reflects the unique demands of Covid-19, but it is alarming nonetheless. Breakdowns in communications, as well as understaffing and job stress, are rapid and persistent drivers of safety problems and extremely dangerous to patients—and to workers themselves.

Only one category remained stable since 2019, “Pride and Reputation,” which is whether staff would recommend the hospital to family or friends. “People have pride in how their organizations were responding to Covid, and they knew that leaders were trying to do the right thing,” Gandhi explained.

How Hospitals Can Move Forward

“Though safety culture has declined, hospital leaders can take action to reverse the downward trend,” Gandhi urges. “Safety culture was critical before the pandemic, but as we emerge from this crisis, it is critical that we course-correct to ensure we achieve the safest care going forward.”

Tools are abundant, and many are free or low-cost for hospitals to correct this troubling safety trend. The National Action Plan to Advance Patient Safety, an important consensus document by leading experts on best practices, was issued last fall. Other resources and tools are available from AHRQ.

Studies have shown the advantage of scientifically grounded strategies like “High Reliability” or “Lean/Six Sigma” processes to dramatically improve safety. The key to making them work is leadership, according to author Mark Graban, a prominent authority on Lean/Six Sigma principals. Leaders should pinpoint organizational problems—no matter how seemingly small—and clear barriers to solutions and coach the problem-solvers.

Safer hospitals are better for workers and vice-versa. “Workers who know that their leaders are demonstrably committed to their safety and their patients’ safety as a precondition of any other work— and not a tradeoff with other goals—are empowered to perform at their highest level,” said Ken Segel, a noted quality improvement expert and CEO and managing director of the safety organization Value Capture.

National Policy Action

There are several bipartisan policy proposals circulating in Washington to address patient safety, and the Press Ganey paper reinforces the urgency for Congress to act.

The Patient Safety Movement Foundation has a series of proposals to improve transparency and align payment for health services with excellence in patient safety.

An initiative by AARP and others (including my organization) would mandate reporting of health care acquired infections by all facilities, like ambulatory surgery centers and long term care facilities, beyond the subset of hospitals required to report currently. The Centers for Disease Control and Prevention has a small but effective operation in place to accomplish this goal called the National Healthcare Surveillance Network (NHSN), which works with all 50 state health departments to collect and analyze infection data. However, few facilities are required to report the data to NHSN, so most do not. As a result, during the pandemic, policymakers were significantly delayed gathering accurate infection data from critical hot spots like nursing homes, which in turn delayed response. That should never happen again. 

An influential coalition of national advocates, spearheaded by the Jewish Healthcare Foundation of Pittsburgh, aims for the establishment of a National Patient and Provider Safety Authority, modeled after the National Transportation Safety Authority (NTSB). This would lend needed national focus to the issue and ensure we make progress when there is a crisis the way NTSB does when there is a crash.

These proposals for action would solidify our national commitment to safety and guarantee transparency and accountability going forward. We cannot allow the bitter irony of setbacks in fighting infections after we just fought the most dangerous infectious disease in modern history. We need action now.