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Emergency Department Mistakes by Pat Iyer

Monday, September 21st, 2009

Errors in the Emergency Department

Most of the mistakes in the emergency department (ED) that have the potential to compromise patient safety are caused by human error, according to a study published online September 18 in BMC Emergency Medicine. “[EDs] are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety,” Marleen Smits, MD, from the Netherlands Institute for Health Services Research, Utrecht, and colleagues write. “This can only be achieved if interventions tackle the dominant underlying causes.”

The aim of this study was to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure. The study evaluated medical errors in the EDs of 10 hospitals in the Netherlands (1 university hospital, 3 tertiary teaching hospitals, and 6 general hospitals) for 8 to 10 weeks. ED staff members were asked to report all unintended events, no matter how trivial or commonplace, that could have harmed or did harm a patient. A total of 522 events were reported, ranging from 46 to 71 per ED, for an average of 52 reports. Most of the reports (85%) were made by nurses; resident physicians or consultants reported 13% of the unintended events, and clerical staff reported 2%. The reporter was directly involved in 83% of the unintended events. Most occurred during daytime hours (44%); 34% occurred during evening and night, and for 22% of the unintended events, the time of occurrence was unknown or unspecified by the reporter.

Most errors occurred during medical examinations or lab tests (36%). More than half of the unintended events (56%) had consequences for the patient, and in 45% of these instances, the patient suffered some inconvenience, such as prolonged waiting time. One third of patients received suboptimal care, such as a delay in starting antibiotic treatment. The consequences of error were more severe in the 8% of patients who required an extra intervention, the 6% of patients who suffered pain, and the 3% of patients who suffered a physical injury, Dr. Smits and colleagues write.

Most root causes of error were human (60%), followed by organizational (25%) and technical (11%) causes. Nearly half of the root causes could be attributed to other departments either in or outside of the hospital. In citing limitations to their study, the investigators note that, because the reporting was not anonymous, it is possible that certain mistakes were underreported. “This may have biased the results towards the reporting of less significant events, events without consequences for the patient, and errors originating in other departments, because these are ’safer’ to report.”

In addition, most errors were reported by nurses, and therefore the study results give information about events that are mainly related to nursing care and less to care by residents and specialists in the ED. Although the majority of errors had no consequences for the patient or resulted in only minor inconveniences, their accumulated effect on patient well-being is likely to be large, the authors write. They conclude: “Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments.”
BMC Emerg Med. Published online September 18, 2009.

Comments: The results of the study are intriguing. Are nurses really making the majority of errors, or are they more likely to report errors than physicians?

I am moderating a webinar on the topic of emergency department liability on September 30. Our panel consists of an emergency department physician, an emergency department nurse, and a plaintiff’s attorney. We’ll share case studies and discuss what makes a valid case for the plaintiff or an easily defensible case. Join us!

What are these?

Tags: emergency department medical errors, emergency room errors
Posted in Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

2010 National Patient Safety Goals by Pat Iyer

Wednesday, September 16th, 2009

MRSA skin infection

The Joint Commission has released the 2010 National Patient Safety Goals. The Joint Commission sets standards for, evaluates, and accredits more than 16,000 healthcare organizations and programs in the United States. These include hospitals and home health agencies as well as ambulatory care services, behavioral health programs, clinical laboratories, and long term care organizations. In addition, The Joint Commission provides certification of disease-specific care programs, primary stroke centers, and health care staffing services.

