Hospitals are failing to report many cases of patients being harmed during medical treatment, even in states such as Maine where reporting is mandatory, according to a new national study.
Half of states have reporting systems for “adverse events,” such as medication errors or surgery on the wrong body part, but few of those incidents are brought to authorities’ attention, according to a July 19 report by the U.S. Health and Human Services’ Office of Inspector General.
Maine counted 163 such events in 2011, largely “unanticipated deaths,” according to a June report that found “serious under-reporting” in the state. The finding was drawn from national health care quality data that estimate adverse event rates based on factors such as hospitals’ sizes, the number of procedures performed and the community’s population, according to Joe Katchick, a registered nurse who monitors the reporting program in the Department of Health and Human Services’ Division of Licensing and Regulatory Services.
The real number of cases of serious patient harm in Maine, or “sentinel events,” as DHHS identifies them, likely was closer to 300 or 400 last year based on those formulas, he said.
Of the 163 events that were reported, 61 involved patients who went to the hospital with an illness or injury that was not life-threatening but died unexpectedly, according to the June report. Injuries from falls and pressure ulcers, or bed sores, were other problem areas.
Twice surgeons operated on the wrong part of a patient’s body. In 16 cases “foreign objects,” such as surgical tools and sponges, were left behind in patients’ bodies.
There also were three assaults, including a sexual assault on a patient, and three patient suicides or attempted suicides resulting in serious disability.
The report doesn’t identify which health care facilities reported adverse events. The program’s aim is to encourage reporting and remedy circumstances that allow patients to be harmed, not to punish a hospital or publicize its mistakes, Katchick said.
“We don’t share facilities’ stats even with other facilities,” he said.
Fear of blame could discourage hospitals from reporting and learning from adverse events, which also are handled through other accountability channels including the licensing process and the courts, said Jeff Austin, a spokesman for the Maine Hospital Association.
“The goal here is improvement, so people need to feel that they are in a quality improvement environment as opposed to a lawsuit or front-page newspaper story environment,” he said.
The Office of Inspector General study found that weak reporting of serious medical mistakes to state systems likely was due to hospitals failing to recognize events as reportable rather than neglecting to report known events.
The study was an update to another Office of Inspector General report that found 27 percent of Medicare beneficiaries hospitalized in October 2008 were harmed during medical treatment.
Maine saw a spike in sentinel events in 2010 that continued into 2011, which the June report attributed to changes to the criteria in 2009 and growing appreciation among health providers for preventing medical errors through better transparency.
Because there’s no national standard for reporting adverse medical events, the 25 states that do have reporting systems, along with the District of Columbia, take different approaches. Maine uses criteria outlined by the National Quality Forum and in state statute.
The reporting system, put in place in 2003, tracks serious, preventable events and errors at hospitals, ambulatory surgical centers, dialysis units, and facilities for people with mental retardation. Adverse events at long-term care facilities are tracked under a separate system.
The sentinel event program operates independently of the licensing division at DHHS, sharing information about medical errors only when there’s an immediate safety risk, Katchick said.
So far in 2012, more than 70 sentinel events have been reported, he said.
Katchick is currently the sole staffer in the program, so he’s reviewing every adverse event report that comes in.
DHHS is currently recruiting a manager for the program.
Hospitals have 24 hours to report a sentinel event to the state or they could be subject to fines. DHHS then does a review, sometimes on site depending on the circumstances and severity of the case. Hospitals have 45 days to determine how the mistake happened and then identify whether any processes need to be changed and develop a plan for adjusting them.
DHHS also conducts audits to be sure hospitals have required systems in place to deal with adverse events, Katchick said.
“If we don’t know they’re not reporting, we have no auspices because we don’t know it’s happening,” he said. “If we do find them, there’s the possibility of a financial penalty if we find that they did not report something that was truly a sentinel event.”
The fine totals up to $10,000 for each event.
While not every sentinel event in Maine is properly identified and reported, hospitals are committed to training staff to recognize them, Austin said.
