Report Your Medical Errors

Trooper States: They Played "Russian Roulette" with my Daughter

2008-06-20T08:59:00.000-07:00

A state police trooper currently stationed at the South Yarmouth barracks, John McCormack is accustomed to working within a chain of command and respecting authority.

So when his 1-year-old daughter, Taylor, ended up at Children's Hospital Boston, he let the doctors take charge.

It's a decision, McCormack says, he lived to regret.

Within hours of her arrival on Sept. 30, 2000, Taylor was in a coma. In less than a week she was dead.

In a case that's been publicized in the press and now in a book, it turned out that the resident in charge delayed crucial emergency surgery to repair Taylor's brain shunt because he couldn't contact the attending surgeon by pager. The surgeon said he had set his pager to vibrate and fallen asleep.

Nobody tried to contact him by home phone or cell phone. The resident told the McCormack family that other surgeries were tying up the operating room — a statement that was later proved untrue.

"They played Russian roulette with my daughter," McCormack says. "They looked us in the face and they lied to us."

Taylor's story and 10 others are profiled in a new book about deadly hospital errors, "Fatal Care: Survive in the U.S. Health System."

The stories range from a healthy teenage boy who died after receiving an overdose of a nonsteroidal anti-inflammatory drug after routine surgery to a man who died of a heart attack after emergency room staff ignored his wife's frantic calls for help.

http://www.capecodonline.com/apps/pbcs.dll/article?AID=/20080619/LIFE/806190301

Solutions for Medical Report Errors

2008-05-07T07:57:00.000-07:00

Future of Medical Transcription

30,000 jobs open right now which demand the MT skill set; not enough grads to meet current demands. (MTIA/AHDI).
Employment of medical transcriptionists is expected to grow faster than average through the year 2016. (Department of Labor)
A need for 5.3 million healthcare workers to fill job openings created by departures and new positions. (Department of Labor)

Credentialing the Medical Transcription Workforce

Only graduates from AHDI-approved schools + RMT credential qualify for National Registered Apprenticeship Program. (Department of Labor)
Certified medical transcriptionists earn as much as 1/3 more
than their noncertified counterparts. (Advance for HIM)
Low margin of error (2%) in this industry for risk management.

Military Spouse Initiative

Targets 750,000 military spouses with education and lifetime
career, both of which move with them. (AHDI with DoD and DoL Military
Spouse Initiative)
Pilot military spouse education program successful in 18 military installations (8 states); need for more funds to educate many spouses being turned away.
Army of nearly 100 AHDI representatives now linking POCs via career fairs, forums, listservs, military staff and spouse briefings, shore to shore.
$3000 per year per student x2 years (realistic time frame to achieve excellent education) to include textbooks, references, supplies,
certified instructors, ongoing job placement.

Medical Errors/Need for Quality

100,000 people die annually from medical errors, roughly the equivalent of a city the size of Green Bay, Wisconsin, or equivalent to an almost full DC-10 or 747 jumbo jet crashing into the sea every single day of the year! (United Press International)
8th leading cause of death in the US, documented annually since year 2000. (NCBI, PubMed, multisource)
Medical mistakes strain patients' bank accounts -- $37.6 billion annually. (United Press International)
1 in 15 hospitalized children are the victims of mix-ups, overdoses, and harmful reactions to drugs prescribed during hospital stays. This translates to 540,000 kids afflicted every year. (Personal Injury Lawyer Blog)
Hospitals currently average between 10 and 30 mistakes for every 100 procedures. (United Press International)
Medicare patients who experienced a patient-safety incident had a 1:5 chance of dying as a result of the incident during 2004 to 2006. (HealthGrades study)

Electronic Health Record

About 10 percent of physicians use an EMR, and more than half are primary care physicians. (The Doctors Company)
A review of 363 malpractice claims revealed that system errors contributed to 30% of the claims; 32% of these system errors were medication-related errors, 27 % were communication errors, and 13% were medical record errors. (The Doctors Company)

Apprenticeship Funding Needs

Apprentices start at 50% of the wages an employer pays an experienced MT.
2-year apprenticeships available in acute care, 2000 hours OTJ training.
Propose potentially $4000 per year per new hire for MT service owners who hire grads, and for $10,000 investment, government can provide lifetime career = biggest bang for taxpayer dollars.

