Hospital Mistakes, Never Events and Health Reform in 2009

June 7th, 2009 · 1 Comment

Last month, the State of California Department of Public Health decided to make an example of two hospitals by levying fines of $25,000 each for using a faulty respirator on a man with emphysema, and sending a patient home after back surgery with a sponge stuffed in around his spine. Additionally, they levied lesser fines of varying amounts against eleven other hospitals for lapses in patient care that placed patients in jeopardy. Thus we have the same tire old methods with health department inspectors conducting surprise audits of patient cases once every three years on average and levying fines which rarely go above $25,000. Now that the public eye is on health care reform, many state regulatory agencies are scurrying about to assess the damages. Many state health department officials have added reporting requirements and have removed the veil of secrecy from the realm of in-hospital negligence in hopes that the humiliation of bad publicity would motivate administrators to run a tighter ship. Thus far, we see no evidence that this strategy is working. Nobody wants to deal with the fact that there is a 1 in 500 risk of death just from being in any hospital even though that would like an airliner falling out of the sky every week. However, if there were that much trouble with air travel, people have other options; whereas if someone is on the way to a hospital with a life-threatening condition, there is no other alternative.

Accordingly, what we need to realize is that the current regulation systems are utterly useless because there is no personal accountability other than becoming defendants in a medical malpractice lawsuit. For example, what do we do about a hospital corporate management team that blatantly refuses to keep its life support equipment in good repair? What if somebody dies because a machine didn’t work at the moment the staff needed to use it to correct a life-threatening condition as a result of the failure to make the necessary repair? In any other situation, a person who knowingly causes and allows a potentially lethal condition to exist is guilty of criminally negligent homicide. If the situation were truly horrendous, the authorities might even ad “with depraved indifference”. Therefore, every time a hospital administrator causes death with a wanton disregard for the patients’ safety and well being by refusing to provide equipment in good working order, that person should go to jail. But that doesn’t happen in this country because we don’t have special safety standards like we have with air travel. A couple of years ago, when two pilots showed up drunk at a Texas airport there was a huge scandal and the inebriated flyboys never made it to the cockpit because they were arrested at the gate. When a surgeon shows up soused, the operating room manager either cancels the cases for that day, or the good drunken doctor stands by and watches while a resident performs the procedure. There is usually no scandal and no disciplinary proceeding because the hospital business managers see the physician as their cash cow and they don’t want to tarnish their public image.

In conclusion, President Obama keeps saying that the health care system is broken and that it’s not sustainable. He claims that we keep paying more for less. Actually he’s right; but he has focused on coverage and cost and has not bothered to deal with what goes on in hospitals, rehab centers and nursing homes and the more than 200,000 preventable deaths and more than 600,000 disabling injuries per year from trauma, pressure ulcers, medication errors, surgical blunders, infections, pulmonary emboli, internal hemorrhage and the like. It is really a simple matter of nurses, doctors and management personnel being more meticulous in how they perform patient safety courses of action. There are certain procedures that they must perform at the beginning of every shift to maintain patient safety like checking equipment and supplies, assessing the patients and their environments and re-checking patients’ identities. However, health care workers are not diligent enough in conducting such procedures. If they were, there wouldn’t be so many casualties. There are too many people in the health care professions and management who don’t know how to promote patient safety and don’t care to learn. Therefore, we need Congress to develop a complete set of regulations requiring interventions for prevention of all of the named events that should never happen. Pilots are diligent in their safety checks because their lives are on the line too. Doctors and nurses need to have the same motivation for the same level of thoroughness; they need to have something to lose if they cause death or catastrophic injury through wanton negligence, like their livelihood and freedom.

Other Internet Media Sources:

Review of medication mix-up at Alberta hospital will be made public

Tags: Medication Errors · Economic Crisis · Editorial · Hospital Operations · Hospital Management Policy · Hospital Trauma · Nursing Home Litigation for Neglect and Abuse · Elder Care · Health Care Reform · Health · Obama · Hospital Pharmacy · Health Informatics · Turkey Reform · HMO's · Health Care Consumer Alert · In the News · Bedsores · Operating Rooms · Emergency Room · Hospital · Hospital Acquired Infection · Critical Care · Medical Evidence · Hospital Quality · Patient Safety · Nursing Neglilgence · Quality Assurance · Medical Mistakes · Nusring Shortage · Surgery · Medical Malpractice · Medical Error Alert · Hospital Mistakes · Conscious Pain and Suffering · Nursing Home Quality

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1 Posts about Digg as of June 7, 2009 » The Daily Parr // Jun 7, 2009 at 11:44 pm

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