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Author: Bo Frith

Drug Errors: An All-Too-Common Problem

September 18, 2019

More than 1 in 10 patients suffer injuries in the course of their medical care with half of those injuries being preventable. Among the preventable errors, 12 percent lead to a patient’s permanent disability or death, according to a meta-analysis of systemic review of medical acre published in July of 2019. [1]

The study, which analyzed data on more than 300,000 patients from over 70 scientific studies, highlights the severity of medical mistakes. Incidents relating to drugs and other therapies account for 49 percent of injuries, and injuries relating to surgical procedures account for 23 percent. While the study is not limited to the United States, the authors of the study state the findings apply to medical care in the United States.

The findings of the study, while concerning, are not surprising unfortunately. A landmark 2016 study by researchers at Johns Hopkins University reveals medical errors are the third leading cause of death in the United States, trailing only heart disease and cancer.[2] We’ve written about this issue before, but the data continue to point to the severity of the problem.  

Drug errors are a particularly significant issue. As the study above highlights, drug mistakes are a leading cause of medical injuries. Drug errors cause more than one million serious injuries or deaths in the United States every year.[3] Our office has handled many cases where a patient was given the improper dosage of a medication. We have also handled cases where a patient was prescribed a drug with significant, even fatal, side effects.

A drug error can happen at any point in the prescription process from the time the drug is prescribed to the time the drug is given. Most often, the error is by a nurse or doctor, but at times a pharmacist makes a mistake in filling or dispensing the prescription.

How to Prevent Drug Errors

Patients should pay close attention to what their doctor or pharmacist tells them about the drug they are taking, the correct dosage, and any potential side effects. A patient should ask questions if there is any aspect of the instructions that he or she does not understand. Patients should tell doctors the names of all prescription drugs, over-the-counter pharmaceuticals, and vitamin supplements they are taking to avoid potentially dangerous interactions.

Above all else, be an advocate for yourself.


[1] Panagioti M, Khan K, Keers RN, et al., Prevalence, Severity, and Nature of Preventable Patient Harm Across Medical Care Settings: Systematic Review and Meta-Analysis. BMJ. 2019;366:l4185, available at https://www.bmj.com/content/bmj/366/bmj.l4185.full.pdf.

[2] Medical Errors Are No. 3 Cause of U.S. Deaths, Researchers Say. NPR. May 3, 2016, available at  https://www.npr.org/sections/health-shots/2016/05/03/476636183/death-certificates-undercount-toll-of-medical-errors.

[3] Pharmaceutical Errors. Justia, accessed Sept. 18, 2019, available at https://www.justia.com/injury/medical-malpractice/common-types-of-medical-malpractice/medication-errors/.

Mortality Statistics and Your Hospital

May 31, 2019

The New York Times published a recent story on the secret recordings of doctors discussing concerns about poor surgical care. The outcomes from surgeries were so bad the doctors questioned whether they should refer patients for surgery if it meant in-house surgeons would perform the operation. You can read the article here. The popular podcast The Daily also published a story on the topic. You can listen to the podcast here.

The hospital offering the poor care now refuses to release its mortality statistics. The Times is suing the hospital for the release of the information. The information is called risk-adjusted mortality statistics. The data details patient deaths at a specific hospital for heart and lung surgeries. The data is adjusted to account for factors that may make some procedures and/or patients riskier than others. Medical experts regard the data as an excellent indicator of a hospital’s performance, including whether a hospital is losing patients who should not die.

Risk-adjusted mortality statistics are published on a website run by the Society of Thoracic Surgeons. The statistics are searchable from hospital to hospital on a wide range of heart and chest surgeries. Hospitals self-report the statistics to the website. There is no requirement for hospitals to report such information.

Patients should be concerned about a hospital which refuses to report its mortality statistics. As one of the doctors in the Times article states, “You should think twice about going to a [hospital] that doesn’t publicly report. People don’t buy a car without knowing what the gas mileage is.”

Searching through the website, the following hospitals in Southwest Virginia did not report their mortality statistics:

  • LewisGale Medical Center
  • Carilion Franklin Memorial Hospital
  • Carilion Giles Community Hospital
  • Carilion Tazewell Community Hospital
  • Carilion Stonewall Jackson Hospital
  • Carilion New River Valley Medical Center
  • Sovah Health Martinsville
  • Wythe County Community Hospital
  • LewisGale Hospital Pulaski
  • Russell County Hospital
  • Buchanan General Hospital

All Doctors Are Not Created Equal

May 15, 2019

Doctors are not gods.  They are not infallible, all-knowing deities picked by God Almighty to spread His wisdom to us mere plebes.  Doctors receive a lot of training.  Doctors work long hours and are well compensated for their work.  But doctors are people just like you and me.  Some doctors are better, or worse, than other doctors.  This makes sense as some teachers, mechanics, barbers, chefs, lawyers, etc. are better than others.  

