Death by Mistake

"WHOOPS" IS NOT A WORD any hospital patient wants to hear. Yet every day, errors occur in San Diego hospitals. At best, the error is nonthreatening, such as the wrong one of two patients in a room being taken for an x-ray— a mistake doctors say is quite common. At worst, the error is fatal; there’s a drug overdose, or a heart attack patient doesn’t promptly receive medication that could save his or her life.

To Err Is Human, a landmark federal report issued in 1999, estimates that as many as 98,000 Americans die in hospitals each year from preventable mistakes. It provided the impetus for what has now become a national campaign, “Save 100,000 Lives.” Announced late last year by the Institute for Healthcare Improvement, the movement is designed to prevent common hospital errors that can result in needless complications and patient deaths.

In tandem with the national program, a San Diego campaign, “Saving 1,000 Lives,” officially kicks off next month with seven hospitals participating.

“Since 1 percent of the U.S. population lives in San Diego County, we have the opportunity to save 1,000 lives each year by ensuring the use of the best medical practices,” says Dr. Joseph E. Scherger, director of the San Diego Center for Patient Safety, based at the University of San Diego, California. Scherger, who’s coordinating the local effort, is one of the authors of To Err Is Human.

How does he rate San Diego hospitals in terms of patient safety?

“There’s really no way of saying our hospitals are better or worse than the national standard,” says Scherger, who also represents the San Diego County Medical Society. “By the old standards, I’d say we’re okay. But are we, in San Diego, leaders for improvement? It’s spotty.”

Medical errors, he says, generally are not caused by recklessness or “bad” hospital personnel. Rather, mistakes occur because hospitals are not implementing systems that overrule predictable human error.

“We rely on smart people always remembering, and most of the time they do,” Scherger says. “But the rate of error is way higher than it needs to be.”

As with the national campaign, Saving 1,000 Lives targets six practices that, if implemented consistently, would reduce patient complications and prevent what might be called death by mistake. The guidelines include empowering any hospital employee to deploy “rapid response teams” at the first sign of a patient’s decline; improved care for patients experiencing an acute myocardial infarction (heart attack); and prevention of so-called adverse drug events, of “central line–associated bloodstream infections” (referring to the intravenous delivery of drugs or fluids), of surgical-site infections and of pneumonia caused by a mechanical ventilator. Scherger says the San Diego campaign adds a seventh practice for hospitals to implement: safer intravenous infusion of high-risk medications.

“If we just take what we know is solid, evidence-based care and implement it more than 90 percent of the time,we’d drive the complication rate way down, near zero,” Scherger says. The local initiative will indeed have teeth to make changes for improvement at hospitals, he adds. Task forces of top hospital decision-makers are being formed for each of the seven targeted goals and will report on the success of the new strategies following their implementation. Hospitals signed up to participate in the campaign are Children’s, Naval Medical Center San Diego, Scripps, Sharp, Tri-City, UCSD Medical Center and the Veterans Administration.

SEVEN OUT OF 100 PATIENTS experience a serious medication error while in the hospital, Scherger says, making it one of the most-common critical mistakes. Patients who have these adverse drug events, he adds, are almost twice as likely to die as a result. Mistakes can include prescribing the wrong drug, giving the wrong dose and the wrong frequency of use.

Scherger says many hospital errors could be prevented by what he calls better information management—for example, abandoning the paper trail upon which hospital records rely and turning to computerized technology. “Most pet stores have better information management than hospitals,” he says.

Reasons hospitals have been slow to embrace computerized records include the expense of the technology and the complexity of the information a hospital must keep. Doctors, especially those who aren’t hospital employees, also have resisted entering their orders into computers, insisting instead on the time-honored method of putting pen to paper.

Scherger cites the botched transition to computerized record technology at Los Angeles’ world-renowned Cedars-Sinai Hospital as a prime example. In 2002, the hospital had to abandon its recently installed $34 million computer system because doctors refused to use it. Physicians with privileges to practice at the hospital claimed the new system was too time-consuming and glitches were rampant.

While most San Diego–area hospitals are in some phase of implementing computerized records, the Veterans Administration Medical Center has been “paperless” for several years. Each patient has a bar-code on his or her identification armband that is integrated with the hospital’s computerized patient-record system. All procedures, lab and test results and prescribed medications are entered into the computer.

“One of the advantages is that there’s never a problem reading a doctor’s handwriting,” says Cindy Butler, a V.A. hospital spokeswoman. “All orders are entered by computers.” The only patient “chart” that exists is the one accessed by computer, not a clipboard hanging at the end of a hospital bed.

Clinical safeguards for each patient are built into the system, Butler says. Each medication prescribed for a patient is marked with the individual’s bar code, and if a drug order might lead to an adverse reaction, its administration is blocked. The computerized system has reduced medication errors by 70 percent at the hospital, according to Butler.

While V.A. doctors initially complained the computerized system was too time-consuming, “They love it now,” says Butler, “and I can’t imagine that anyone would want to go back to the old way.”

Kaiser Permanente, which is the country’s largest private-sector provider of healthcare, last year began rolling out HealthConnect, a $3 billion electronic medical record project. It eventually will give doctors realtime access to their patients’ comprehensive medical information, on-line in the hospital or exam room, and patients also will be able to access their information on-line. HealthConnect should be fully operational by mid- 2007 for the 500,000 KP members in San Diego County, says local Kaiser spokesperson Sylvia Wallace.

PATIENTS CAN HELP ensure their safety, too. “Patients need to be as informed as possible about what’s supposed to happen while they’re in the hospital,” says Scherger. “They don’t have to know greatly technical details, but they should know what’s going to happen before, during and after a procedure.” He encourages patients to ask questions about what medications are being administered and what tests are being performed, and he recommends that any hospitalized patient suffering from a serious or life-threatening condition be accompanied “at all times” by a family member or friend who will ask those pertinent questions.

If something doesn’t seem right or is confusing, patients or their representatives should speak up. Hospitals, Scherger says, can project a chilling authority, and patients or family members feel uncomfortable complaining. “You’ve got to put that aside,” he says. “Just ask questions in a respectful way. Most good personnel welcome questions.”

The bottom line for patients: Be informed, and inquire about all procedures, Scherger says. “If you’re ignorant and passive about your treatment —and I don’t mean that in a bad way—you’re taking a real chance in today’s system.”

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