February 7, 2007 in City

Pressure ulcers top list of hospital errors

By The Spokesman-Review
 

By the numbers

Medical errors reported at Washington hospitals since June.

11: Surgery – wrong body part

4: Wrong surgical procedure

17: Foreign object left after surgery

3: Death or serious disability from use or function of a device

6: Death or serious disability – medication error

1: Maternal death or serious disability during a low-risk pregnancy

41: Stage 3 or 4 pressure ulcers

4: Patient death – fall

1: Patient abduction

6: Sexual assault on patient

1: Death or serious disability from physical assault by staff

Source: Washington state

Department of Health

Twice since June, practitioners at Sacred Heart Medical Center in Spokane left objects inside patients after surgery.

At Coulee Community Hospital in Grand Coulee, someone operated on the wrong body part.

And at three regional hospitals – Deaconess Medical Center, Holy Family Hospital, and Valley Hospital and Medical Center – patients developed bed sores severe enough to damage flesh, muscle, tendons and bone after being admitted to the facilities.

Those medical mistakes are among 95 errors or other problems reported by hospitals across Washington since a new law went into effect eight months ago, state Department of Health records showed.

The so-called “adverse events” include a newly expanded list of 27 serious problems that include medication errors, deadly patient falls, performing the wrong surgery or sending a baby home with the wrong person.

Hospital officials across Eastern Washington said reporting errors is nothing new, that they’ve long used internal and external accounts of mistakes to improve patient safety. They cautioned that evaluating hospital safety and quality is a complicated process and that results can’t be judged by one simple standard.

“It’s difficult to look at these numbers and to know what they really mean,” Dr. Jeff Collins, chief medical officer at Sacred Heart, said Tuesday. “It’s not the same as looking in Consumer Reports and buying a TV.”

But Collins and others also acknowledged that they took immediate steps to correct the problems noted in the reports.

At Sacred Heart, where foreign objects were left in two patients after surgeries, staff members reiterated procedures in one case and instigated a new computer inventory of surgical items in the other, Collins said.

He declined to specify the objects left behind.

“One in particular is unique enough that it would have been identifiable,” he said, adding that both cases were thoroughly investigated.

At Coulee Community Hospital, surgical procedures underwent “a total review” after a doctor operated on the wrong part of a patient’s wrist on Dec. 5, said Administrator Jerry Lane.

“It was performed on the bottom part of the wrist instead of the top part of the wrist,” he said. “It was the wrong surgery on the wrong place.”

Surgeons are now required to mark the site and to take a “time out” with the surgical team before an operation begins, Lane said.

The new Washington law was part of legislation last year that tackled medical liability reform.

Since the law took effect June 7, records show that hospitals across Washington recorded not only medical errors but also attacks on patients by staff members, including an abduction, a physical assault and six sexual assaults on patients – one at Mount Carmel Hospital in Colville.

Officials there did not immediately return a call for comment.

By far the most commonly reported problem – cited 41 times – was development of stage 3 or 4 pressure ulcers acquired after admittance. Those are bedsores so severe that they eat deeply into flesh and even bone, posing the potential for serious infection and death, according to standard medical definitions.

Deaconess Medical Center reported instances of stage 3 or 4 pressure sores five times, including as recently as Jan. 10. Hospitals are required to report adverse instances within two days, said Byron Plan, executive manager in the state office of Health Care Survey.

Valley Hospital and Medical Center once reported a case of pressure sores; Holy Family Hospital logged a single instance of the problem.

Pressure sores pose a thorny problem for hospitals, said Shelley Peterson, chief nursing officer for Empire Health Services, which operates Deaconess and Valley Hospital and Medical Center.

Although reporting stipulates they develop after admission, it’s not always easy to tell which patients are prone to the problem, she said.

“Someone who’s morbidly obese or someone who is very frail, that can develop in two hours’ time,” Peterson said. “These pressure sores do come on quite suddenly. It’s not necessarily a sign of poor nursing.”

That’s a view echoed by Cindy Hecker, assistant administrator for patient care services at Harborview Medical Center in Seattle, which logged nearly a quarter of all of the medical mistakes recorded since June.

As a Level 1 trauma center for a five-state region, Harborview admits the most seriously injured and ill patients. Officials there expected to show up more often on a public log of mistakes, she said.

“I don’t think it’s a bad thing to look at them,” she said.

But the public should put the errors into context of the severity of injuries and the vulnerability of the patients, she said.

“The fact that they get a pressure ulcer is not something that we’re proud of,” Hecker said. “But we saved their lives.”

Advanced pressure sores weren’t previously reportable, health officials said. The condition was added when state lawmakers adopted standards approved by the National Quality Forum, which in 2002 endorsed a list of problems that are “serious, largely preventable and of concern to both the public and health care providers,” according to a news release.

The revised reporting requirements are so new that state health officials have yet to decide which problems to investigate or what standards to use, Plan said.

No hospital will be disciplined for reporting errors, he noted. Instead, results from investigations will be compiled and used to improve patient care.

“It’s not going to be regulatory; it’s going to be educational,” Plan said.


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