2008-05-05T21:01:00.000-07:00

I am a sixty-three-year old breast cancer survivor, It has been more than six years since my episode with the disease. Last fall, I had follow-up scan and was informed that the cancer had metastasized to my lung. As a result, I would need additional tests and biopsies. Naturally, I was in shock from the news. After two months of multiple CT scans and painful procedures, doctors reported that the “nodule” had disappeared and concluded that the condition was simply an infection.

Today, me and my husband are trying to recover emotionally and financially, since many of the unnecessary tests were not reimbursed by my health plan -- it's a damned if you do, damned if you don't catch 22.

Where does the fault lie in all this? If my initital study had been read by a lung diagnostic specialist, instead of the general radiologist who looked at it, I think there would have been an increased likelihood of an accurate diagnosis the first time. We just assume that diagnostic results are definitive -- but it is really a question of interpretation, skill and experience.

http://www.yourmisdiagnosis.com/

2008-04-15T22:13:00.000-07:00

GOLDEN, Colo. (April 8, 2008) – Patient safety incidents cost the federal Medicare program $8.8 billion and resulted in 238,337 potentially preventable deaths during 2004 through 2006, according to HealthGrades' fifth annual Patient Safety in American Hospitals Study.

The overall incident rate was approximately three percent of all Medicare admissions evaluated, accounting for 1.1 million patient safety incidents during the three years studied. With the Centers for Medicare and Medicaid Services scheduled to stop reimbursing hospitals for the treatment of eight major preventable errors, including objects left in the body after surgery and certain post-surgical infections, starting October 1, the financial implications for hospitals are substantial.

The HealthGrades study, which also identifies those hospitals with patient-safety incidence levels in the lowest five percent in the nation, also found: Medicare patients who experienced a patient-safety incident had a one-in-five chance of dying as a result of the incident during 2004 to 2006.

Medical errors with the highest incidence rates were bed sores, failure to rescue, and post-operative respiratory failure and accounted for 63.4 percent of incidents. Failure to rescue improved 11.1 percent during the study period, while both bed sores and post-operative respiratory failure worsened during the study period.

Of the 270,491 deaths that occurred among patients who developed one or more patient safety incidents, 238,337 were potentially preventable.

If all hospitals performed at the level of Distinguished Hospitals for Patient Safety™, approximately 220,106 patient safety incidents and 37,214 Medicare deaths could have been avoided while saving the U.S. approximately $2.0 billion during 2004 to 2006.

http://www.eurekalert.org/pub_releases/2008-04/h-mec040308.php

2008-04-14T09:16:00.000-07:00

About 10 percent of physicians use an EMR, and more than half are primary care physicians. A review of 363 malpractice claims from The Doctors Company revealed that system errors contributed to 30 percent of the claims. Thirty-two percent of these system errors were medication-related errors, 27 percent were communication errors, and 13 percent were medical record errors.

Medication errors involved monitoring (one-third were failures to properly monitor Coumadin), wrong dosage, inappropriate medication, failure to consider side effects, drug-to-drug interactions, and errors related to medication reconciliation.

http://209.85.173.104/search?q=cache:mxBVXu1kpMcJ:www.thedoctors.com/KnowledgeCenter/PatientSafety/ssLINK/CON_ID_001464+%22medical+record+errors%22&hl=en&ct=clnk&cd=4&gl=us

2008-04-12T19:31:00.000-07:00

The most ridiculous interview on Fox News spring 2008 with an MD when asked what patients can do about medical mistakes:

"They should ask more questions about what medicine is being prescribed for what. . .Internists are covering for PCPs who don't know the patients all that well. . .Hopefully, someone will be with the very ill who will ask on their behalf."

COMMENTARY: When you are sick enough to be hospitalized, you are not the one asking questions; baby twins do not ask questions, and very few patients have family who can formulate questions on their behalf 24/7. Even fewer patients can hire a responsible and knowledgable human bedside monitor.

Patients are patients. They are not in the hospital to police it. Once again, we are paying more for services and getting less. What are we paying for, if not c-a-r-e?