The 2010 effort has streamlined the goals, refined language, and emphasized the importance of the healthcare-associated infections goal. This goal was first released in 2009 and is to be fully implemented in 2010. There has been increased attention paid to the development of healthcare-associated infections due to multi-antibiotic resistant organisms. Some states collect information from hospitals and report on the incidence of such infections. Some plaintiff attorneys have filed suits related to hospital-acquired infections, under these theories of liability:

Transmission of infection to the patient
Delay in diagnosis of infection
Improper treatment of infection

The 2010 Goal applies to methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (c-diff), Vancomycin-resistant enterococci, multidrug-resistant gram-negative bacteria, among others organisms. The goal focuses on:

Conduction of periodic risk assessments for multidrug-resistant organism acquisition and transmission
Provision of education for staff at the time of hire and annually thereafter
Education of patients and families who are infected or colonized with a multidrug –resistant organism about healthcare-associated infection strategies
Implementation of a surveillance program for multidrug-resistant organisms based on the risk assessment
Measurement and monitoring of prevention processes
Provision of multidrug-resistant organism process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff and other clinicians
Implementation of policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms
When indicated by the risk assessment, implementation of a laboratory-based alert system that identifies new patients with multidrug-resistant organisms
When indicated by the risk assessment, implementation of an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms

What can you do to protect yourself and your loved ones in a healthcare environment? The single biggest action you can take is to insist that healthcare providers wash their hands before contact with the patient. This is not the time to be shy. Speak up. This is an issue foremost in my mind this week as my husband prepares to enter the hospital for a triple bypass. I’ll be washing my hands before touching him and trusting that the healthcare providers will do the same.

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Tags: hospital-acquired infection, MRSA, National Patient Safety Goals, nosocomical infections
Posted in Damages, Healthcare Risk Management, Joint Commission, Medical malpractice, Patient safety | No Comments »

Using technology to make patient care safe by Pat Iyer

Monday, September 14th, 2009

A recent issue of Healthcare Informatics provides hope that technological advances can improve patient safety. One of the most significant barriers to care delivery is communication. Nurses, says Turisco, are often placed in the middle of the communication loop, where they constantly receive and place calls to physicians, pharmacy and lab, all while trying to tend to patients. Fran Turisco is research principal in the Waltham, Mass.-based Emerging Practices Healthcare Group of CSC (Falls Church, Va.) “So the issue is how you cut out some of the middle men in these communication loops,” she says. “And how do you shorten the time frame between when a nurse needs to talk to someone and when she actually gets to talk to that person, then either make a care decision or figure out what needs to get done next.” Nurses act as the hub in the wheel, and communicate with every other department in a healthcare facility. This communication is vital but time-consuming.

A hands-free voice activated badge in use at University Hospitals Case Medical Center in Cleveland, leadership addressed the problem by rolling out hands-free communication systems from San Jose, Calif.-based Vocera in the NICU. The technology enabled clinicians to call for assistance or answer pages by using a voice recognition button. With the badges, which run on the hospital’s wireless platform, nurses can call for help or communicate with colleagues across departments. This innovation addresses the ongoing issue of placing calls to others, and being interrupted when the call is returned.

Bar-code technology is gaining ground as a way to reduce medication errors. The medication is scanned at the bedside and verified as being correct for the patient, whose arm band is also scanned. The system catches errors at the point of administration, the last step before the medication enters the patient.

Another common theme in patient safety is workflow issues. A number of organizations are addressing the problem by deploying patient flow systems to provide nurses with improved visibility of both bed availability and patient status. With these solutions, instead of making several calls and chasing down charts, nurses can look at a screen to find out what rooms are available, how long patients have been waiting to see a physician, and when patients need to be turned.

When I was a nursing quality assurance coordinator, we tackled the seemingly simple issue of getting beds ready after a discharge. The backup of patients in emergency departments, medical surgical units, and recovery rooms waiting for a bed has important quality of care issues. One of the biggest selling points for patient flow systems, according to Turisco, is the ease of use factor. “It’s one of these technologies that you almost think is too good to be true because it’s not that hard to install. You can configure it in a short period of time to do exactly what you want.”

Here are the take home messages:

The proliferation of wireless technologies in the hospital setting has significantly impacted the way nurses deliver care.
The primary goals chief information officers are looking to achieve in implementing wireless technologies are to improve communication, workflow efficiency and patient safety.
Organizations that have successfully implemented wireless technologies have had nursing leaders involved in every key step of the process.

Read more about 10 common errors and what is being done to make patient care safer here.