I recently read a seminal article on this topic called “The Health-Care Bell Curve” in New Yorker Magazine.[1]  The article was written in 2004, but the issue remains as important today.  People used to assume the differences among doctors in a particular specialty were insignificant.  Today, we know that assumption is wrong.  If you plotted a graph showing the results of doctors in a specific specialty, you would find a bell curve: a handful of doctors with disturbingly bad outcomes, a handful with remarkably good outcomes, and a great undistinguished middle.

The New Yorker article points to studies in a variety of fields to illustrate the importance of the individual doctor on patient outcomes.  In ordinary hernia operations, the chances of recurrence are 1 in 10 for surgeons at the low end of the bell curve, 1 in 20 for those in the middle, and 1 in 500 for those at the very top.  The 10 year survival rate for patients with treatable colon cancer ranges from 63% to 20%, depending on the surgeon.  For heart bypass surgery, risk-adjusted death rates can vary from 5% to 1% depending on the surgeon, which is no small difference when life or death is at stake.

The healthcare industry does not like to acknowledge the common sense reality that all doctors are not created equal.  Patients, however, should always be aware of this fact.  Advocate for yourself.  Research all you can on the best doctor and healthcare system for your procedure.  We have written about this extensively in the past: see articles here, here, and here.  It is often said that the most important decision you make is the person you choose to marry.  I would offer that a close second is the doctor you choose to provide healthcare for yourself or a loved one.


[1] Gawande, Atul. The Health-Care Bell Curve. The New Yorker (Nov. 28, 2004), available at https://www.newyorker.com/magazine/2004/12/06/the-bell-curve.

Dental Errors Can Lead to Infectious Disease (HIV, Hepatitis, etc.)

April 19, 2019

Infectious disease from improperly cleaned instruments is an all-too-common occurrence in our healthcare system. Every year in the U.S., an estimated 648,000 people develop infections during a hospital stay, and about 75,000 die.[1] Many of these infections are completely preventable through, for example, proper cleaning of medical instruments.

The cleaning process for medical instruments is relatively straightforward process. There are two main steps.[2] The first step is removing contaminating debris and scrubbing the instruments with a disinfectant. The second step involves steam cleaning the instruments with hot, pressurized air. Both steps are vital to ensuring instruments are safe to use on future patients.

Unfortunately, many dentists’ offices fail to properly clean their instruments. Unclean instruments can lead to the spread of potentially deadly infections to patients such as HIV, hepatitis, MRSA, etc. Several studies are highly critical of the sterilization process for dental instruments, particularly the second step of steam cleaning.[3] Recently, a Vermont dental clinic notified over 60 patients they may have been exposed to infectious disease because the dental instruments were not steam cleaned.[4] The U.S. Department of Veterans Affairs investigated two incidences where 500 patients tested positive for bloodborne pathogens and 7,000 patients in Oklahoma were at risk for HIV and hepatitis.[5]

We often advise clients to be informed as the best way to ensure better healthcare outcomes. The failure to clean dental instruments is unfortunately something patients have little information about or often no way of knowing. If a dentist’s office informs you that you may have been exposed to infectious disease due to improperly cleaned equipment, we advise contacting our office.


[1] Consumer Reports. How Your Hospital Can Make You Sick. (July 29, 2015) available at https://www.consumerreports.org/cro/health/hospital-acquired-infections/index.htm.

[2] Dental Advisor. What Are Some Common Errors That Can Lead to Sterilization failure? (accessed Apr. 19, 2019) available at https://www.dentaladvisor.com/questions/what-are-some-of-the-common-errors-that-can-lead-to-sterilization-failure/

[3] Smith, A.J., Bagg, J, Hurrell, D., and McHugh, S. Sterilization of Re-Useable Instruments In General Dental Practice. British Dental Journal. (Oct. 27, 2007) available at https://www.nature.com/articles/bdj.2007.912

[4] Thurston, Jack. Dirty Dental Tools Put Dozens at Risk for Disease. New England Cable News. (Dec. 8, 2016) available at https://www.necn.com/news/new-england/Unsterilized-Dental-Equipment-Patients-Testing-Morrisville-Vermont-405451466.html.