Maine hospitals perform well nationally in patient safety, but mistakes still happen and need to be reported, he said.
“We need to track this, we need to report it and we most importantly need to fix whatever problem there was, if there was one, so that it doesn’t happen again,” Austin said.
And before everyone goes beserk, I’ve had surgeries for throat cancer, gall bladder, lymph nodes, a salivary gland, tonsils, and prostate at EMMC and St Joseph and I received the best care on all levels anywhere….
You were lucky. My spouse didn’t get such good care.
mine went in for a COLD!died 12 hrs later!EMMC
There had to be more to it than that. But I’m sorry for your loss.
So sorry for your loss. That is a horrible way to lose a spouse.
Unfortunately the medical community in general is self-regulated for the most part. The public has only very limited access to statistical data which demonstrates the favorable viability of hospital operations, and that has only happened recently. I find this quote interesting: “Fear of blame or reprisal could discourage hospitals from reporting…” I would think fear of blame would do exactly the opposite, that this fear would only make them work harder to make sure nothing bad happens. As it is there are no negative repercussions for screwing up. The public needs ALL the information to make informed decisions and to “encourage” these medical facilities to clean up their act. Accountability!
As a nurse, I have to say you are right. The fear of blame (but mostly fear of hurting patients) is in the mind of all healthcare providers. But there is still a fear of losing your job, embarrassment, guilt, etc. Those are normal human responses to making a mistake. What complicates it is though mistakes during patient care are a serious issue, we are all human and everyone makes mistakes at their job. Contractors measure incorrectly and have to tear apart a project to fix it, costing the company, and maybe the consumer, money. Accountants enter the wrong numbers during computation and have to redo a tax form. Waitresses write down the wrong item and bring customers the wrong order. It happens. Granted it’s more serious when a medical mistake is made-I’m not downplaying that by any means-but to never expect a mistake is unrealistic. Now wrong site surgery is unacceptable and 100% avoidable. Other errors such as falls from side effect of a new medication and giving a medication a person was allergic to because it wasn’t listed on the medication list-well those are more likely. Hospitals do have checks and balances procedures to be sure mistakes don’t happen, but yes, they’re only as good as the people using them. I guess my point is that it isn’t going to matter if you get the numbers of certain hospitals. You’re going to see mistakes at ANY facilitity. So does that mean no one ever goes to the hospital? There are also ways patients can take inititive to be sure errors aren’t made, as well, to help assure they are getting the safest care possible.
I do not believe that harmful mistakes are inevitable. I believe they are
preventable. One big step in the right direction is to encourage patients
to keep a trusted relative or friend with them as a bedside advocate. For
Patients who are impaired by medication, weakness or disability, advocates can
be an extra pair of eyes and ears. They can monitor handwashing, correct
medication dispensing, and assist the patient with simple tasks like patient
hygiene and with walking. They can alert caregivers when something is going
wrong, and often times they are the first to notice that something IS going
wrong. They can keep a journal for the patient and a list of questions for
caregivers. A patient advocate at the bedside can literally be a life saver,
yet many hospitals make them go home at the end of visiting hours. This rule is
random and unnecessary and it puts patients in more danger during non visiting
hours.
Check lists and so called “bundles” are step by step processes that are
available for everything from urinary catheter insertion and care to surgery.
Yet, I have personally heard doctors scoff the pre op check list…..a necessary
last minute safety check done just prior to incision. How would you feel if your
airline pilot skipped his pre take off check list?
When every hospital, every doctor, and every associated caregiver is engaged
in observing the “rules” of safety, including the check lists and bundles,
handwashing, evironmental disinfection, antibiotic stewardship, patient and
advocate engagement, the 5 “rights” of medication dispensing, safe staffing
levels, and all of the other known effective steps and processes for patient safety, most
patients can breath a sigh of relief and trust our professional health care
providers to give us safe high quality care. Harmful events are preventable and
every single patient deserves to have the safest and best care possible.