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Tags: technology and patient safety
Posted in Communication skills, Patient safety | No Comments »

How a medical malpractice suit can make a difference by Pat Iyer

Thursday, September 10th, 2009

The story of Josie King

Why do people file medical malpractice suits? One reason is to get answers about what happened to result in the injury. Another is to prevent the same thing from happening to another person. Although risk managers, practitioners, and administrators may make changes after a bad outcome has occurred, it is not often that the plaintiff gets the satisfaction of knowing that. It is even rarer the terms of a settlement to solidify a plan to share the details of a medical tragedy.

A recent Oregon case shows the power of sharing a lesson that will protect other patients. The plaintiff was an 8-month-old infant who entered a hospital for removal of a cyst that extended through his nose to his brain. The surgery was without complications. After surgery, the infant had fevers, pneumonia, and showed signs of a possible cerebral spinal fluid leak. The discharging physician was a first year resident; the attending neurosurgeon did not see the infant on the day he was discharged. Eight hours after discharge, the infant was taken to the emergency department of another hospital because he was vomiting and lethargic. The emergency department physician called the defendant hospital and was advised that the infant was probably having a medication reaction. The parents returned eleven hours later, when their child was profoundly ill. There was no clear evidence of a systemic infection and possible brain damage.

The infant was emergently transported back to the defendant hospital. He was diagnosed with meningitis, brain damage, and organ failure and suffered a stroke. He requires a ventilator twelve to twenty hours a day, is tube fed, and without effective use of his legs or left arm. He is profoundly developmentally delayed and does not talk. A $12.2 million settlement was reached. The hospital also committed to use the case as a teaching example for its residents for the next ten years and to provide certification of this to the plaintiff’s parents each year from the president of the university.

Source: Lewis Laska, “Infant discharged following brain surgery without being seen by anyone other than junior resident”, Medical Malpractice Verdicts, Settlements, and Experts, February 2009, page 19

The power of sharing the lessons learned from a tragedy of this nature is huge. Unfortunately, it is rare for plaintiffs to achieve this kind of gain. I can think of another case – one we handled at Med League-in which this occurred. I was involved in a Philadelphia case of a young man who developed leg pain and shortness of breath on the day of discharge. The nurse did not inform the physicians, and the man was discharged via telephone order. He collapsed at home and died from a pulmonary embolism. As part of the settlement, the hospital made a policy that a patient had to be seen in person on the day of discharge. They also agreed to use this case in teaching each group of interns and residents.

Anyone not familiar with the story of Josie King, an 18-month-old child who died as a result of medication error, should visit the Josie King Foundation . I heard Sorrel King, Josie’s mother, talk three years ago. Her story lingers. Sorrel took the settlement money provided by Johns Hopkins, the hospital where the incident occurred, and put it back into patient safety efforts. Her work has saved lives of people all over the world. A new book pictured above, has just been released, which describes her crusade.

The key to educate, change, and inspire healthcare professionals with lessons learned so that deaths and injuries make a difference in daily practice.

What are these?

Tags: Josie King, Medical malpractice, medication error, why people sue
Posted in Damages, Healthcare Risk Management, Medical malpractice, Medication errors, Nursing malpractice, Patient safety | No Comments »

Has the Nursing Shortage Gone Away? By Pat Iyer

Wednesday, August 19th, 2009

Your life may depend on a nurse

Prior to the recession, dire predictions about the coming shortages of nurses and faculty stressed the need to recruit and retain more nurses. Then, spouses lost jobs and non-working nurses returned to the workplace. Fully staffed facilities, layoffs, and financial collapse and closure of some hospitals have resulted in difficulty finding nursing positions.