[5] Field Hearing on Improving Patient Safety and Quality Care at the Dayton VA Medical Center. United States Senate Committee on Veterans’ Affairs. S. Hrg. 112-23. (Apr. 26, 2011) available at https://www.govinfo.gov/content/pkg/CHRG-112shrg66599/pdf/CHRG-112shrg66599.pdf

Virginia Hospitals Punished By Medicare

March 28, 2019

In 2019, Medicare penalized 800 U.S. hospitals for the high number of injuries and infections suffered by their patients. The penalties were enacted through a program in the Affordable Care Act where the federal government cuts Medicare reimbursements for hospitals with high rates of patient infections and injuries. The idea being that if hospitals suffer financially for poor outcomes, hospitals might improve the quality of care they provide.

Hospital patients suffered an avoidable injury in 9 out of every 100 hospital stays in 2016, or about 2.7 million times, according to a June report from the federal Agency for Healthcare Research and Quality.[1] Such injuries include adverse medication reaction, injury from a procedure, falls, or infections.

Sadly, our hospitals do not seem to be getting the message. Medicare has punished over 1,500 hospitals at least once.[2] In 2019, 110 hospitals were punished for a fifth straight time.[3] The 800 hospitals penalized in 2019 was the highest number since the since the program was created.[4]

Virginia hospitals fared especially poorly. Medicare punished 18 Virginia hospitals in 2019, listed below[5] with Southwest Virginia hospitals in bold:

  • Sentara RMH Medical Center in Harrisonburg
  • Sentara Norfolk General Hospital
  • University of Virginia Medical Center in Charlottesville
  • Carilion Roanoke Memorial Hospital in Roanoke
  • VCU Health System in Richmond
  • Novant Health UVA Prince William Medical Center in Manassas
  • Southside Regional Medical Center in Petersburg
  • Bedford Memorial Hospital in Bedford
  • Carilion Franklin Memorial Hospital in Rocky Mount
  • Inova Fair Oaks Hospital in Fairfax
  • Hiram Davis Medical Center in Petersburg
  • Reston Hospital Center
  • Chippenham and Johnston-Willis hospitals in Richmond
  • Lewisgale Hospital in Pulaski
  • Carilion Tazewell Community Hospital in Tazewell

Many of the Virginia hospitals punished in 2019 have been punished by Medicare in the past.[6] The best thing patients can do is to thoroughly research hospitals where they are considering receiving care. In times of an emergency, patients may not be able to choose their hospital. But for non-emergency situations, patients have more options.

Publicly available information is becoming more and more accessible. A great starting point is this database maintained by the Kaiser Family Foundation on which hospitals have been penalized by Medicare for poor outcomes.


[1] Agency For Healthcare Research and Quality, U.S. Department of Health and Human Services, AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results, 2014-2016, (June 2018), available at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf.

[2] Jordan Rau. Look Up Your Hospital: Is It Being Penalized By Medicare?. Kaiser Health News. (Mar. 1, 2019), available at https://khn.org/news/hospital-penalties/?penalty=hac.

[3] Jordan Rau. Medicare Trims Payments to 800 Hospitals, Citing Patient Safety Incidents. Kaiser Health News. (Mar. 1, 2019), available at https://khn.org/news/medicare-trims-payments-to-800-hospitals-citing-patient-safety-incidents/?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=70379732&_hsenc=p2ANqtz–jVTYTEQbjLtSjZS24-NBlqf1PZSO0EtnHOyEJ0p0PaprvWjCjhmGnbwDk2SxUkdYdeqjeQgosIxO8BZQpuCie1_SGl9Vcwuz7ob2U_UhOiSuwy9Y&_hsmi=70379732.

[4] Id.

[5] Katie O’Connor, Virginia Hospitals Among Those Penalized By Medicare. Virginia Mercury. (Mar. 13, 2019), available at https://www.virginiamercury.com/blog-va/virginia-hospitals-among-those-penalized-by-medicare/.

[6] Id.

New, Facility Specific Data on Virginia Nursing Homes

December 17, 2018

Inadequate staffing is a widespread and persistent problem in nursing homes in Virginia. We have written extensively about how there are no minimum staffing requirements for Virginia nursing homes. Despite the failure to ensure staffing at the state level, the federal Centers for Medicare & Medicaid Services (CMS) asserts “nurse staffing is directly related to the quality of care that residents experience.”[1]

The federal government recently indicated serious concerns about inadequate staffing, particularly on nights and weekends. A November 30th, 2018 letter from CMS warned about inadequate staffing at nursing homes.[2] A New York Times analysis found 11% fewer nurses providing direct care and 8% fewer aids on weekends as opposed to weekdays.[3] Nursing home residents and their families often tell us of the difficulty in getting basic help, such as assistance going to the bathroom, on weekends. The federal government is so concerned about inadequate staffing at nursing homes it recently ordered states to conduct more weekend inspections.[4]