Still have to disagree on the inevitable mistakes part. Again, not excuseable, but it happens. And I 100% agree with all of your patient advocate suggestions. The problem is, family members forget that their loved ones are in the hospital for medical care but that we have multiple patients, hospitals are often working understaffed, and that staff doesn’t always have the time or notice that education hasn’t taken place, etc. Now, as a nurse, having a family member with a notepad writing down every thing I ever did was a bit daunting, as at times I wondered “gee, is this a lawsuit waiting to happen?” like they were just waiting for a mistake to happen. But having an extra set of ears and eyes is so helpful, as when a patient is sick they aren’t always aware of what is going on. I wish there were more family members involved, as many drop in for 10-20min and start demanding this be done, that be done, complaining that this hasn’t been done, etc. Well pull up a chair and help your father eat his dinner. Help your mother get her bath or brush her teeth. These types of activities are often assigned to CNAs who have 10 other patients at meal and bedtimes. So the extra help with these items is so appreciated!
The purpose of a journal is not to make caregivers paranoid. It is to keep track of who was caring for that patient and what was advised by them. Often, different caregivers give different advice or even different care, often times in the same shift or day. So, if notes are taken, a list of legitimate questions for the primary caregiver…generally the doctor, can be generated. Also, patient should be asking to see their medical records. Sometimes they learn more about their condition from their records than they do from their caregivers. Clear, accurate and timely communications WITH the patient and/or their advocate can avert many errors and miscommunications.
Promoting patient advocacy for patients and educating them about how they can help their loved one goes a long way in a patient’s recovery.
As an RN, I respectfully disagree with your call for family members to become involved with patient care. That’s our job. What I do appreciate is family members helping me with assessments — they know the patient better than I ever will — and alerting me to changes in condition that could signify a downward trend. I have no problem with a family member writing down everything I do, either: It merely backs up the same record I am creating for a patient. I think the real issue here is creating work environments where employees are not afraid to admit mistakes for fear of losing their job and who are constantly striving for improvement. P.S. For those pointing to c-diff as an example of a hospital-acquired infection that is preventable, there is growing evidence that suggests that infection is linked to a particular medication that is widely used.
I agree, it is your job (as it use to be mine when I worked at EMMC ER). But, as you know, understaffing and chaos often leaves simple patient care tasks undone. Hygiene suffers, assistance with ambulating is not available when needed, meals get cold waiting for help with eating/feeding, etc. Engaging family/advocates to help with these simple tasks helps to keep patients comfortable and safe. It isn’t meant to step on toes…it is meant to help patients.
RNs cannot legally delegate tasks of any kind to family members, whether you call it “delegating” or “engaging.” Period. If you question what the big deal is, ask yourself who is responsible for the injuries suffered by a patient who falls while ambulating with a family member who’s been “engaged” by the RN. Yesterday, I walked in on a helpful family member feeding her mother a turkey sandwich. The patient had had a stroke and had dysphagia. The last thing I need is freelance help. What if she’d choked? Families bring patients to hospitals for skilled care, not for more of the same care they can provide at home. Yes, long waits for help can be frustrating. But you don’t compromise safety by illegally delegating care to untrained providers.
It wasn’t my intention to imply that nurses should delegate tasks to family
members (advocates). My suggestion was that the Patient should engage a family
member or loved one to advocate for them and help them with simple tasks. It is
the right of the patient to do that. It would never be correct protocol for a
nurse to delegate anything to a family member, but there is certainly nothing
wrong with accepting offered help or information.
It is just as likely, if not more likely that the hospital kitchen would
send a solid diet to a patient who is not supposed to eat or is just on liquids
as it is for a family member to make that mistake (like the turkey sandwich
story). Sorry, I vehemently disagree on this advocacy issue…..it is a
responsibility of the patient’s advocate (chosen by the patient) to know as
much as possible about the patient and to help them in any way they can, short
of professional nursing or medical care. In some cases, the patient’s chosen advocate also cares for them at home. My father would have died 4 months
earlier if I had not been by his bedside when he went into sepsis…..the nurse
in the room didn’t recognized the symptoms of sepsis and just thought “he was
tired”. How many family members have helped you with recognizing a crisis? Many family members helped me when I was still a practicing ER nurse.