Can we relax about the nursing shortage? Unfortunately not. The numbers are working against us. Both nurses and nursing faculty are aging. Take New Jersey, which is likely typical of the nationwide problem. More than half of New Jersey’s nurses are between the ages of 46 and 60, with an average age of 50. This means that nearly a third of the state’s workforce will reach retirement age in the next decade. Simple- just educate more people to become nurses, right? Unfortunately not. Nursing faculty are in short supply, and their average age is 55. The nursing curriculum requires extensive clinical experience and prevents a large number of students (more than 10) to be assigned to a clinical instructor. Nursing schools must limit the number of students who can be safely supervised. More than half of New Jersey’s schools of nursing already restrict student enrollment because of limited numbers of faculty, and thus are turning away people who want to go into nursing.

Several studies performed by Dr. Linda Aiken of University of Pennsylvania have directly tied the quality of care with the number of registered nurses. The more patients the nurse is responsible for, the worse the care. The availability of well educated and experienced nurses has a direct impact on the quality of nursing care and the outcomes for patients. Many of the medical or nursing malpractice cases our company has been involved are associated in some way with inexperienced nurses.

How are we going to fix the nursing shortage? Some grant money is becoming available to help subsidize education for developing more faculty. Schools must be able to pay faculty a decent wage to compete with the higher levels of compensation earned by nurse practitioners. Work environments must respect the unique contributions of nurses and make them an integral and valued part of the healthcare team. Retention programs must flourish. Let your state elected officials know you support funds for nursing education. Your life may depend on having a nurse at the bedside.

Source of statistics: Innovative public/private partnership launches in state legislative hearing, New Jersey Nurse, July/August 2009

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Tags: Linda Aiken, Nursing malpractice, nursing shortage
Posted in Medical malpractice, Nursing malpractice, Patient safety, Priorities | No Comments »

Reducing Distractions is Reducing Medication Errors – by Pat Iyer

Wednesday, August 12th, 2009

The sterile cockpit means no interruptions at critical times

My father was fascinated by airplanes when I was little. I recall going to Idlewild Airport in New Jersey to watch planes land. My father was trained as an aeronautical engineer. Little did I know as a child the lessons of the airline industry would spread to healthcare and set an example for systems to reduce patient errors. Crew or Cockpit Resource Management is a term that began in 1979 as a way of defining ways to reduce pilot error through better use of the crew. The patient safety movement is now taking lessons from the airline industry. The airline industry has defined the sterile cockpit as a place which controls interruptions during critical moments of flight.

Nurses prepare medications in busy hallways of hospitals and nursing homes. It is easy to interrupt and distract a nurse during the critical steps of preparing medications. Some concerned experts in patient safety suggest the use of a vest to be worn by a nurse during medication administration. The bright orange vest says, “Do not disturb.” I first heard about the use of vest when Gary Sculli, a former pilot turned nurse, spoke to the New Jersey chapter of the American Society of Healthcare Risk Management (ASHRM). I have been an ASHRM member for many years.

Nurses at Kaiser South San Francisco Medical Center ordered bright orange, construction-style vests off the Internet, which the nurses thought looked “cheesy.” They also found them hot and resisted sharing them with fellow nurses. “They felt it was demeaning,” said Becky Richards, RN, BSN, MA, adult clinical services director Richards. But of even greater concern, despite education about not interrupting nurses during med passes, the vests seemed to attract attention. The hospital tried again on a renal floor, with separate medication rooms. But again, it just didn’t seem to click. “We were really thinking about abandoning the whole idea, because the nurses did not like it,” Richards said. But when the medication administration data came in at the end of the year, the hospital found that during the four and five months after the pilot finished, those two units combined had a 47 percent decrease in errors. The units had not done anything else to reduce errors, just the education about no distractions and the vests.

“At that point we knew we could not turn our backs on our patients,” Richards said. The quality forum nurses tweaked the program, finding more attractive neon yellow vests and reaching out to the medical staff, housekeeping and other departments for support. Kaiser South San Francisco kicked off the new program hospital-wide in April 2007, with the exception of oncology, which refused to participate, writing letters and signing a petition. The hospital decided not to play hardball.