Furthermore the most gross negligence was attributed to nurses as opposed to written documentation providers. How many nurses do you know who want to be questioned about what s/he is doing and would give an extremely ill person an answer that would be truthful as well as understood? That was such a cop-out answer coming from a medical physician!

For medical errors that exist in written documents, baby twins do not point those out, either. Sick people do not confirm that they are being given the same medications they were prescribed at home. Laymen cannot monitor medical doctors with 12 years of education. That was such a cop-out answer coming from a medical physician.

Medical transcriptionists need to speak to physicians' groups about expert credentialed MTs who can be trusted and expected to provide, at least, accurately documented records to significantly lessen the potential for medical mistakes. Other sector of healthcare need to design an effective self-monitoring system for their healthcare workers. The medical community needs to take responsibility for errors and not crank out ridiculous "solutions" as the above.

All it takes for poor medical records to continue to be full of errors is for knowledgeable (wo)men to do nothing. The recipe for disaster persists.

2008-04-12T19:29:00.000-07:00

http://www.foxnews.com/wires/2008Mar10/0,4670,SebastianapossLegacy,00.html

Horst and Luisa Ferrero took their intelligent, healthy and happy 3-year-old, Sebastian, in for a medical exam last October. Two days later he was dead, killed by a series of medical errors that began with a massive drug overdose.

2008-04-12T19:27:00.000-07:00

100,000 deaths a year since year 2000 due to medical mistakes:

http://64.233.167.104/search?q=cache:6UMW47XC7VEJ:www.upi.com/Health_Business/Analysis/2007/05/18/analysis_hospitals_face_heat_to_cut_error/6727/+%22eighth+leading+cause%22%22medical+mistakes%22+2008&hl=en&ct=clnk&cd=3&gl=us

". . .hospitals currently average between 10 and 30 mistakes for every 100 procedures."

2008-04-12T19:23:00.000-07:00

Dennis Quaid's baby twins overdosed on heparin:

http://www.hecklerspray.com/dennis-quaid-describes-horrible-baby-twin-almost-deaths/200813055.php

Reuters reports:

"It's bigger than AIDS. It's bigger than breast cancer. It's bigger than automobile accidents and yet, no one seems to really be aware of the problem."

In the Quaids' case, staff at Cedars-Sinai Medical Center near Beverly Hills gave their two-week-old twins. . . 1,000 times the recommended dose of the blood thinner heparin last November.
'It basically turned their blood to the consistency of water, where it had a complete inability to clot. They were basically bleeding out at that point,' Quaid said."

2008-04-12T19:18:00.000-07:00

Cancerous kidney left in; wrong kidney removed.

http://www.startribune.com/lifestyle/health/16769816.html

"We feel just profoundly responsible for this," said Dr. Samuel Carlson, chief medical officer for Park Nicollet Health Services, which owns Methodist
Hospital.

(Understatement?)

2008-04-08T20:35:00.000-07:00

Newspaper from Mysore (hmmmm, what's in a name?). . . training their blind and nonEnglish speaking to do medical transcription for US clients. No ill meant toward the blind or the Mysores, but here's the quote:

There is scope for more than 1,000 jobs in Mysore itself. But, there is a dearth of trained persons with work experience. Unlike in other Business Process Outsourcing Units, there is no need for persons to speak fluent English. Hence, only those who can write in English language are needed.

http://www.starofmysore.com/index.asp

COMMENTARY: This is confirmation of the evident need for highly skilled medical transcriptionists to surveil medical records. Of all skill sets, MTs are best trained to partner with physicians and healthcare providers for accuracy. Medical records will be transcribed for US citizens "forever after" by those who do not live in the US, did not grow up with our alphabet, may be blind and now not expected to speak fluent English because the jobs are for those who can write in English.

However, the fact is that so long as medical records are transcribed by English-2nd-language (or 3rd or 4th language) in countries with an altogether different alphabet, possibly blind, and not expected to speak fluent English because the jobs are for those who can write in English--means no soon end to medical errors.

The real reason MTs would do well to take a full 2-year education is to prepare them to edit clinical medicine content to address the 100,000 deaths annually related to medical errors. (8th cause of death in the US). Who is doing the risk management?

