Lawmakers for the state of California passed a disclosure law in 2006 that requires hospitals to report each time a patient suffers certain adverse events caused by inadequate medical care during hospitalization. Some officials call these adverse events “never events” because they should never be happening in the first place. The bill identifies 28 such events that must be reported to the state’s Department of Public Health.
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As data has become available that covers 10 months beginning with July 2007, more than 1,000 never events have been documented and ten hospitals have been fined $25,000. California hospitals admitted 4 million people in 2007.
Some of the events reported include:
- Too little oxygen being pumped via ventilator hose to a 9-day-old infant at Stanford University Hospital when a technician assembled the equipment incorrectly. The diagram for assembly was drawn backwards.
- Surgeons removed the appendix of the wrong patient when a CT scan was placed into the wrong patient file at Dominican Hospital in Santa Cruz.
- A 76-year-old woman died at Pomona valley Hospital Medical Center when she was given two drugs her doctor never prescribed.
- A man died from heart failure in the waiting room at Kaiser Foundation Hospital in San Jose after waiting more than an hour for emergency care in spite of the fact his blood sugar level tested too high to even register on the hospital’s glucometer. All 25 emergency care bays were full at the time.
- One surgical patient at Scripps Memorial in La Jolla was given a painkiller after surgery that is not approved for use after surgery. When she stopped breathing, she was given corrective medication but at a dosage only 1/10th the strength required to be effective. She survived but the hospital was levied one fine for each error.
- 466 patients developed pressure sores, also known as bed sores, that were so severe dead skin formed a crater in the patients skin or it rotted entirely through to the patient’s muscle and bone tissue.
- 145 surgical patients left the operating room with foreign objects, including surgical instruments, still in their bodies.
- 34 people died while being anesthetized.
- The wrong procedure, the wrong body part, or the wrong patient were operated on in 41 surgeries.
Investigation revealed that these events happen when hospitals do not follow the safety procedures that were developed to prevent them.
There are fewer emergency rooms per capita in California than in any other state. This limited availability of emergency treatment facilities has lead to overcrowding, which many officials say is also part of the problem with the errors in treatment that are being reported.
Some spokespersons for the medical community praise the reporting procedure as a way to quickly fix problems within the system while others say it is impossible to prevent all cases which fall under the reporting guidelines listed in the disclosure law.
The president of the Institute for Healthcare Improvement, a nonprofit organization based in Massachusetts, says his organization estimates 15 million adverse events occurring in hospitals throughout the United States every year. He further says it “will always be true” that adverse events are not reported in the vast majority of cases.
In seven states across the US, patients are not held responsible for the medical expenses caused by errors occurring in the hospital.
A California assemblyman proposed a bill that would ban reimbursement to hospitals when the 28 errors occurred that are defined in the disclosure law. Lobbyists representing hospitals and doctors objected, however, on the grounds that not every adverse event is the result of a mistake and a hospital should not be penalized for treating patients injured at other medical facilities.
A compromise was reached and the proposed bill was amended so that the number of preventable errors not bringing reimbursement was reduced to just the eight for which Medicare refuses reimbursement.
The US government’s Centers for Medicaid and Medicare services will stop paying hospitals for the expenses accrued when eight specific mistakes are responsible. Some of the mistakes that will result in non-reimbursement, beginning in October 2008, include infection contracted during surgery or from the use of catheters, bed sores, and objects left inside surgical patients.
According to the 2006 California disclosure law, the public health department will begin posting information online identifying all hospital errors no later than 2015.
Source: LA Times