“We were blown away in May. The hospital experienced a 20 percent decrease in medication errors, even though one unit refused to participate,” Richards said. “And that was the only unit that experienced an increase from their previous month’s error rate.”
Source: Decreasing Disruptions Reduces Medication Errors – NurseZone

This report verifies the importance of creating a safer environment for preparing medications. Controlling interruptions and eliminating distractions saves lives.

What are these?

Tags: crew resource management, CRM, medical errors, Medication errors, Patient safety, sterile cockpit
Posted in Medical malpractice, Medication errors, Nursing malpractice, Patient safety | 1 Comment »

Are there frivolous lawsuits? By Pat Iyer

Monday, August 3rd, 2009

Expert witnesses screen out nonmeritorious cases

The other day, a woman who sells healthcare insurance made a casual comment to me about how insurance rates are affected by frivolous lawsuits. Let’s be clear. There are two kinds of medical malpractice claims: those that settle or go to trial and the plaintiff wins, and those that are defensible and are taken to trial, and the defense wins. About 3-5% of all medical malpractice claims are taken to court.

I explained to this woman that a defensible claim is not necessarily frivolous. There are any number of reasons why a claim is defensible. For example, there are two schools of thought on how a patient should be cared for, and the provider selected one of these two acceptable treatment methods. Or the standards of care were followed, but the patient had a bad outcome. It often takes the skills of an expert witness to determine if there is a link between the actions of the healthcare provider and the ultimate outcome.

I explained to this woman that potential cases are carefully screened. A busy plaintiff attorney’s office might get several calls a week, and reject 95% of the cases due to lack of liability, lack of damages, or lack of causation. Our company’s nurses and physicians have evaluated hundreds of cases over the years, and have found that some of the cases that have gotten through the preliminary screening by the plaintiff firm are without merit when an expert has reviewed them. Expert witness conclusion that a case is non meritorious acts as a wall to further pursuit of a claim by a plaintiff.

I explained to this woman that is way too expensive to take on a case that does not, at least on the initial evaluation, look like it has merit. It is costly to order records and pay for experts. Many families do not have the funds to foot these costs, so the plaintiff firm has to take on the expenses. It is increasingly difficult to find physicians willing to act as experts for the plaintiff. Some have been told by their hospital that they are not permitted to review cases for the plaintiff. Some are discouraged by their professional societies. See http://tinyurl.com/lwgfxp. Many states require a specialist in the same clinical area to review a claim and file an affidavit of merit before a case can go forward.

I do not see frivolous cases being filed.

Now, the government is tackling the difficult and complex task of trying to fix the healthcare system. A recently released study by the Americans for Insurance Reform (AIR) explored the question of whether the need to provide affordable healthcare insurance should be linked to restricting people’s access to the medical malpractice litigation system. What follows is a summary of their key findings. The full report can be accessed here.

Let’s keep the focus of healthcare insurance reform on bringing affordable healthcare to those without and those who are underinsured. Let’s focus on saving patient’s lives and preventing medical errors that kill and maim patients.

AIR says:

In discussions about how to solve our vast national health care crisis, questions are often raised about why the system is so expensive and how costs can be reduced to make health care affordable for everyone. Some of the discussions have focused on medical malpractice insurance and liability issues, raising questions about the cost of insurance for doctors and whether there is a need to further limit patients’ ability to bring claims against incompetent doctors or unsafe hospitals.

To answer these questions, Americans for Insurance Reform, (AIR), a coalition of nearly 100 consumer and public interest groups around the country, has produced the most comprehensive review of medical malpractice premiums, claims, profits and the impact of medical malpractice tort law limits to date. Based on its analysis, AIR finds:

Medical malpractice premiums, inflation-adjusted, are nearly the lowest they have been in over 30 years.
Medical malpractice claims, inflation-adjusted, are dropping significantly, down 45 percent since 2000.
Medical malpractice premiums are less than one-half of one percent of the country’s overall health care costs; medical malpractice claims are a mere one-fifth of one percent of health care costs. In over 30 years, premiums and claims have never been greater than 1% of our nation’s health care costs.
Medical malpractice insurer profits are higher than the rest of the property casualty industry, which has been remarkably profitable over the last five years.
The periodic premium spikes that doctors experience, as they did from 2002 until 2005, are not related to claims but to the economic cycle of insurers and to drops in investment income.
Many states that have resisted enacting severe restrictions on injured patients’ legal rights experienced rate changes (i.e., premium increases or decreases for doctors) similar to those states that enacted severe restrictions on patients’ rights, i.e., there is no correlation between “tort reform” and insurance rates for doctors.

