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'It's never just one thing' that leads to serious harm

January 28, 2008|Susan Brink | Times Staff Writer

A technician mistakes an "a" for an "o" in a drug name. A doctor misplaces a decimal point in a prescription order. A nurse reaches for a vial in a cabinet as she's done hundreds of times before, only this time the light is dim and she fails to notice that the powder-blue label is more of a sky blue. The slip-ups are often simple, and always human, and all have happened in U.S. hospitals.

Each simple mistake is supposed to be countered by a recommended backup, a second or third set of eyes -- in other words, guidelines to reduce human error. A lot has to be overlooked in the cascade of errors that result in serious patient harm.

"It's never just one thing that goes wrong when a serious event happens," says Michael Cohen, president of the Institute for Safe Medication Practices, an organization that tracks prescribing errors and is sometimes called in to examine a hospital's mistake. "We've detailed a situation where we found over 50 mistakes in the system before an infant was killed." The incident, he said, was a 1,000-fold overdose of the blood thinner heparin in an Indianapolis neonatal intensive care unit that resulted in the deaths of three infants in 2006.

For The Record
Los Angeles Times Wednesday, February 20, 2008 Home Edition Main News Part A Page 2 National Desk 2 inches; 79 words Type of Material: Correction
Hospital errors: An article about hospital errors in the Jan. 29 Health section quoted Michael Cohen, president of the Institute for Safe Medication Practices, as saying, "We've detailed a situation where we found over 50 mistakes in the system before an infant was killed." The article said Cohen had been referring to an incident at an Indianapolis hospital in which three infants died. Cohen actually had been describing an incident at a Denver hospital in which one infant died.
For The Record
Los Angeles Times Monday, February 25, 2008 Home Edition Health Part F Page 5 Features Desk 2 inches; 75 words Type of Material: Correction
Hospital errors: A Jan. 28 article about hospital errors quoted Michael Cohen, president of the Institute for Safe Medication Practices, as saying, "We've detailed a situation where we found over 50 mistakes in the system before an infant was killed." The article said Cohen had been referring to an incident at an Indianapolis hospital in which three infants died. Cohen actually had been describing an incident at a Denver hospital in which one infant died.

Late last year, the infant twins of actor Dennis Quaid and his wife, Kimberly, were the victims of a nearly identical mistake, an overdose of heparin at Cedars-Sinai Medical Center. "It was the exact same situation in a hospital in Indianapolis that we investigated a year earlier," Cohen says. "The pharmacy dispensed the wrong dose to the nursing station."

The Quaids' newborns, who were being treated for a staph infection, have since been released, and the hospital has been cited by state regulators for its handling of drugs. Its practice, regulators say, had placed pediatric patients in jeopardy.

The mistake calls attention to how far hospitals have to go in preventing medical errors and in learning from the mistakes of others, even though many have made progress in protecting patients within their own institutions. Despite a decade of rising public awareness of such mistakes and research into how to prevent them, even one of the country's premier institutions and a celebrity couple were not immune. Hospitals still have a long way to go to avoid mistakenly hurting their charges.

"People used to say that hospital mistakes are kind of like the poor -- they're always with you," says Dr. Lucien Leape, one of the authors of a 1999 Institute of Medicine report that estimated 100,000 people died each year in the U.S. from preventable hospital errors. "Well, no, they don't have to be."

Hospitals are trying. In a program called the 100,000 Lives Campaign, some 3,000 of the nation's 5,000 acute care hospitals, including Cedars-Sinai, have voluntarily instituted up to six changes in practices aimed at reducing errors. The Joint Commission, a national organization that accredits hospitals and other healthcare facilities, now requires that patients be informed of "unanticipated outcomes."

But while accountability is improving, hospitals still face increasingly complex technology. And medical culture, built on individual excellence, not teamwork, is slow to change.

Unfortunately, Cohen says, few hospitals learn from the mistakes, or improvements, of others. His organization published the results of the Indianapolis incident in a newsletter sent to every hospital in the country. If hospitals are to improve, he says, they have to study errors that have happened elsewhere.

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First instinct: Denial

The mid-1990s saw a rash of medical errors that caught the attention of the public, and the medical profession: A Florida man had the wrong leg amputated, a New York woman had surgery on the wrong side of her brain, and Betsy Lehman, a newspaper reporter whose beat was health, died of an accidental chemotherapy overdose at one of the nation's top cancer centers, Boston's Dana Farber.

At first, the American Medical Assn. responded with a public relations campaign, calling the incidents "isolated" mistakes, according to an analysis of the era published in the April 27, 2002, British Medical Journal. By 1996, however, the AMA launched a National Patient Safety Foundation and changed its stance, admitting that such errors were "common."

But it was the 1999 Institute of Medicine Report that shocked the country, and shamed the medical profession into voluntarily adopting systems changes. The report estimated that 100,000 patients died annually from preventable hospital errors -- about the same as the yearly tally of deaths from motor vehicle accidents, breast cancer and AIDS combined.

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