The New York Times reported that Medicare and Medicaid wants consumers to report medical mistakes and unsafe practices by doctors, hospitals, pharmacists and others who provide treatment.  Federal officials say that medical mistakes often go unreported, and that patients have potentially useful information that could expose reasons for drug mix-ups, surgery on the wrong body part, radiation overdoses and myriad other problems that cause injuries, infections and tens of thousands of deaths each year.   Research shows that at least one-fourth of patients in and out of hospitals experience “adverse events” in their care.

“In a flier drafted for the project, the government asks: “Have you recently experienced a medical mistake? Do you have concerns about the safety of your health care?” And it urges patients to contact a new “consumer reporting system for patient safety.” The government says it will use information submitted by patients to make health care safer.”

A draft questionnaire asks patients to “tell us the name and address of the doctor, nurse or other health care provider involved in the mistake.” And it asks patients for permission to share the reports with health care providers “so they can learn about what went wrong and improve safety.”

Reports would be analyzed by researchers from the RAND Corporation and the ECRI Institute, a nonprofit organization that has been investigating medical errors for four decades.

 

ProPublica investigated why so many people do not report medical errors.  “Many of the people who suffer harm while undergoing medical care do not file formal complaints with regulators. The reasons are numerous: They’re often traumatized, disabled, unaware they’ve been a victim of a medical error or don’t understand the bureaucracy.

It’s a collective problem because patient safety flaws that remain hidden, if they are not corrected, may be repeated.  Propublica has collected a staggering number of people harmed while undergoing medical treatment.  “A review of medical records by the U.S. Health and Human Services Department’s inspector general found that in a single month one in seven Medicare patients was harmed in the hospital, or roughly 134,000 people.  “An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths,” the IG found, “which projects to 15,000 patients in a single month.”

A July report by the HHS inspector general’s office found that only 12 percent of harmful events identified by the office even met state requirements for reporting them. Compounding the problem: Hospitals themselves only reported 1 percent of the harmful events.

 

KSDK.com reported the sentencing of Ashley Michelle Sweeney’s after stealing from nursing home residents by stripping rings from patients’ fingers at a Veterans Nursing Home in Roanoke, VA.   Incredible.  Stealing from elderly veterans!

Sweeney was sentenced to 24 years in prison, with all but 5 suspended after testimony in which she admitted that she had pawned four Veterans’ wedding bands to support her drug addiction.   She might only serve a couple of years.  Sweeney has been ordered to never work as a nurse or nurses’ assistant again.  Who would hire her?

Brittney Heather Cook, a co-worker of Sweeney’s who worked as an aide at the same Nursing home, has also been implicated in the property thefts, and is scheduled for sentencing soon.

 

Sherri Sprenger, a staff member at Lutheran Home Nursing Home in Cape Girardeau, Missouri was charged with elder abuse.  Sprenger claims she lost her temper and slapped a resident across the face when the woman yelled at her one day this past August.  The incident was discovered when the family of the resident found bruising on her face and contacted local authorities.

The initial sentence was a three month jail sentence but Sprenger will only get probation, eighty community service hours, anger management counseling, and is required to write a letter of apology to the resident’s family.

Is this enough of a punishment for a woman who physically attacked a ninety eight year old woman?  This incident begs the question, who is being hired to take care of our country’s sick and elderly?

See articles at Southeast Missourian and KFVS.

Boston.com reported that Chief U.S. District Judge Mary M. Lisi doubled the damages against Antonio Giordano.  The nursing home executive must repay $12 million to the federal government for diverting money for personal benefit causing two nursing homes to fail. Giordano is in prison on conspiracy and embezzlement charges. Judge Lisi increased the damages to deter future violations by other individuals who raid publicly funded projects.

 

A new clinical study spearheaded by UCLA’s School of Nursing has found a direct correlation between pressure ulcers — commonly known as bedsores — and patient mortality and increased hospitalization.  The research is the first to use data directly from medical records to assess the impact of hospital-acquired pressure ulcers on Medicare patients at national and state levels.
According to the study, featured as the lead article in the current issue of the Journal of the American Geriatrics Society, seniors who developed pressure ulcers were more likely to die during their hospital stay, to have longer stays in the hospital, and to be readmitted to the hospital within 30 days of their discharge.

The study found that 4.5 percent of the patients tracked acquired a pressure ulcer during their stay in the hospital. The majority of these bedsores were found on the tailbone or sacrum, followed by the hip, buttocks and heels. The study also revealed that of the nearly 3,000 individuals who entered the hospital with a pressure ulcer, 16.7 percent developed at least one new bedsore on a different part of their body during their hospitalization.
 

As reported by The Hawk Eye, an Iowa nursing home is still refusing to accept any responsibility for the death of a resident even after a jury determined the facility was at fault.   Gene Bozarth, who was suffering from Alzheimer’s disease, fell while he was a resident of Danville Care Center and suffered a broken neck, wrist, and several facial bones.  Bozarth died days later due to fall related respiratory failure.

A Des Moines County jury awarded $600,000 in damages to the estate of Gene Bozarth.  After the award, the facility’s attorney filed a motion requesting a new trial and for the jury’s verdict to be removed. Thornton filed the frivolous motion on the grounds that the jury based their decision on, “passion and prejudice, not the testimony presented at trial.”

Thornton also has issues with the way the award was allocated.  The Jury awarded $100,000 for Bozarth’s pain and suffering yet Thornton callously maintains that even though Bozath broke his neck and smashed the bones in his face he suffered “virtually no pain for seven days.” Additionally the attorney disputed the $450,000 amount awarded to Bozarth’s widow.  “There is not sufficient evidence to sustain the award of $450,00 for loss of consortium.  Damages for spousal consortium are also limited in time to … Gene Bozarth’s normal life expectance.” Thornton harshly claims that since medical testimony claimed that Bozarth’s life expectancy was no more than 12 months he was going to die anyway so $450,000 was too much to give to his widow.

It is sad that even after a jury determined they were at fault, the facility still will not accept responsibility and continues to look for a way out.

The Wall Street Journal had a great article about the epidemic of medical malpractice in the health care system.  Medical errors kill enough people to fill four jumbo jets a week. “When there is a plane crash in the U.S., even a minor one, it makes headlines. There is a thorough federal investigation, and the tragedy often yields important lessons for the aviation industry. Pilots and airlines thus learn how to do their jobs more safely.”  This is not the case with medical errors which are usually not disclosed, or worse, covered up.

Surgeon Marty Makary has his ideas for making American hospitals more transparent about their safety records and more accountable for the quality of their care.
As doctors, we swear to do no harm. But on the job we soon absorb another unspoken rule: to overlook the mistakes of our colleagues. The problem is vast. U.S. surgeons operate on the wrong body part as often as 40 times a week. Roughly a quarter of all hospitalized patients will be harmed by a medical error of some kind. If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer’s. The human toll aside, medical errors cost the U.S. health-care system tens of billions a year. Some 20% to 30% of all medications, tests and procedures are unnecessary, according to research done by medical specialists, surveying their own fields.

Change can start with five relatively simple—but crucial—reforms.

Every hospital should have an online informational “dashboard” that includes its rates for infection, readmission (what we call “bounce back”), surgical complications and “never event” errors (mistakes that should never occur, like leaving a surgical sponge inside a patient). The dashboard should also list the hospital’s annual volume for each type of surgery that it performs (including the percentage done in a minimally invasive way) and patient satisfaction scores.”

Online Dashboards, Safety Culture Reports, Open Notes, Cameras, and No Gag Rules are the five ideas proposed by Dr. Makary.  Basically, it boils done to Reporting Mistakes and Transparency.