AIR concludes that there absolutely no reason to further limit the liability of doctors and hospitals, who already benefit from more liability protection for their negligence than any profession in the country. Further, doing so would have almost no impact on overall health care expenditures – except that the costs of medical error and hospital-induced injury would remain.

What do you think? about tort reform? Healthcare reform? Which is more important?

Read another perspective here.

If you like this post, DIGGIT and I will write more about the topic.

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Tags: Expert witness, Healthcare reform, Legal nurse consulting, Medical malpractice, Tort reform
Posted in Expert witness, Healthcare reform, Legal nurse consulting, Medical malpractice, Patient safety, Tort reform, Trial lawyer skills | 1 Comment »

On Challenging an Authority by Pat Iyer

Monday, July 13th, 2009

Challenges to authority save lives

A nurse sees a physician about to commit a grievous error. A resident watches an attending physician brush aside warning signs of a medical error. What factors go into challenges that may save a patient’s life? Malcolm Gladwell provides insights in Outliers. The author of The Tipping Point and Blink, Gladwell’s engaging writing is a delight. Here’s what I gained on this subject.

The concept of power distance is concerned with attitudes toward hierarchy, specifically with how much a particular culture (or group of professionals within that culture) value and respect authority. There are low-power distance index countries, like the United States, and high power index countries, like the Philippines. Here’s what we see in nursing: a nurse can be ignored or chastised if she challenges a physician from a male-dominated society where women are considered to be less than equal. On the other hand, a nurse from a society that puts physicians on a pedestal may be unable to challenge the decision making when needed.

How does this apply to patient safety and medical malpractice? And how can healthcare providers prevent those lost or ruined lives that result from medical disasters? How do we avert medical and nursing malpractice if those who speak up are ignored?

1. First, healthcare staff should be given the skills and the words to use to question authority. One of my job responsibilities in 1987 was to teach assertiveness skills to Filipino nurses. I recall the startled expressions on their faces when they realized they were expected to challenge physicians. This was not part of their training at the time. The healthcare culture must actively and visibly support the need to speak up. This is an incredibly threatening concept for those stuck in the high power distance mindset.

2. We can learn from the airline industry. Crew Resource Management concepts are being adopted by healthcare institutions. For example, according to Gladwell, many airlines teach a standardized procedure for copilots to challenge the pilot if he or she thinks something has gone terribly awry. They may say, “Captain, I’m concerned about…”then, “Captain, I’m uncomfortable with…” and if the captain still does not respond, “Captain, I believe the situation is unsafe.” And if that fails, the first officer is required to take over the airplane. Imagine nurses, residents, or others being taught how to telegraph their concerns in such a fashion. Nurses are taught to contact their nursing supervisor if a challenge to a physician is ignored.

3. I think there is another factor at work, which Gladwell refers to as “practical intelligence”. This includes things like knowing what to say to whom, knowing when to say it, and knowing how to say it for maximum effect. It is knowledge that enables you to read the situation correctly and get what you want. A person with high practical intelligence would know how to challenge another person’s actions or decision making in a way that would bring results. The nursing supervisor should embody these skills.

4. Keep in mind that healthcare medical disasters can happen just as quickly as a plane can plunge into the ocean. A bleeding vessel in the operating room, the incorrect administration of intravenous chemotherapy into spinal fluid, the fetus that shows signs of needing to be delivered right now- all constitute emergencies. The person with low power distance, communication skills and practical intelligence is in the best position to save patient lives.

