'It's never just one thing' that leads to serious error

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'It's never just one thing' that leads to serious error

http://www.latimes.com/features/health/la-he-

errors28jan28,1,185313.story?track=rss

By Brink, Los Angeles Times Staff Writer - January 28, 2008

A technician mistakes an " a " for an " o " in a drug name. A doctor

misplaces a decimal point in a prescription order. A nurse reaches

for a vial in a cabinet as she's done hundreds of times before, only

this time the light is dim and she fails to notice that the powder-

blue label is more of a sky blue. The slip-ups are often simple, and

always human, and all have happened in U.S. hospitals.

Each simple mistake is supposed to be countered by a recommended

backup, a second or third set of eyes -- in other words, guidelines

to reduce human error. A lot has to be overlooked in the cascade of

errors that result in serious patient harm.

" It's never just one thing that goes wrong when a serious event

happens, " says Cohen, president of the Institute for Safe

Medication Practices, an organization that tracks prescribing errors

and is sometimes called in to examine a hospital's mistake. " We've

detailed a situation where we found over 50 mistakes in the system

before an infant was killed. " The incident, he said, was a 1,000-fold

overdose of the blood thinner heparin in an Indianapolis neonatal

intensive care unit that resulted in the deaths of three infants in

2006.

Late last year, the infant twins of actor Dennis Quaid and his wife,

, were the victims of a nearly identical mistake, an overdose

of heparin at Cedars-Sinai Medical Center. " It was the exact same

situation in a hospital in Indianapolis that we investigated a year

earlier, " Cohen says. " The pharmacy dispensed the wrong dose to the

nursing station. "

The Quaids' newborns, who were being treated for a staph infection,

have since been released, and the hospital has been cited by state

regulators for its handling of drugs. Its practice, regulators say,

had placed pediatric patients in jeopardy.

The mistake calls attention to how far hospitals have to go in

preventing medical errors and in learning from the mistakes of

others, even though many have made progress in protecting patients

within their own institutions. Despite a decade of rising public

awareness of such mistakes and research into how to prevent them,

even one of the country's premier institutions and a celebrity couple

were not immune. Hospitals still have a long way to go to avoid

mistakenly hurting their charges.

" People used to say that hospital mistakes are kind of like the poor -

- they're always with you, " says Dr. Lucien Leape, one of the authors

of a 1999 Institute of Medicine report that estimated 100,000 people

died each year in the U.S. from preventable hospital errors. " Well,

no, they don't have to be. "

Hospitals are trying. In a program called the 100,000 Lives Campaign,

some 3,000 of the nation's 5,000 acute care hospitals, including

Cedars-Sinai, have voluntarily instituted up to six changes in

practices aimed at reducing errors. The Joint Commission, a national

organization that accredits hospitals and other healthcare

facilities, now requires that patients be informed of " unanticipated

outcomes. "

But while accountability is improving, hospitals still face

increasingly complex technology. And medical culture, built on

individual excellence, not teamwork, is slow to change.

Unfortunately, Cohen says, few hospitals learn from the mistakes, or

improvements, of others. His organization published the results of

the Indianapolis incident in a newsletter sent to every hospital in

the country. If hospitals are to improve, he says, they have to study

errors that have happened elsewhere.

First instinct: Denial

The mid-1990s saw a rash of medical errors that caught the attention

of the public, and the medical profession: A Florida man had the

wrong leg amputated, a New York woman had surgery on the wrong side

of her brain, and Betsy Lehman, a newspaper reporter whose beat was

health, died of an accidental chemotherapy overdose at one of the

nation's top cancer centers, Boston's Dana Farber.

At first, the American Medical Assn. responded with a public

relations campaign, calling the incidents " isolated " mistakes,

according to an analysis of the era published in the April 27, 2002,

British Medical Journal. By 1996, however, the AMA launched a

National Patient Safety Foundation and changed its stance, admitting

that such errors were " common. "

But it was the 1999 Institute of Medicine Report that shocked the

country, and shamed the medical profession into voluntarily adopting

systems changes. The report estimated that 100,000 patients died

annually from preventable hospital errors -- about the same as the

yearly tally of deaths from motor vehicle accidents, breast cancer

and AIDS combined.

Leape, a leading researcher on medical mistakes, had long said the

number was a conservative estimate. Sure enough, five years later, a

review of Medicare records by the Denver-based healthcare ranking

group HealthGrades found nearly twice as many deaths from preventable

errors -- up to 195,000 -- in the country's healthcare facilities.

The higher estimate was never published in a peer-reviewed journal

and included deaths in settings other than hospitals, such as nursing

homes.

But since then, hospitals have begun responding to their state's

reporting laws, and, individually and voluntarily, launching their

own efforts to improve. One of the most notable is an effort

sponsored by the Institute for Healthcare Improvement, a nonprofit

group based in Cambridge, Mass., whose aim is to improve healthcare.

In that push, called the 100,000 Lives Campaign, 3,000 of the

nation's 5,000 hospitals volunteered to concentrate on one or more of

six changes statistically proven to reduce errors. Those changes

included following evidence-based guidelines to reduce infections and

improve care for heart attack patients and to assemble teams to

respond to the earliest signs of a patient crisis.

After a year, the institute reported that the changes made within the

participating hospitals probably saved more than 120,000 lives, even

more that what the IOM said was its conservative estimate of

accidental deaths.

A death related to a medical error can be proven, but a death avoided

is more difficult to document. In the November 2006 Journal on

Quality and Patient Safety, the 100,000 Lives Campaign compared the

volunteer hospitals' actual deaths in one year with statistically

expected deaths, based on data from the base year 2004. Based on the

analysis, 122,300 people walked out of hospitals in 2005 unscathed --

and never knew it might have been otherwise.

Now, all those hospitals and 700 others are signing up for a follow-

up campaign called the 5 Million Lives Campaign, aimed to halt not

just deaths, but also injuries and near misses.

Even simple changes can make a difference. One statewide hospital

group in Michigan followed a plan devised by Dr. Pronovost, a

critical-care specialist at s Hopkins Hospital, that involved a

simple checklist, fashioned after the kind of safety list pilots are

required to check on each takeoff and landing. A landmark study in

the Dec. 28, 2006, New England Journal of Medicine of 108 ICUs in

Michigan hospitals found that by using the checklist unfailingly,

common infections from medical tubing could be reduced by two-thirds.

Wash hands with soap. Check. Clean patient's skin with antiseptic.

Check. Wear sterile mask, gown, glove. Check. Put sterile drapes over

entire patient. Check.