The old saying goes…”it takes a village”…and a patient advocate can
help patients in many different ways….with or without the “permission” of an
RN.
I have a question for you….who is responsible for the injuries a patient
incurs when they fall getting out of bed to use the bathroom after they have
waited a half hour or longer for a nurse to come after using the call button? I
know that a nurse can’t be in more than one place at a time, and that staffing
is almost always short, but this happens all the time. Engaging a patient
advocate is the patient’s right and choice and it will make them safer.
I could not agree more with you. They have no one to be accountable too. My spouse had a gaul bladder operation. The Doctor (Kimberly Liber) put a jp drain in. It lasted about 4 days and fell out. When I called about it I was told, “Oh it’ll be ok.” The incision was still leeking all over the place. What kind of care is that? My spouse was taken by ambulance to EMMC,(ugh) and ended up being admitted. We actually got a statement where BC/BS paid for the stay. I wanted to sue but was persueded not to.
Thank you! At St. Joes, we do our best to give great care but like any hospital we can make mistakes. After all, we are human and human is perfect. We do learn from our mistakes and because of them changes are made when there is a need.
And if i did have a surgery go wrong who do i go to and where do i start?
Lanham & Blackwell @ 133 Broadway in Bangor would be a good place to start
This is an interesting article. I think part of the solution for Hospitals’ failure to report is to advise patients and or their families report sentinel events to the State. Patients are very astute and they know if they have been harmed during their care, yet there is no mechanism for them to report to the State. This way the secrets of Hospitals and other Healthcare facilities remain safe.
This article doesn’t mention anything about the suffering of harmed patients ….it only mentiones how afraid the hospitals are of lawsuits, and how if harm is publicized their image might suffer. Remember….patients suffer a great deal from these errors and injuries.
Full disclosure, honesty, and accountability go a long way to repair damage. Offers of compensation for patients who have been harmed would also help. Personally, I have no sympathy for Hospitals (or other facilities) when they harm a patient, particularly if the same mistake happens over and over. Hospital Acquired Infections are a perfect example of that. My sympathy is with the patient who has suffered and/or died at the hands of those who were trusted to provide them with professional safe healthcare. If this harm happened in a restaurant, or on a plane, regulators would be all over them, and they would indeed be paying fines. We need to stop protecting Hospitals and their images and begin protecting vulnerable trusting patients while under a Hospital or other facility’s care. Most healthcare harm and infections are preventable, so there is no excuse for ongoing poor performance OR failure to report sentinal events and other injuries/infections that patients experience.
hospitals cover up what they do in Bangor because they are afraid of lawsuits….they have cronies working in state agencies to help them cover it up….take it from someone who has survived it….the truth never comes out in Maine….
Hospitals have Patient Advocates for people to access if they fell harm is being done.Accident’s are bound to happen and I don’t think hospitals need your sympathy
I agree with you Honesty,full disclosure and accountability are important and health professionals are ethically and legally mandated My question… are administrators following the same ethical and moral mandate
Hospital employed patient advocates get their paychecks from the Hospital. While I do appreciate that they are sincere in their efforts for patients, they are beholden to the facility they work for. Accidents are not bound to happen…they are preventable.
You make some very valid points, but remember-nonmedical persons do not always know every circumstance surrounding the care or condition of the patient. The poor woman who commented about her husband going into the hospital with a ‘cold’ and dying 12 hours later from poor care…I can’t believe that (that his poor care was what killed him). I don’t believe she got the information she should have about what actually was going on with her spouse. But you are correct, there is no excuse for repeated mistakes and failure to report adverse events.
You (if you are an RN) can’t possibly believe this?
From Web MD:
“From 1999 to 2004, C-diff became four times more lethal, with death
rates increasing from 5.7 per million Americans to 23.7 per million
Americans in 2004. During one hospital outbreak in Quebec, Canada, the
one-year death rate hit 17%.”
