medical errors « Medical-Legal Topics

Posts Tagged ‘medical errors’

What’s a medical error? Part 1 by Pat Iyer

Tuesday, July 27th, 2010

I was talking to my son and his girlfriend about medical errors and he asked me to define them. Here are some cases we have handled.

* the hospitalized patient who was alert, oriented, and ambulatory until the nurse administered an inappropriate dose of Morphine, resulting in a serious overdose;
* the emergency department patient who developed quadriplegia after the nurse removed the cervical collar without an order and without the spine being cleared;
* the unsupervised nursing home resident on a pureed diet who choked on deli meat he grabbed off another resident’s tray;
* the newborn infant delivered by vacuum extraction who experienced signs of respiratory distress that went unnoticed by the nursery staff until the infant experienced a respiratory arrest and expired due to complications from a brain hemorrhage;
* the critical care sitter who sexually assaulted a patient;
* the intubated patient who pulled out his endotracheal tube because the nurse did not restrain his hands and he could not be re-intubated:
* the paraplegic receiving supplemental nutrition via a nasogastric feeding tube who experienced an aspiration event and died because the RN programmed the feeding pump incorrectly, resulting in the infusion of an excessive amount of feeding over a short period of time;
* the unsupervised emergency department psychiatric patient who jumped off the roof of the hospital while waiting to be admitted to a psychiatric unit
* the medical surgical patient who rolled off the bed while the sheets were being changed because the nurse did not put the side rail up;
* the surgical patient who developed compartment syndrome and nerve damage because the surgery shredded the popliteal artery in his knee and the nurses did not perform neurovascular checks

What are these?

Tags: medical errors, Medical malpractice, nursing error, Nursing malpractice, nursing negligence
Posted in Legal nurse consulting, Medical malpractice, Nursing malpractice, medical errors | No Comments »

What’s a medical error? Part 2 by Pat Iyer

Monday, July 26th, 2010

I was talking to my son and his girlfriend about medical errors and he asked me to define them. Here are some more cases we have handled.

* the oncology patient who suffered from a large extravasation of a chemotherapeutic drug;
* the patient who fell off the operating room table because the nurse did not apply safety straps;
* the patient whose swollen leg was not reported to the physician on the day of discharge, and who died of a pulmonary embolism shortly after discharge
* the man who jumped through a window because the nurse did not recognize the need to start one to one supervision
* the surgical patient diagnosed with a retained sponge despite the “correct” sponge count;
* the nursing home patient scalded in a bathtub;
* the psychiatric patient who had a history of suicidal ideation and attempts, who was unmonitored, left the hospital, and hung himself in the nearby woods;
* the pediatric patient who went into respiratory distress and whose home care nurse asked his father to come home instead of following directions to call 911;
* the nursing home patient who fractured two hips after being dropped out of a hydraulic lift by a nursing assistant, who did not report the incident;
* the postoperative woman who experienced intra-abdominal hemorrhage and subsequent shock that went undetected by the Post Anesthesia Care Unit nurse.
* untold numbers of pressure sore cases

What are these?

Tags: medical errors, Medical malpractice, nursing errors, Nursing malpractice
Posted in Legal nurse consulting, Medication errors, Nursing malpractice, medical errors | No Comments »

Why don’t healthcare providers follow the rules? Part 2 by Pat Iyer

Monday, July 19th, 2010

Wrong site surgery is the most common medical error

Wrong site surgery is the most common sentinel event

Normalization of deviance occurs when a provider, such as a nurse, knowingly disregards a safety practice, like using two patient identifiers to verify patient identity. Repeated deviation from the safe practices tends to “normalize” the risky behavior in the nurse’s mind. In another example, The Joint Commission Medication Management Standard requires labeling of all medications. Yet a survey by the American Nurses Association indicated that only 37 percent of nurses surveyed reported they always label syringes and 28 percent never label syringes when administering medications.

Despite awareness and education, some providers choose to willfully disregard safety practices. Patient safety experts define a “no blame” culture as one that argues that most errors are committed by hardworking people; the traditional focus on identifying who is at fault is a distraction. A “just culture” differentiates between blameworthy and blameless acts. Two physicians, Wachter and Pronovost, acknowledge that there are areas of performance that pose a clear risk to patients, such as failure to practice hand hygiene, use a checklist to reduce blood stream infections, mark the surgical site to prevent wrong-site surgery, or perform a preoperative time out.

