5 Scary Things About Healthcare Quality

Cheryl Clark, for HealthLeaders Media , October 31, 2013

Among the recent California immediate jeopardy fines against hospitals that harmed patients was a $100,000 penalty against Sharp Memorial Hospital in San Diego was a particularly egregious and sad incident, not just because of the harm it caused a 53-year-old man, but because of how preventable it was.

Medical Errors

>>>Slideshow: CA hospitals penalized
for medical errors

The patient was assessed at a nearby hospital, where a physician performed imaging studies that revealed a cancerous mass on his right kidney. He was referred to Sharp for surgery.

The physician erred in his notes, writing that the mass was on the left kidney.

He promptly corrected it to clarify that the lesion "is actually located within the **RIGHT** kidney." But the Sharp surgeon failed to see the second note, did not bring the patient's kidney images with him into the operating room, and neglected to remotely access them electronically, despite his team asking if the surgery should be postponed until he had those images.

The Sharp surgeon told state investigators that he "intended to access the images related to the case, but forgot the necessary log-on information needed to access the images remotely."

The patient's healthy kidney removed, a second surgery was necessary to remove the cancerous kidney, and the patient will be subjected to dialysis treatments for the rest of his life.

3. Missing Hospital Patient Found Dead In Hospital Stairwell

One medical error that would clearly make John T. James's list comes under the category of utterly unfathomable. It's the gruesome story of what happened to Lynne Spalding, 57, a patient at San Francisco General Hospital. On Sept. 19, Spalding was admitted for treatment of an infection, but two days later she could not be found.

Spalding's body was discovered in a hospital stairwell 17 days later. An autopsy is underway to determine the cause of death.

And the story gets worse. An attorney for Spalding's family told the San Francisco Chronicle that he was told by hospital officials that four requests were made to law enforcement officials to search for the patient. It's unclear whether those searches were conducted.

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3 comments on "5 Scary Things About Healthcare Quality"

Suresh Nirody (11/1/2013 at 2:53 PM)
He didn't actually "count" anything... He looked at four studies(covering 4,252 records reviewed, which were associated with a total of 38 deaths) and then extrapolated their rates to the total 34.4 million discharges in 2007 to get his lower boundary... Beyond the deaths he estimates a mind-boggling 2-4 million serious adverse events (not resulting in death) a year! What IS shocking is that the 1999 IOM report was based on data from studies in 1984, and this latest report is based on years old data as well. It is an indictment of the system that analysis of something so important has to rely on such old data! Also, given the magnitude of the numbers discussed, I've been completely amazed to NOT have seen any analysis of this report, either to support or to disagree with the methodology and his numbers and conclusions... Surely there are learned people who can, and should, do this!

Lisa Sams MSN, RNC (11/1/2013 at 1:27 PM)
Cheryl, thank you for highlighting the James article. The doctor consider "father" of patient safety is confident in the analysis. And you raise an important question about the level of interest in harm and death that occur during a hospital stay. Unless it happens to someone we know....or to ourselves....I believe we have learned to ignore the data because it is One Person at a time. Many attempt to tell their story and organizations like the Walking Gallery offer visual representation of lost or harmed loved ones. These are system issues, as mentioned in other comment. But calling it a system problem does not remove the provider, administrator and other staff from the analysis. As a long time advanced practice nurse, I see the value in system analysis and development of a plan that can be tracked until the culture change is truly integrated into care. If we can reach critical mass with patient communities and clinicians sharing information, collaborating and basically taking charge of the problem it will change. No clinician goes to work looking to cause harm and when it happens it is devastating. It is time to share basic information with patients and families in how to stay safe in the hospital, to push back, to question and when necessary engage the CEO through a Risk Management report...done on a scrap of paper is all it takes. Yes, these are complex system issues but if your spouse, your mom or your child is not receiving the care you think they should then push and push hard. We have a good history of patient community driving change in the 60's & 70's. It was women who changed our closed doors and drug induced hospital births to family centered care. They became educated and expected more.

stan davis (10/31/2013 at 7:15 PM)
very irresponsible to write "He says that at least 210,000 deaths a year in the U.S.[INVALID]and as many as 440,000[INVALID]can be blamed on provider mistakes". nowhere in the paper does it state this as "provider mistakes". the errors are part of a system, and requires a system approach to fix.




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