The ability to find out staffing levels at individual nursing homes is critical to ensuring quality care for your loved one. Until recently, it was difficult for family members to determine which facilities staffed appropriately. Now, there are easy-to-use resources available. On December 11, 2018, the Long Term Care Community Coalition, an advocacy group, announced it will publish staffing information for every nursing home in the country. Simply visit their website, www.nursinghome411.org, to download sortable spreadsheets for every state that include:

  1. The facility’s direct care RN, LPN, and CNA staffing;
  2. The ratios of care staff to residents;
  3. Select non-nursing staff hours per day, including administrators, social workers, and activities staff; and
  4. The extent to which the facility relies on contract staff to provide resident care.

You can download the Virginia data set for the second quarter of 2018 here. Every family member with a relative in a nursing home should review this data to see if the facility they use has been staffing appropriately. 

The data are not encouraging. In the second quarter of 2018, Virginia nursing homes averaged 3.5 hours of total direct care per resident per day.[5] A landmark 2001 federal study indicated at least 4.1 hours are needed to meet a typical resident’s needs.[6] Virginia nursing homes also averaged 0.4 hours of RN staff time per resident per day, less than the 0.5 hours averaged nationally and significantly less than the 0.55-0.75 RN hours recommended by the same 2001 study.

 

 

 

 

[1] U.S. Centers for Medicare and Medicaid Services. Payroll Based Journal (PBJ) Policy Manual Updates, Notification to States and New Minimum Data Set (MDS) Census Reports, (Nov. 30, 2018), available at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-02-NH.pdf.

[2] Id.

[3] Jordan Rau. ‘It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years. New York Times (July 7, 2018), available at https://www.nytimes.com/2018/07/07/health/nursing-homes-staffing-medicare.html.

[4] Id. at Payroll Based Journal.

[5] Available at https://nursinghome411.org/wp-content/uploads/2018/12/VA-Staffing-2018Q2.xlsx.

[6] U.S. Centers for Medicare and Medicaid Services. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. (December 2001). Available at https://phinational.org/wp-content/uploads/legacy/clearinghouse/PhaseIIVolumeIofIII.pdf.

Pregnancy Deaths – A Uniquely American Problem and What Expecting Mothers Can Do to Protect Themselves

November 19, 2018

In America, thousands of mothers suffer significant injuries or die during childbirth. Each year more than 50,000 American women suffer severe injuries from childbirth. About 700 American women die each year from childbirth. A recent study from the USA Today demonstrates half of the deaths and injuries can be prevented by implementing safety practices mostly ignored by hospitals today.[1] 

In the study, fewer than half of women received prompt treatment for dangerous blood pressure readings that put them at risk for stroke. At some hospitals, less than 15 percent of mothers in peril received recommended treatment. Many of the hospitals failed to take safety steps such as quantifying women’s blood loss or tracking whether moms with dangerously high blood pressure received medication timely.

Today, the United States is the most dangerous place to give birth in the developed world.[2] From 1990 to 2015, maternal deaths in other developed nations flatted or declined significantly. Other countries reduced maternal deaths by monitoring care provided and implementing maternal safety practices.

Childbirth in America does not have to be so dangerous. Regulators and oversight groups could require hospitals to report data on childbirth complications and injuries. As opposed to the inaction in regulating births, regulators monitor elder care aggressively. For example, Medicare requires hospitals to disclose information on compilations for hip and knee surgeries. Unfortunately, there is little information available on maternal health.  No national tracking system exists for childbirth complications.

Despite the lack of information, expecting mothers can take a variety of steps to protect themselves. Mothers should know common warning signs and proper safety responses. For example, mothers are at risk of stroke once their blood pressure hits 160/110 (or either of those numbers individually). If blood pressure reaches 160/110 (or either individually): 1) the healthcare provider should retake the mother’s blood pressure within 15 minutes to ensure the reading is accurate; and 2) if still in the danger zone, the healthcare provider should give blood pressure medication to the mother within an hour.

Women should ask if their hospital tracks patient outcome data the maternal care. The Alliance for Innovation on Maternal Health (AIM) contains many of the best maternal safety practices. Expecting mothers should familiarize themselves with the guidelines included in the AIM Program and ask whether their hospital is one of the 985 hospitals enrolled in the AIM Program.[3] 

It is regrettable the burden of receiving proper maternal care falls on patients.  But, as is so often the case in the American medical system, patients must take an active role in their treatment to ensure the best possible care.