Nurses are implicated in some of these issues. They work for the organization, which typically has relatively clear lines of authority and procedures for dealing with failure to follow accepted practices. On the other hand, physicians have traditionally been independent entrepreneurs, not employees. They are subject to weak peer enforcement. Peers often recoil from disciplining each other and hospitals have been reluctant to punish physicians for fear of alienating them and losing the business they bring in. The tradition of lax enforcement of safety rules has led too many physicians to ignore them. Wachter and Pronovost argued for a clear definition of unacceptable behaviors, with the initial warnings and counseling. Continued failure to adhere to safety practices after the initial penalty would lead to suspension or loss of clinical privileges (for physicians and others subject to credentialing, such as advanced practice nurses) or firing.

Isn’t it about time we stopped dangerous practices?

More reading:
Beaulieu, L. and Freeman, M, “Nursing shortcuts can shortcut safety”, Nursing 2009, December 2009, 16-20
Wachter, R. and Pronovost, P., “Balancing ‘no blame’ with accountability in patient safety”, New England Journal of Medicine, October 1, 2009, 1401-1406.
Cohen, M. “Risky imposter”, Nursing 2008, May 2008, 20.

What are these?

Tags: hand hygiene, hospital-acquired infection, medical errors, normalization of deviance, wrong site surgery
Posted in Healthcare Risk Management, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Why don’t healthcare providers follow the rules? Part 1 by Pat Iyer

Wednesday, July 14th, 2010

Wrong site surgery is the most common medical error

I’ve been updating a chapter on the roots of patient injury for the fourth edition of Nursing Malpractice. I’ve been thinking about the reasons people don’t follow policies and procedures. Back in the 1980s when I ran a nursing hospital’s staff development department, I learned that if people did not have the knowledge, this was an educational problem and we were to educate. If they knew how to perform their jobs but chose not to, this was a management problem and their managers were to counsel and discipline. Now we think about this issue in expanded terms.

1. Safety standards are not monitored or enforced
People may not do their jobs correctly because there are no consequences if they don’t. Managers must be clear about the need to follow policies and procedures and the consequences of not doing so. Continual monitoring and education about the importance of patient safety sends an obvious message about the value of patient safety policies.

2. Lack of knowledge
Staff may be unaware of how to perform aspects of their job. They need training and competency checks. They may lack knowledge about how medical errors occur. Integration of patient safety information into the curriculum of schools of nursing helps to increase knowledge and skills.

3. Dysfunctional systems
Convoluted systems are sometimes created by providers or administrators who lack essential training in human factors and systems engineering, which may make it too hard to adhere to the practice. This invites workarounds because it becomes too difficult to follow the procedures.

What are these?

Tags: hand hygiene, medical errors, normalization of deviance, Patient safety, wrong site surgery
Posted in Healthcare Risk Management, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Why inexperienced people make mistakes

Tuesday, January 26th, 2010

A group of residents eagerly perform complex surgery in the middle of the night while the attending surgeons who are supposed to supervise them are happily sleeping at home. Why is this very real scenario a bad idea? Why do interns, residents, nurses, and others make errors that injure patients? The answer lies in learning theory.

The Dreyfus Model of Skill Acquisition used by Pat Benner, a nursing theorist, breaks knowledge into two components: “techne” and “phronesis”. Techne knowledge is book knowledge: the information that is captured from procedural or scientific knowledge. The student must be given safe and clear directions on how to proceed, as there is no previous experience on which to draw. For example, a student nurse I supervised discovered her patient was short of breath. She attributed the symptom to anxiety, talked to the patient about her concerns, and held her hand. A more experienced person would have applied oxygen.

The second kind of knowledge is phronesis, which is acquired through learning in the practice setting. A nurse who makes a series of rapid decisions during an emergency draws on phronesis. The rapid response team members in hospitals are made up of experts who use this kind of knowledge.

The evolution of the expert practitioner passes through stages

Benner’s model of expertise, which is based on the Dreyfus model, describes how an individual may pass through five stages in developing expertise. Not everyone reaches the proficient or expert stage.

The novice rigidly adheres to rules or plans, has little situational perception and can’t make judgments. This individual is learning skills in clinical settings and must be closely supervised when delivering patient care.

The advanced beginner is a new graduate. The person functions with limited situational perception (the ability to put clues together to make decisions) and has difficulty discriminating between what is important.