You can actually go into a hospital for minor surgery and die in 48 hours from this disease.
Yes, and she said 12 hours and didn’t say what he passed away from. My point was what was it? Was it an unforseen issue that unfortunately ended his life while he was at the hospital? Or yes, what is something he contracted at the hospital? She said nothing about diarrhea or c-diff, just a cold. The risk of c-diff infection in the hospital increases with the length of stay. He was there 12 hours? So the likelyhood that he contracted c-diff specifically in the hospital is unlikely. If he did have it, he probably had it beforehand, and his compromised immune system could have caused a flare-up.
I’m guessing that you probably see a lot of patients who come in after years of abuse and neglect to their bodies and then assume a doctor and nurse is going to be able to just “save them.” I do agree with you that we the nonmedical folks don’t know the circumstances and I can only imagine the things you folks must witness. I’ve heard some family members of my own blaming a hospital for my uncle’s death. Truth is, 4 packs of cigarettes, not eating for a week at a time, and a 1/5 of Whiskey every day probably didn’t help and likely contributed to his liver and kidney failure.
Of course there are some patients who have done irreparable damage to themselves and no amount of care can fix that. We are discussing preventable harm to any patient….like your uncle for instance. If he was in the hospital, and he got a serious infection that he did NOT have when he was admitted…that is not acceptable, even if he was sick with cirrhosis or COPD or other self inflicted disease. It is preventable harm from healthcare that we are discussing…..and that should not happen to anyone.
I was actually commenting to RN regarding her post about us in the nonmedical field who don’t understand the underlying circumstances. In my uncle’s case, he did develop an infection (confusing and I don’t understand it, but sounds like he had a respiratory infection that ended up spreading elsewhere.
My family wanted to blame the hospital (and perhaps they did play a role in it, I’m not entirely sure as I’m one of those non-medical folk), but it wasn’t the hospital’s fault at all that he had a compromised immune system and was so incredibly weak (blood tests came back with some other underlying blood condition that was causing the weakness, etc., and I’m SURE it had something to do with his lifestyle) and his body just shut down.
Rest his dear soul, we loved him dearly, but he abused himself his entire life and then wanted the doctors to cure him. Towards the end of it, something as common as a case of the sniffles just may have done him in. My family’s take was “he went to the hospital with a respiratory infection and ends up in kidney failure!”
That being said, I completely agree that hospitals should be held accountable and should be reporting these types of things, and I also feel that we the public have a right to know how any given hospital is doing in terms of these issues. However, I also can see RN’s point that often times it’s easy for us who don’t know what we’re talking about to make up things in our heads and assume it is always the hospital’s fault when there may be something else we don’t understand.
Kathy, I particularly like your point that if harm is not reported and acted upon, the provider continues to perpetuate a lower standard of care that results in increased patient harm. It is human to not want to be criticized but this is critical to our nation and we are falling behind other nations because of poor and costly health care.
Big Paul is going to be outraged, Maybe?
I highly doubt that.
Does EMMC have enough paper to do all the reporting. They have their little secrets.
Someone should find out why Waldo County General In Beklfast Maine has such a HUGE precentage of people getting blood clots after surgery.It seems like everyone I talk to about this subject,has at least 1 story about it.Something weird is going on.
Maine Med is the worst in my experience. I had a nurse tell me after three pediatricians checked my newborn and ok’d our release from care after birth that I was “going to kill” my child because my child was sick and needed care. This nurse was horrible and would not check with the doctor’s who had examined my child but harassed me. I filed a complaint with the hospital and assured them I would not sue but for a mother with a newborn, this behavior is inexcusable and needless. On the flipside, finding a good primary care physician in Maine is challenging at best. This state is very rural which leaves itself open to subpar care at many levels in my experience.
If I were you, I would have asked to speak with the Charge Nurse and told her/him what was happening. Advocating for your care and speaking out at the time (because you never know what could have happened-perhaps the nurse would have been reprimanded, you would have gotten explanation into her behavior, etc.) Wouldn’t you have felt better and probably would not been calling Maine Med a horrible place due to one bad experience with a single employee if felt you’d been heard and the situation addressed from the get go? Having a baby is a wonderful thing and it is too bad you had this experience.
