Special Report: Hospital Safety

Like many people, Anthony Passaro Jr., a 60-year-old retired postal worker from Wantagh, New York, harbors a strong fear of hospitals. His fear just happens to run deeper than most. Stays in the hospital nearly killed both of his parents. In 1993, his mother, Eleanor, barely survived a botched laser surgery for gallstones. The surgeon accidentally nicked her bile duct with the laser, setting off complications that continue to this day.

A few years later, both parents were rushed to the hospital after their car was blindsided as they drove through a busy intersection. Their injuries were minor, but their trouble was just beginning.

As Passaro’s father, Anthony Sr., rested in his hospital bed, a nurse handed him some diabetes pills — pills that were supposed to go to the patient in the next bed. Passaro’s father didn’t have diabetes, and he quickly fell into a coma. He woke up two days later, but he never fully recovered. “From the day he came out of that coma, he was never right again,” Passaro says of his father, who died several years ago.

Hospitals are supposed to be places of recovery and healing. But they can also be dangerous. According to a highly publicized report released in 1999 by the Institute of Medicine, the number of Americans who die every year from medical errors in hospitals may be as high as 98,000. That’s more than twice the number of people who die annually from car accidents. What’s more, a 2005 report from a healthcare quality ratings company put the number of deaths due to medical errors even higher. The organization’s report estimated that each year from 2001 through 2003, more than 241,000 people died due to potentially preventable medical errors. Whichever estimate you choose, the basic message is clear. Whether they’re being treated for a heart attack or a heel spur, patients who set foot in a hospital should know how to protect themselves.

Dangerous medicine

As the Passaros know all too well, the biggest threat often comes in little pills. The Institute of Medicine says that studies show between 400,000 and 800,000 drug-related injuries occur every year, and that these are very likely understimates. And as a study published in the Archives of Internal Medicine shows, medication mistakes are an ongoing problem. Researchers discovered a 19 percent error rate when they checked on the drugs given out at 36 hospitals and skilled nursing facilities in Colorado and Georgia, the study reported. Many patients received drugs at the wrong time or at the wrong dosages. Others were given the wrong medication or missed their doses completely.

With so many medications flowing through the average hospital ward, some mistakes are inevitable, says Mark Graber, chief of medicine at the Veterans Administration (VA) Hospital in Northport, New York. “Medical care is extremely complex, and giving medications is the most complex thing we do,” he says. The average patient at the VA hospital takes nine different medications, he says, and the doses and schedules are constantly changing.

Some hospitals are working to take the errors out of prescriptions. Accreditation guidelines for hospitals now mandate patient safety programs include a list of look-alike or sound-alike drugs, as well as a “do not use” list of abbreviations and dose designations for health care providers. VA hospitals are helping to lead the way by having patients wear bracelets with bar codes that match up with bar codes on their medications. Some other hospitals use computer programs to eliminate the potential for mix-ups in the pharmacy. Prescriptions are entered in the computer directly instead of being handwritten. At the VA Medical Center in Topeka, Kansas, medical prescription errors dropped 86 percent between 1993 and 2001 after the hospital implemented a bar code system.

But the majority of hospitals have no such computerized systems in place, and despite the obvious advantages of bar codes and computers, many hospitals still take the old-fashioned approach: The doctor writes the prescription, the pharmacist reads the handwriting (or tries to), and the patient takes the medicine. No alarms go off if the patient gets the wrong drug or the wrong dose. Each prescription requires perfect communication — which sometimes fails to occur — between the doctors, pharmacists, and nurses. In 2004, the US Food and Drug Administration announced a new rule requiring that most prescription drugs and some over-the-counter drugs be labeled with bar codes that clearly identify the medication. The FDA estimates that the rule will help prevent nearly 500,000 adverse events and transfusion errors, while saving $93 billion in health costs over 20 years. The FDA also wants to improve the reporting procedures for safety problems so that issues affecting public health don’t get lost amid the paperwork.

Right now, vigilance is a patient’s best defense. “Every patient should know exactly what medications they are on,” Graber says. If a new medication shows up, if one disappears, or if there’s a sudden change in dosages, the patient needs to ask questions. “You just have to be as alert as you can,” he says. “Unfortunately, a lot of people in the hospital aren’t in the best position to be alert.”

Lost in translation

Vigilance is still more difficult if a patient does not speak English and deals only with English-speaking doctors and nurses. Almost half of the patients who need professional medical interpreters don’t get them, according to a report published by the Agency for Healthcare Research and Quality. Making matters worse, ad hoc interpreters, such as family members, friends, untrained staff, or strangers at the hospital, are likely to misinterpret medical instructions, not tell patients about medication side effects, and omit questions asked by doctors.