5. Patient safety application:
The person who is a silent witness to the disaster, who is afraid to speak up and be a patient advocate, and the person who ignores those who question decision making may end up as part of the chain of a medical disaster.

6. Business application:
If you work within a law firm or legal nurse consulting firm, actively encourage your staff to speak up, to question, to point out problems. Listen to their concerns. You might be functioning with blinders on and not able to see an emerging situation. Thank those who are watching over your shoulder and serving as your safety net.

What are these?

Tags: challenging authority, crew resource management, medical negligence, Patient safety
Posted in Business skills, Communication skills, Medical malpractice, Patient safety | 1 Comment »

Michael Jackson: A Demerol Death? by Pat Iyer

Monday, June 29th, 2009

Michael Jackson- Demerol Overdose?

Reports state Jackson stopped breathing shortly after receiving an injection of Demerol. Attempts to resuscitate him were not successful. Was it the combination of medications or the Demerol which caused him to stop breathing? Toxicology reports are pending.

Recent reports reveal that Michael Jackson took an unusual combination of drugs:

Demerol and Vistaril twice a day- Demerol is a pain reliever, and Vistaril potentiates or accentuates the effects of Demerol.
Dilaudid 3 mg twice a day- Dilaudid is one of the strongest narcotics on the market.
Vicodin- an oral narcotic
Prozac 20 mg –antidepressant
Zoloft -antidepressant
Xanax -treats panic or anxiety disorders
Ritalin -for attention disorders
Prilosec-reduces stomach acid

It is unusual to see a patient taking two antidepressants and even more unusual and dangerous to take three narcotics. The danger lies in the accumulation of the medications in the body. Reports on the Internet also emphasize that the singer had lost weight and was skeletal-thin. The risk of overdose increases as weight loss occurs if the dosage is not also decreased.

Demerol is a narcotic pain reliever that used to be given with regularity in hospitals. (It is still acceptable to use Demerol in the recovery room for shivering.) It has fallen out of favor for a few reasons – there are more effective and safer pain relievers on the market and secondly, it is poorly tolerated by elderly people. Visual hallucinations may occur in this population. I recall my mother telling me that when she received Demerol after surgery when she was in her mid 70s. I advised her to request a different medication. She saw moving figures on the hospital room wallpaper. Days after her last Demerol shot, as she was being driven home, she saw icicles hanging in the sky. Another danger: the metabolites of Demerol can accumulate, and cause oversedation and death.

What you can do as an attorney involved in a medical or nursing malpractice case involving a potential overdose from Demerol (or another narcotic): Look at the weight and age of the patient. Ask a legal nurse consultant to do a timeline. This person will need to review the medication administration records and the narcotic sign out logs to determine how much Demerol the patient was given for pain control. Get a pharmacologist and possibly a toxicologist involved to look at the connection between the Demerol and the death.

I have lectured about the dangers of oversedation. Several years ago I was an expert witness for the plaintiff in a case that revolved around oversedation from Demerol. The case resulted in a settlement for the family of the patient. The article on Med League’s blog includes the actual facts of the overdose.

Susan Hill (fictitious name) was wheeled up to her postoperative medical surgical room at 11:30 AM. Mrs. Hill weighed 120 pounds; she was recovering from a hysterectomy. Her postoperative medications included Demerol (meperidine) 50-100 mg IM every 3-4 hours PRN (as needed), and Phenergan 12.5 mg IV every 6 hours PRN for nausea. The nurse assigned to the patient until 7 PM administered 50 mg of Demerol at 12:30 PM and 100 mg at 2 PM and 5 PM. Phenergan 12.5 mg was given IM at 12:30 PM, 2 PM and 5 PM. The nurse administered Phenergan to potentiate the action of Demerol. Read more.

What are these?