Dear RN, If I’d only had you for a nurse! :) I did talk to someone higher up and let them know of her treatment of me (this was the second child I had there) and that she deliberately withheld pain meds after my c-section once she found out I was not staying another night before I filed a complaint I was calm about it but I never went back. The first time was almost worst to the point I fired the doctor for misdiagnosing me with something I didn’t have (had been my obgyn through the pregnancy and suddenly the day of delivery I’m in heart failure which was definitely not the case) and showed zero symptoms of. So with two bad experiences (though to be fair the delivering doc I replaced him with agreed there was nothing wrong with me and actually listened, that time it was one bad doctor), I won’t go back. There are some great caregivers out there, I’m just not finding them plentiful here.
163 unanticipated deaths while under the care of hospital or physician or 163 events total?
My mother was sent home from a Bangor hospital with a huge wound on her arm, caused when the tech giving her the EKG ripped the pad off and took the skin with it. At one point, a nurse changed the dressing and put tape across the wound, which tore more skin when they ripped it off. After home care nurses stopped caring for the wound, I had to do it for a couple more weeks, they had showed me how to care for it. Over a year later my mother still has a big white spot where the wound occurred.
I won’t even get into the mistakes they make with her meds when she is in the hospital…….or address the lack of personal hygiene care…….
What kind of tape was that ?
this is why we must educate ourselves preventative care and first aid at least. I would recommend everyone should at least know what meds you take side effects interactions and parameters for why you actually need the medication. In the elderly especially be aware of side effects and sensitivities occur more often. My best advice is to stay on top of symptoms and get treatment before hospitalization is needed. For chronic conditions and those who need hospitalization know treatment p;lan, discharge criteria and ask for follow up services at home, request med teaching from the nurse providing meds before you take them and have personnel explain all procedures take your time signing documents!
One question, how old is your mother? Does she take steroids for anything on a regular basis? I ask because skin tears can happen with elderly people as our skin thins as we age and medications like prednisone can also thin the skin and make it prone to injury. I’ve seen the elderly come in after a fall with a huge gash because of their fragile skin that the average person wouldn’t even have more than a bruise from.
As for the meds and poor hygiene, this is where is is important for the patient, or their families, to get involved. Be sure the hospital has the correct information, bring in all meds, review allergies, and question all medications given in the hospital. Hygiene issues are often a lack of staffing, which is too bad and we staff members complain about too. But this is where family can step in and help out, too.
Hmmm… is it possible that Maine’s hospitals are safer than the national average? A better focus on quality care … wouldn’t that explain the difference in errors?
WE control the type of care that we get from Health service facilities. Often i think that patients believe that they have to take what ever type of treatment they get when going through the door because they are in pain or are sick and are in need of relief. Its is so important that we SPEAK UP, if we feel we are being treated improperly, if we are hurt, or if we are not given the right types of medications. We do not ask enough questions, about ourselves or our family members, expecially the elderly. For the price of services the medical profession charges, we should be getting the best possible care. I have found that mentioning a LAWYER when you feel you are being treated badly often changes their attitudes pretty quick.
I’m all for families advocating for their loved ones. If you’re unhappy with the care being provided, however, I’d suggest that mentioning a lawyer is a great way to create hostility — and that’s the last thing you want in someone who’s giving meds or monitoring your family member’s condition. Suggestion: Put family photos at your loved one’s bedside. They are a constant reminder of who else is on the team of people caring for the patient.
So another words, mentioning a Lawyer might get them worse care then they are already getting? Wouldnt that act be considered more criminal than Negligent? Me thinks YES
They need more staff working the floors, which they don’t have. They have a top heavy administration just like most places. St. Joes is much better for caring than EMMC in my opinion. I know a lot of people that work at EMMC and its always the same, they don’t have enough line staff to cover Maine’s growing population.