[1] Young, Allison. Hospitals Know How To Protect Young Mothers. They Just Aren’t Doing It. USA Today (July 27, 2018), available at https://www.usatoday.com/in-depth/news/investigations/deadly-deliveries/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/.

[2] Id.                                                                                                                

[3] Available at https://safehealthcareforeverywoman.org/aim-program/.

Choosing Your Doctor: The Importance of Procedure Volume at a Given Healthcare Facility

June 14, 2018

Family image 2One of the most important decisions a person can make is which doctor to trust with his or her medical care.  A recent blog post[1] on our website discusses factors to consider when selecting your doctor, including the number of times a doctor has performed the specific operation you will undergo.  If you are planning on open heart surgery, for example, it would be important to know how many times a doctor has performed that operation.  In fact, the number of times a doctor has performed a specific procedure is one of the most predictive factors in determining the success rate of future medical care.[2]  Patients, however, should not limit their analysis to just the total number of times a doctor has performed a specific operation.  A much more predictive metric is the number of times a doctor has performed a specific operation at a given healthcare facility.

As with all things, context matters — particularly in a complicated area such as healthcare where teamwork is vitally important.  In cardiac surgery, for example, a successful patient outcome depends not only on the individual surgeon, but the varied contributions of many healthcare providers such as anesthetists, intensive care specialists, intensive care nursing, ward nursing, junior medical staff, and so on.[3]

In the May 9, 2018 episode of Malcolm Gladwell’s excellent podcast Revisionist History, Gladwell discusses the effect of context on individual performance.[4]  In the podcast, Gladwell highlights the landmark 2006 study by Harvard Business School Professors Robert S. Huckman and Gary P. Pisano, The Firm Specificity of Individual Performance: Evidence from Cardiac Surgery.[5]  Surgeons often have privileges at different hospitals and facilities, meaning a given surgeon may perform the same operation at several different hospitals.  Using patient mortality as the metric, Huckman and Pisano found that the quality of a cardiac surgeon’s healthcare at given hospital improves significantly with increases in his procedure volume at that hospital, but does not improve significantly with increases in the same procedure at other hospitals. 

Huckman and Pisano demonstrate that increases in procedure volume for a surgeon at a given healthcare facility lead to a decrease in patient mortality at that facility.  However, the same surgeon doing the same procedure at a different healthcare facility may be just as deadly at operation number 1 as they are on operation number 1,000 at that facility.  Mere procedure volume is not predictive.

Huckman and Pisano’s findings are not entirely surprising because a surgeon is but one part of a team of doctors providing healthcare to a patient.  Like any person, a surgeon has strengths and weaknesses.  The team of doctors at a specific hospital may have worked together in the past with knowledge of their strengths and weaknesses with established routines to maximize strengths and minimize weaknesses.  In essence, the skill, expertise, and success rate of healthcare is team specific.

As a result, a vital factor to consider when selecting a doctor is the healthcare facility and team where the operation will be performed.  Without breaking down procedure volume to the level of a given healthcare facility, the statistic loses its predictive value.  Such a general number fails to account for the fundamental importance of a healthcare team and facility in successful patient outcomes.  As part of that, one should consider the number of specific procedures a doctor has performed at a given facility.


 

[1] https://frithlawfirm.com/blog/medical/medical-errors/find-good-doctor-virginia/.

[2] E.L. Hannan, J.F. O’Donnell, H. Kilburn, Jr., H.R. Bernard & A. Yazici, Investigation of the Relationship Between Volume and Mortality for Surgical Procedures Performed in New York State Hospitals, Am. Med. Assoc. (1989), available at https://www.ncbi.nlm.nih.gov/pubmed/2491412.; E. Hannan, H. Kilburn, H. Bernard, J. O’Donnell, G. Lukacik & E. Shields, Coronary Artery Bypass Graft Surgery: The Relationship Between Inhospital Morality Rate and Surgical Volume After Controlling for Clinical Risk Factors, 29 Med Care 1094–107 (Nov. 1991), available at https://www.ncbi.nlm.nih.gov/pubmed/1943270.

[3] A. Merry, W. Brookbank, Merry and McCall Smith’s Errors, Medicine and the Law 366 (Cambridge University Press, 2017). 

[4] Available at https://itunes.apple.com/us/podcast/revisionist-history/id1119389968?mt=2&ign-mpt=uo%3D4.

[5] http://www.people.hbs.edu/rhuckman/firm_specificity.pdf