The competent practitioner can see his or her actions within a broader context, and is capable of making sounder judgments. Conscious deliberate planning takes place along with standardized and routine procedures.

The proficient individual sees the situation holistically rather than in terms of its component parts. This individual more readily makes decisions, perceives differences from the normal pattern of a patient, and functions better with ambiguity. The proficient person has learned from experience and has an easier time making decisions.

The expert practitioner no longer relies on rules, guidelines or maxims, and intuitively grasps what is important in a situation. A registered nurse with expert knowledge may well exceed the knowledge of inexperienced physicians and may save a patient’s life by insisting on evaluation, diagnostic testing, change in medication, or another needed course.

A clinically experienced person enters a new healthcare setting as a new employee without knowledge of the politics, procedures, and policies. It takes time to learn “how we do it here.”

And thus we face the dilemma in health care: an inexperienced person will not learn without the opportunity to do so. He or she has to start somewhere. Yet, we don’t want that person to learn on us, our mother or father or child. When my husband had a triple bypass three months ago, the cardiac surgeon at Johns Hopkins proactively told us that he performed surgery. He said he had people in the operating room helping him, but he did the surgery. We were relieved to hear that.

A fair number of medical or nursing malpractice cases that come into Med League involve errors made by inexperienced people, whether they are new employees or new healthcare practitioners. Here are my suggestions:

Attorneys handling medical or nursing malpractice cases should be careful to determine the level of experience of the defendant. Determine the degree of supervision that should have been provided versus what was actually provided.
Ask about the orientation program the new employee should have received. Determine how much orientation staff agency employees received.
Ask the defendant if he or she sought help. Some of us, whether because of age, culture, or personality, would rather try to solve problems without help. This can be a recipe for disaster.
If you or a loved one needs care, seek the most experienced practitioner or hospital you can find.
If you or a loved one detects the person assigned to your care seems unfamiliar with your needs or medical equipment, insist that individual seek help from a more experienced person. Be an advocate for safety.
If you or a loved one needs surgery in a teaching hospital, insist that the attending physician be present. You may even cross off the consent form that allows residents and interns to perform parts of the surgery.

What do you think? How should inexperienced people learn? Send us a comment.

Parts of this blog post came from Moniaree Parker Jones, “Nursing Expertise: A Look at Theory and the LNCC certification Exam”, Journal of Legal Nurse Consulting, Spring 2007. Other parts came from the School of Hard Knocks.

What are these?

Tags: making mistakes, medical errors, Medical malpractice, personal effectiveness
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Is the Government Interested in Medical Error? Based on a chapter by Carol Armenti JD MA

Wednesday, January 6th, 2010

There is little question that government interest in medical error is economic rather than benevolent for even the legislative language of medical malpractice speaks, not to the injuries caused to the patient, but to the government’s budget. When the New Jersey Legislature enacted “The Patients First Act,” ironically, it spoke not to the rights of the patients, but to medical malpractice insurance. “The State’s healthcare system and its residents’ access to healthcare providers are threatened by a dramatic escalation in medical malpractice liability insurance premiums, which is creating a crisis of affordability in the purchase of necessary liability for our healthcare providers. . .” 1

Apparently the New Jersey Legislature found the appropriate response to escalating premiums was not to prevent harm but to reform tort liability. The Legislature took the position that tort reform ensures “that healthcare services continue to be available and accessible to residents of the State and to enhance patient safety at healthcare facilities.” 2

New Jersey is not alone in passage of tort reform legislation, which responds to patients suffering medical harm by increasing the burden on plaintiffs’ bar, thereby protecting physicians from suit. While obvious financial self-preservation motivates much of the tort reform rhetoric instigated by healthcare providers and insurers, patient advocates who sometimes speak the language of tort reform may be motivated by other self-interests.

With a myopia driven by the personal pain of the patient, or the patient’s family members, patient advocates lobby for reforms which will promote emotional healing. Advocates may attempt to teach physicians to feign sympathy in exchange for release-exacted transparency by assuaging their hearts. Transparency rarely requires additional quid pro quo. In such scenarios medical error may be admitted and specious regrets conveyed, but no commitment to prevent further occurrence of the medical error results. See how a medical malpractice suit can make a difference at http://t8mzr.th8.us

What do you think? Is the government really interested in saving lives?