St. Joe’s staff don’t know the difference between a clear liquid diet and a liquid diet. There definately is a difference.
Is the premises of this article that the state hospitals are not reporting as many errors as some formula thinks it should? Well, I think that people are under reporting the actual number of flying pigs based on my research. Something had better be done about that!
As to the care at Maine hospitals, the three that I have had dealings with over the past year have provided good care and, yes, there was one incident of a medication error that involved a very special medication not available at two in the morning. I can’t find fault with that as the hospital was very upfront about what was happening and how they would deal with it.
Back to counting red convertibles to make sure that the right number shows up!
I did file a complaint with DHHS. DHHS did not care. They sent me a letter back saying they only cover Mainecare, medicade cases. I called them and I asked them if they look into complaints covered by private insurance they said yes.. I told them thats not what your letter says. Then they told me they sent me the wrong letter. I am totally convinced no one at DHHS knows what they are doing.
DHHS……..does more really need to be said ?
Ombudsman would be who you can report to call eastern agency on aging and get the phone number don’t know off hand
Obumacare.
What? What has this got to do with anything. Implementation of AHCA is still two years away.
All hospitals have committee’s after committees, meetings after meetings and on and on. I thought all hospitals had reviews committees regarding this for many years. There is a medical review committee, there are federal and blue cross audits done where they find overcharges that need to be reversed and so on. I cannot believe that in all hospitals that patient procedure reviews are not done and noted. What happens to these charts and comments, may be another story. In addition, its up to the charge nurse to keep her patient notes as well as any treating physician.
Always clearly mark the effected areas with a sharpie before going under the knife.
Remember that Dr. Eric Steele had a column stating for patients not to be afraid of asking questions, especially about sterility in the offices and hospital environment–hand washing with hot, soapy water is important; just using the hand sanitizers, as many healthcare workers have resorted to, is not a good thing.
Respectfully, the Centers for Disease Control sets the standard for hand hygiene. Soap and water must be used in specific situations: when hands are visibly soiled, in advance of sterile procedures, and after treating a patient with c. difficile, for example. Health care workers “resort” to hand sanitizers in other situations because that is what the CDC has told them is in fact “a good thing” and the correct thing to do based on research.
The CDC also reports that we are not controlling or reducing the occurrence of C Diff, and it is in fact getting more prevalent in some settings. Maine Nursing homes had the 2nd highest prevalence of C Diff in the country. Hand sanitizers do not kill C Diff. Hand washing is more effective. C Diff is invisible, just like all microorganisms, so it is not always known who has it. Because of all these things….I believe old fashioned handwashing should be used as much as possible and hand sanitizers only used in a pinch.
I remember when our first daughter was born in the morning after 28 hours of labor. I went home and came back in the afternoon with my parents to visit. Lindsey, my new daughter was in the nursery and while we were looking at her through the glass she threw up and was choking so I banged on the glass and a nurse came over and cleared her out. After visiting my wife some more I came back alone at 9pm and they brought our daughter to us in our room and she was asleep. We tried to wake her but couldn’t wake her up. By now we were getting frantic so I went to the physician/nurses desk and found the head nurse as the only one on duty this time of night. She came back to the room with me and assured us that this was quite common with newborns. So we took her assurances as she was the authority. after going home and going to sleep I was awoken by the phone. It was 1am and Eastern Maine Medical Center was calling and just told me I need to come in now. Well my daughter was gone. After doing an autopsy they said crib death even though they found liquid in her lungs . We were destroyed for a decade even though we finally got a daughter 1/ 1/2 years later and another one 1 year after that. Needless to say I don’t trust “authority figures” anymore. Not Medical,Educational,Political, Corporate,Financial or any of the other exploiting and corrrupted institutions of the elitists… since then I have seen terrible treatment of my mother at the privatly owned “Maine Veterans Home” here in Bangor as well as others. I could go on and on about the drug corporations secretly paying doctors to prescribe chemicals to children that have been explicitly forbiden. Must be the same doctor run oxycontin stores in florida that give everyone what they want for “pain” from all over the US of A. What gives with this??? hey, Susan Collins, Hey, Olympia Snowe. ya right!