Tags: Demerol, Michael Jackson, Nursing malpractice, overdose, oversedation
Posted in Damages, Legal nurse consulting, Medical malpractice, Medical records, Medication errors, Nursing malpractice, Patient safety | 3 Comments »

Retained Objects after Surgery by Pat Iyer

Wednesday, June 24th, 2009

Hazards of retained surgical instruments

The patient leaves the operating room with a sponge, a clamp, or a towel inside. What is the impact on the patient? We’ve heard the stories of the patient’s clamp that sets off the metal detector in the airport, but many patients find out about the presence of a retained object as a result of a medical change: infection (the biggest risk affecting nearly 50 percent of patients), a fistula (tunnel between two organs), perforation of an organ, or a bowel obstruction. Most commonly, the patient is readmitted to the hospital and has to undergo surgery to remove the retained object. 1.

How do instruments and sponges get left behind? The highest risk is an emergency surgery -there is a nine-fold risk. With the focus on the saving the patient’s life, counts of instruments can fall by the wayside. There is a four-fold risk when there is an unplanned change in surgery based on new findings or changes in the patient’s clinical condition. Obese patients have a higher risk of instruments or sponges being lost in the body. The risk of retained instruments is doubled when more than one surgical team performs surgery at the same time. The risk also increases when there is greater blood loss during the procedure. 2.

There are several patient safety recommendations offered by the American College of Surgeons, The Food and Drug Administration, and the Association of Operating Room Nurses. Recommendations focus on the methods of counting and reconciling discrepancies, the types of sponges used, the need to thoroughly check the wound before closing, and the documentation of counts. (Med League has provided experts on several retained sponge and instrument cases. It is our experience that surgical counts are ALWAYS recorded as correct in these cases.) The use of surgical sponges embedded with radiofrequency chips makes retained sponges easier to locate.

The Centers for Medicare and Medicaid Services took a stand on this problem by announcing it is no longer provided reimbursement for care necessitated by the retained surgical instruments.
Implications for attorneys and legal nurse consultants:

These are difficult cases to defend – retained instruments and sponges during emergency procedures are the most easily defensible cases. Analysis of damages centers around the effects on the patient from the retained instrument or sponge, which can be considerable. During discovery, obtain procedures for surgical counts. Determine if an incident report was completed. Get statements or depose healthcare providers in the operating room at the time.

Were the packages of sponges counted before the surgery to verify the number printed on the outside of the package was correct?
Did the surgeon dismiss the incorrect count without re-exploring the wound?
Did the nursing staff accept the incorrect count?
Was there any sign of breakage of devices after they were removed from the patient?
Were non-x-ray detectable sponges used?
Were counts performed in an audible manner?
When was the count performed in relation to closing the wound?
Did the radiologist versus the surgeon read the x-ray when the count was incorrect?

Have the expert witnesses carefully evaluate the circumstances in comparison to the reasonably prudent, versus the superior standard of care. For example, while radiofrequency sponges are a wonderful innovation, their use is not the standard of care as of now.

References<br>
1. ECRI Institute, Sponge, sharp and instrument counts, Healthcare Risk Control Risk Analysis, Vol. 4, Surgery and Anesthesia, 5, November 2004
2. Gawande, A. et al, Risk factors for retained instruments and sponges after surgery, New England Journal of Medicine, Vol. 248, No. 3, January 16, 2003, 229-235

What are these?

Tags: CMS never events, incorrect surgical counts, operating room errors, retained sponges, retained surgical instruments
Posted in CMS never events, Damages, Medical malpractice, Medical records, Nursing malpractice, Patient safety | 1 Comment »

Medical-Legal Topics

Archive for the ‘Patient safety’ Category

Emergency Department Mistakes by Pat Iyer

2010 National Patient Safety Goals by Pat Iyer

Using technology to make patient care safe by Pat Iyer

How a medical malpractice suit can make a difference by Pat Iyer

Has the Nursing Shortage Gone Away? By Pat Iyer

Reducing Distractions is Reducing Medication Errors – by Pat Iyer

Are there frivolous lawsuits? By Pat Iyer

On Challenging an Authority by Pat Iyer

Michael Jackson: A Demerol Death? by Pat Iyer

Retained Objects after Surgery by Pat Iyer

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