Nearly 90 major medical mistakes logged at Utah hospitals in 2008

Published June 26, 2009 5:32 pm
Outcomes » Range from unanticipated deaths to permanent physical or emotional harm.
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One full-term infant died. Four healthy patients passed away unexpectedly after surgery. Another patient committed suicide. And dozens more left hospitals sick not from their illness but from their stay: They fell down, were given the wrong drug, became infected from surgical equipment left inside their bodies.

There were at least 89 of these most serious medical errors last year in Utah hospitals and surgical centers, up 56 percent from the 57 logged in 2007, according to a Utah Department of Health report requested by The Salt Lake Tribune.

The annual report does not cover all errors - it collects so-called "sentinel events," or mistakes that result in an unexpected death or a serious physical or psychological injury.

Hospitals must report the problems and their correction plans to the health department by state law, which also says the hospital names are confidential.

The goal of reporting is to help the health department and health care providers identify and fix systemwide problems, according to the law.

Despite a years-long effort to cut down on one type of medical mistake - surgical errors - they remain Utah's top problem. There were 45 surgical errors last year, such as performing the wrong surgery on the wrong body part. One example: A gastrointestinal tube that was guided into a lung instead of the stomach.

"We're struggling," said Iona Thraen, who reviews the mistakes as director of patient safety for the state health department.

She said the state's sentinel events committee, made up of nurses and risk managers at Utah hospitals, will zero in on the problem of retained foreign objects after surgery. There were 24 of those cases last year. Nationally, it's a problem, too. Organizations that are voluntarily accredited by The Joint Commission, including 33 in Utah, logged 71 such cases in 2008, making it the fourth-highest sentinel event behind wrong-site surgeries, suicides and delays in treatment.

Retained sponges are Utah's main problem, Thraen said.

"A sponge is like a big gauze, almost like a baby's diaper, depending on the size. They would hold the moisture and the body fluids," she said. "If it's not taken out of the cavity, it's going to create an infection."

The standard practice is for hospital staff to manually count the sponges before and after surgery to ensure they are removed and confirm the removal with an X-ray, said Thraen. When reviewing the cases when sponges were left inside patients, the staff members are usually certain they counted and re-counted the material, she noted.

That's why she wants to discuss new sponge-counting technology: Sponges embedded with a chip that are scanned and tracked using radio-frequency identification technology. The manufacturer - Pennsylvania company ClearCount Medical Solutions - said no Utah hospital has used or evaluated the product.

Hospitals have already tackled wrong-site surgeries, standardizing the way surgical sites are marked on the body. There were eight wrong body part surgeries last year, about the same in 2007. Thraen noted they weren't errors like the wrong leg or hip side being operated on. "We're at the point of whether it's the right digit, right vertebra."

The data comes from the Utah Department of Health's "2008 Report on Sentinel Events." Part of the reason there are more events logged in 2008 compared with the prior year is that the state increased the number of events that must be reported, starting in mid-2007.

The report shows errors are most likely to occur in operating rooms, following by intensive care units. The most vulnerable to mistakes are patients between the ages of 41 and 85.

There were 28 "unanticipated" deaths last year, six cases of "major permanent harm" and 55 "other" outcomes, which included a patient left with permanent incontinence, a retained catheter, a scar from a burn, a fracture requiring surgery and "cognitive deficits."

Some also suffered a brain injury, infections and an unwelcomed sexual advance.

The state started tracking the events in 2001, after a landmark study estimated 98,000 Americans die from medical errors each year. Though no state policy required Utah hospitals to inform their patients of serious errors, patients and families typically are informed, said Deb Wynkoop, director of health policy at the Utah Hospitals and Health Systems Association.

Being transparent benefits the doctors and nurses, she explained, allowing the system to improve. Hospital culture has changed over the past decade, Thraen added.

"It's shifted from hiding to disclosure on an individual patient level," she said. "Lifting the veil of denial or protection and exposing that health care in of itself is a highly risky business and exposing errors ... [is] the only way you're going to be able to make any changes."

As chairwoman of Utah's sentinel events work group, Marilyn Mariani, chief nursing officer at Lakeview Hospital in Bountiful, helps to review trends and make recommendations for systemic change.

"I still think we don't capture all the data in the state of Utah," she said, noting that part of the challenge has been making people understand what falls under a sentinel event. Thorough reporting helps illuminate what needs to change.

"We've got to figure out what are the breakdowns," she said.

But achieving perfection may be nearly impossible to do. "Nobody in health care wants to make a mistake," Mariani said. "It has to do with human factors."

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Keeping count

During a routine inspection of McKay-Dee Hospital in Ogden last year, state health department surveyors cited the facility for compromising patient safety because surgical staff didn't count instruments before and after surgery. They did count sponges and needles.

Inspectors were told that staff only counted instruments during open-heart surgery and that surgeons were "reluctant to allow staff to perform instrument counts" because "it added more time to the surgical procedure," according to the inspection report obtained by The Salt Lake Tribune.

The inspectors discovered the practice during a review of medical records, not because a patient was harmed by the policy. The hospital said it has no record of instruments being left inside a patient in 2008.

Nevertheless, inspectors recommended the creation of an instrument count policy, which was already underway by the surgery department, according to Chris Dallin, a spokesman for Intermountain McKay-Dee Hospital Center. The hospital also agreed to randomly check to make sure it is being implemented.

Some nurses had always been in the habit of counting instruments, Dallin said. Formalizing the policy, which was in place by October, was an effort to standardize procedure, he said.



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