New graduates from best and poorest MT schools are more and more going into "editing." Editing who? Editing the documents transcribing for American-born doctors in New Jersey who have a lisp (no ill meant to the blind or regional dialects or people with lisps or people in Siberia with intermittent Internet access or parents of rowdy children) who dictate into their armpit while driving in city traffic with potato chips in mouth and demanding passengers interrupting. This is not easy for trained experts on both sides of the audio files (meaning dictator as well as medical transcriptionist), to produce a 98% accurate medical document.

How will it happen that medical documents are going to be reliably provided in this fashion?

Is cutting expenses so necessary that we take advantage of people in poor countries, handicapped, and not necessarily speaking fluent English so long as they can write in English to provide our medical records--and then wring our hands because 100,000 people a year are dying from medical errors, not all, but in part due to medical records?

Is it any wonder why there are medical record errors? This is not rocket science.

What about predatory MT programs/schools producing subpar MTs to do the editing of weakly transcribed medical documents provided by offshore providers who are perhaps visually impaired and non-English-speaking?

Isn't it time a credential is required to practice medical transcription--whether here or offshore? Schools/programs become AHDI-approved and demonstrate their ability to graduate students who can qualify for first credential (RMT) and possess the fund of knowledge necessary to even begin to edit medicolegal documents that impact our treatment regimens. These are the people I want transcribing my medical records.

This problem is widely evident now, will be unmanageable by 2012, and fully outrageous by 2016. All effort to try to reign in medical mistakes and lower the 100,000 deaths per year starts yesterday.

It takes us months to articulate the problem (that has been the elephant in the room since year 2000) and months more to project a solution. The wheels of critically managing this medical crisis are not moving forward--they are moving backward because more than 1 person reading this is going to be on the receiving end medical error(s).

What kind of event is the healthcare community waiting for?

2008-04-07T22:16:00.000-07:00

A new detection mechanism for harmful or incorrect use of medicines in hospitals has shown that 1 in 15 hospitalized children are the victims of mix-ups, overdoses, and harmful reactions to drugs prescribed during hospital stays. This translates to 540,000 kids afflicted every year. The report also indicates:

Patient safety experts said the problem is likely even bigger than the study suggests because it involved only a review of selected charts. Also, the study didn't include general community hospitals, where most U.S. children requiring hospitalization are treated.

http://www.injurysite.com/1-out-of-15-hospitalized-children-may-be-harmed-by-drug-mistakes/

1 Misdiagnosis Results in 3-5 Deaths

2008-04-07T21:06:00.000-07:00

Alex's liver went to a 52-year-old man. His pancreas to a 36-year-old woman. His kidneys went to two different men, one 46 and the other 64. A month later, an autopsy revealed that Alex never had meningitis. He had a rare and fast-moving lymphoma cancer -- one that was now working its way through the bodies of four other people. The organs were removed, but the lymphoma already had killed the recipients of his liver and pancreas. The two kidney patients had the kidneys removed and survived. They're now undergoing chemotherapy.
http://www.cbsnews.com/stories/2008/04/01/eveningnews/main3987994.shtml?source=mostpop_story

Medical Records Available to Confirm

2008-04-07T19:22:00.000-07:00

A couple of weeks ago I was a patient. :( Emergency cholecystectomy. I was released after 4 days and had to be readmitted a few days later with pneumonia. I did get the copies of my records afterwards, almost 50 pages, and WOW, were there ever a lot of errors and inconsistencies. They kept saying I was 36 years old, even though on every page it said I was born in 1962. I wouldn't have a problem with being 36, though.

It was weird, like they just made things up and added them, like I was nauseated and vomiting. I specifically remember denying this more than once and it said that on the initial admission papers in the ER. The discharge summary instructions did not match the ones written out for me when I left the hospital. Even the medications were messed up. SCARY! I told the SO that they kept saying my husband was at my bedside. What husband? I've never even had one of those.

They also seemed very reluctant this time to give me the copies, asking me 3 or 4 times why I wanted them. I don't think they should even be allowed to ask you why you want them. Is it really any of their business? AND, they charged me 75 cents per page which I felt was bordering on ridiculous. I don't have any problem at all with them covering their costs to produce copies, but 75 cents a page?? WOW! Some people who wanted to review their records could probably not even afford that and would not be able to purchase them which doesn't seem fair.