California Now Tracking Preventable Patient Injuries

By: Gerri L. Elder

Over 1,000 cases of medical errors that caused serious harm to patients at California hospitals have been reported between July 2007 and May 2008. The hospitals have disclosed these mistakes and mishaps for the first time under a California state law that now requires them to make reports to regulators about all substantial injuries to their patients.

Among the 1,002 cases of injuries disclosed in this time period were a case of a technician at a children's hospital improperly connecting a ventilator hose, resulting in a 9-day-old baby receiving too little oxygen, a case in which the wrong patient's appendix was removed due to improper filing of a CT scan, and a case in which a woman died after being given two drugs that were not prescribed for her.

These cases are officially known as "adverse events." These mistakes and accidents at hospitals that cause personal injury are also considered preventable, yet the data compiled by the State Department of Public Health in California indicates that approximately 100 of these medical mistakes resulting in injury or death happen per month in California hospitals.

Lawmakers and hospitals in at least seven states have worked to pass legislation to protect patients from having to pay for the cost of health care when medical mistakes are made. The Los Angeles Times reported that in Sacramento, Assemblyman Mike Feuer proposed legislation to ban reimbursement to hospitals for all of the types of injuries tracked by state collected data.

However, lobbyists for doctors and hospitals objected and the legislator was forced to scale the bill down to ban the state medical program from reimbursing hospitals for the same few medical errors that Medicare refuses to pay for.

Safety experts say that these "adverse events" in hospitals should never happen. State investigators found that some medical errors in California hospitals happened because hospitals failed to follow the safeguards that were designed specifically to prevent these harmful medical mistakes and injuries to patients.

Last year after the UC San Diego Medical Center had been warned by its own safety committee about errors that continued to occur with a medicine pump, a state probe found that it failed to correct the problem. As a result of one of these medicine pumps being programmed incorrectly by a nurse at the center, a patient died after receiving more than twice the appropriate dose of the specialized blood pressure drug Flolan.

Officials at UC San Diego said that after this patient's death, they have held repeat drills with staffers who treat patients with this drug and have examined every step in the process of using the pump to administer the drug.

Under the California law, hospitals are required to notify state regulators of every occurrence of 28 different types of dangerous medical mistakes including deaths during labor and delivery, medication errors, suicide attempts and sexual assaults.

The senior medical director at the UC San Diego Medical Center, Dr. Angela Scioscia, says that the disclosure law is "a great opportunity to make rapid improvements" because hospitals can learn from the mistakes of others and eliminate the likelihood of similar incidents. One would certainly hope so!

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