Today is National Patient Safety Day. Please remember those who have died or been harmed because of unsafe healthcare, and at the same time honor those health caregivers who give their all to provide safe high quality care every day.
….
Last winter, at one of Maine’s premier medical facilities, I had a “cabbage,” or coronary arterial bypass graft due to calcification in the arteries that supply blood to the heart. I have since gone back to work, full-time, in a physically, cognitively and emotionally demanding profession so you could say all went well with a very positive outcome. But there was an omission in documentation of an issue that my physicians were unaware of. An issue that may or may not have a bearing on my future health as an octogenarian or beyond…
I, too, have experienced a situation that demonstrates the problem of under-reporting. I have never even considered having a lawsuit because that simply wasn’t necessary. My surgeon and the surgical team, all well-educated and well-trained professionals did their customary best during the procedure – and it went exceptionally well, although I did have a couple of nonpreventable issues after the procedure. I experienced a nonhemmorhagic cerebrovascular accident, (CVA = stroke), just hours out from the procedure. I was brought down to radiology and they “spun my head,” or, in other words, I had a CT scan of my head. Fortunately the report did not come back stating “room for rent” nor did it demonstrate evidence of intracranial bleeding, which would have been a drag. Thank goodness it was normal (something my husband disputes but he was in psychiatry so that’s a separate issue).
I was then brought back to my room and, shortly afterwards, had the opportunity to experience a pneumothorax, or “collapsed lung.” Bummer! Couldn’t breathe very well and that, in all seriousness, is not a nice feeling or a good situation. But, after insertion of a chest tube, twice, my lung reinflated and I was again breathing well. During this time, I must express appreciation for the staff assuring adequate pain control during the latter medical issue as having a chest tube inserted is akin to being stabbed by a really focused, masked marauder posing as a doctor – but he did do a really good job as I was again breathing more normally.
So, despite going through these incidents, I healed quite well, thank you very much, and am back to work, continuing to practice in my discipline as a Registered Nurse. Now, the point of all this background information is this: my cardiologist was aware of the pneumothorax as it was documented in the notes. But the neurological excursion was nowhere documented: nor the acute onset and progression of symptoms that necessitated the diagnostic CT scan – nor the resolution of my symptoms. Were there to be any sequelae, such as brief, short term or long term memory loss, cognitive impairment or compromised motor function, any treating physician would not have a clue as to the origin of those issues. Because, as we are taught in school, regardless of our discipline, “if it ain’t documented, it didn’t happen.” And my concern for documentation is the medical need to know what occurred, and when, in order to provide appropriate treatment for the patient and resolve the medical issue. Not for a bottom-feeding, ambulance-chasing shuyster to be able to buy himself a new Cadillac.
When it is the one that you love, 1 error is too many.
In Maine, flowers are planted annually on July 25th (Patient
Safety Day) in a garden dedicated in memory of patients who have died,
and in recognition of patients who have been injured and live with the
lingering emotional and physical effects of preventable healthcare harm.
If you would like to have a flower added in 2012, email:
voice4patients@aol.com. There is no fee. http://www.youtube.com/watch?v=cqBvyQbYbvA.
Everyone makes mistakes. The problem is when a hospital screws up people die.
If people only knew what really goes on. Going in for heart catheterization or a colonoscopy and using unsterilized equipment. This happens all the time. No one really supervises the techs that are paid $10 an hour to make sure all the equipment is clean. Then when the person gets hepatitis the hospital denies they were the cause. This happens all the time.
Sure. I’ve yet to witness a warm and fuzzy feeling for the person whose modus operandus is threats. Hostility impairs relationships and communication in any setting.
This article actually doesn’t have any facts that support it’s headline. The study doesn’t show anything other than Maine doesn’t follow some trends in other parts of the country. It would be just as accurate to say that Maine hospitals are safer than most others in the country. There is only speculation as to the results of this study, no facts.