1. N.J.S.A. 2A:53A-38(b).
2. 13. N.J.S.A. 2A:53A-38(f).

Taken from “Preventing Healthcare-Acquired Conditions Means Never Having to Say You’re Sorry” by Carol Ann Armenti, MA, JD in Patricia Iyer and Barbara Levin, (Editors), Medical Legal Aspects of Medical Records, Second Edition, 2010. Contact us for ordering information.

What are these?

Tags: CMS never events, healthcare acquired conditions, medical errors
Posted in CMS never events, Tort reform, Trial lawyer skills, medical errors | No Comments »

New NJ Bill Mandates Reporting of Medical Errors by Pat Iyer

Monday, September 28th, 2009

On August 31, 2009, New Jersey Gov. Jon Corzine signed into law an act requiring hospitals to publicly report 14 serious medical errors. One of the first laws of its kind in the United States, this legislation also bars hospitals in New Jersey from seeking reimbursement for costs associated with the following “never events” for which Medicare does not allow payment: surgery on the wrong side, body part or person; the wrong surgery; air embolism; transfusion reaction; and a foreign object left inside a patient during a procedure. Commencing in November 2009, New Jersey’s annual hospital performance report—published by the state Department of Health and Senior Services—will include data on the number and rate of the following serious indicators of patient safety in each of the hospitals in the state:

1. Foreign body left during procedure;
2. Iatrogenic pneumothorax (collapsed lung caused by a medical provider);
3. Postoperative hip fracture;
4. Postoperative hemorrhage or hematoma;
5. Postoperative deep vein thrombosis or pulmonary embolism (leg or lung clot);
6. Postoperative sepsis (infection);
7. Postoperative wound dehiscence (opening up of the incision);
8. Accidental puncture or laceration;
9. Transfusion reaction;
10. Birth trauma;
11. Obstetric trauma-vaginal delivery with instrument;
12. Obstetric trauma-vaginal delivery without instrument;
13. Air embolism; and
14. Surgery on wrong side, wrong body part or wrong person, or wrong surgery performed on a patient.

Currently, the New Jersey Department of Health and Senior Services publishes a hospital performance report each year on hospital-specific treatment of heart attacks, pneumonia and heart failure, and prevention of surgical infections. The state health department also issues a report on indicators of quality of inpatient care used to measure the performance of the state’s hospitals in treating common medical conditions. According to New Jersey Commissioner of Health and Senior Services Heather Howard, “We know that public reporting of hospital performance improves quality and promotes excellence in patient safety—as we have seen with dramatic decreases in cardiac surgery deaths.” Publicizing more patient-safety data may assist patients and their families to make informed decisions about their care and the hospitals they choose.
An interesting aspect of the new law is likely to be the determination of whether a cost or expense is associated with any of the “never events” for which payment will be denied by third parties. This factor is anticipated to generate further debate, and many other states are likely to undertake similar efforts to publicize and restrict reimbursement associated with medical errors in hospitals.

On a Federal level, payment implications began on October 1, 2008 for the conditions identified in both the IPPS FY (fiscal year) 2008 and 2009 final rule. For discharges occurring after that date, there is no reimbursement for charges associated with the hospital acquired conditions. Balance billing is prohibited, that is, hospitals may not bill patients for the unreimbursed charges.

Plaintiff attorneys are increasingly focusing on these “never events” as they take the position that they constitute medical or nursing malpractice. It is an easy argument to make: the government says these things should never happen, therefore, if they did, someone did something wrong. Proving liability, proximate cause, and damages continues to be essential to winning a suit. The “never events” may provide an easy roadmap to do so.

What are these?

Tags: medical errors, never events, reporting medical errors
Posted in CMS never events, Medical malpractice, Nursing malpractice, medical errors | 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 »

Medical-Legal Topics

Posts Tagged ‘medical errors’

What’s a medical error? Part 1 by Pat Iyer

What’s a medical error? Part 2 by Pat Iyer

Why don’t healthcare providers follow the rules? Part 2 by Pat Iyer

Why don’t healthcare providers follow the rules? Part 1 by Pat Iyer

Why inexperienced people make mistakes

Is the Government Interested in Medical Error? Based on a chapter by Carol Armenti JD MA

New NJ Bill Mandates Reporting of Medical Errors by Pat Iyer

Reducing Distractions is Reducing Medication Errors – by Pat Iyer

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