Even when medical interpreters are present, they may contribute to diagnostic errors and sometimes botch medical instructions, according to a study reported in the journal Pediatrics. The researchers found that “errors in medical interpretation are common” and that professional hospital interpreters left out key phrases and misinterpreted diagnoses when translating between patients and doctors. On average, there were 31 medical interpretation errors for each hospital visit studied, some of them serious enough to affect the patient’s health, according to the Pediatrics article. In one case, because of a hospital interpreter’s poor translation, a patient was instructed to apply an anti-itch cream over his entire body, not just to a rash on his face. Another interpreter completely omitted questions about drug allergies.

The lesson is that anyone with a less than perfect command of English should, if possible, request care by a doctor or a nurse who shares their native tongue. While asking for the help of a professional medical interpreter may be a second-best option, patients should always be their own best advocate and ask as many questions as is necessary to help them understand their own treatment.

Strength in numbers

One basic problem with hospitals: The people with the most to lose are often dazed with medications or fighting for survival. For this reason, friends and family members can be invaluable allies. In addition to checking and rechecking medications, they can ask and answer questions, serve as go-betweens for nurses and doctors, and provide much-needed moral support. Most of all, they can lend a voice for patients who aren’t being heard. “Even if you’re just going in to have your toe operated on, don’t go in alone,” says Deborah Hunter,* a systems analyst in Washington, DC.

Hunter speaks from painful experience. She was on her own when she had her hip replaced at a major orthopedic hospital. Shortly after the operation, she slipped while trying to get to the bathroom. A medical technician managed to catch her before she hit the ground, but the damage had been done. Her new hip had dislocated, and the steel socket was cutting into her muscle.

The pain was excruciating, and Hunter let everyone she came into contact with at the hospital know it. But nobody took her seriously, even as the metal dug deeper into her flesh. The surgeon who had performed the operation was out of the state trying to start a new practice, and Hunter ended up being evaluated by a doctor of osteopathy who specialized in head trauma. Without thoroughly examining the joint or even taking a single x-ray, the doctor told Hunter she was simply “hypersensitive” to pain. Hunter needed surgery, but all she got was Demerol and a lesson in self-hypnosis.

In retrospect, Hunter wishes she hadn’t tried to go it alone. “I really needed to have somebody who could tell everyone that I wasn’t a big complainer,” she says. If a relative had been there to demand x-rays and generally cause a ruckus, she probably would have received immediate treatment, she says.
The lesson stuck. When Hunter did eventually have another surgery on her hip — this time by another surgeon — she surrounded herself with friends serving as her advocates.

Hunter also learned to do a little homework. “I went to my [first] surgeon sight unseen because he was well-known,” she says. “I never asked about the aftercare. You can have the best surgeon in the world, but if he doesn’t make aftercare a priority, you can be as damaged as I was.”

Despite precautionary measures, even the best of surgical teams can make mistakes. One study on medical mistakes found that operating teams sometimes leave sponges, clamps, or other tools inside patients, and often fail to count the equipment before and after surgery. These mistakes happen in up to 1 of every 1,000 patients who get abdominal surgery every year, according to the study in the New England Journal of Medicine.

To stem these sorts of mistakes, hospital safety standards set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals to describe to patients how they plan to prevent surgical errors like these from happening.

Sleuthing for safety

After nearly losing his mother during her routine gallbladder surgery, Anthony Passaro became a believer in pre-operation detective work. He found out after the fact that the original surgeon was relatively inexperienced. When it came time to repair the damage, he looked around until he found a top-notch surgeon who really knew his way around the gallbladder.

In this age of the Internet, many patients check to see if their doctor has faced any malpractice suits. Although a long list of lawsuits should set off alarm bells, malpractice suits are not, as a rule, the best gauge of a doctor’s abilities or commitment to safety, Graber says. Most medical errors don’t lead to lawsuits. Passaro, for one, declined to press charges against the nurse whose error sent his father into a coma. And, in many cases, people press charges for mistakes that were beyond a doctor’s control, he says.

Choosing the right hospital can be just as tricky, he says. There’s no easy way for patients to know how many errors occur in a given hospital — and even if figures became available, they could be deceiving, Graber notes. “Most people assume that hospitals that report a lot of errors are more dangerous than hospitals that report relatively few, but that’s not necessarily true,” he says. “You want to go to a hospital with an active interest in errors,” one that is doing something about them.

These days, most hospitals are starting to take safety seriously. In a sense, they have no choice. Since January 2003, hospitals havent been able to earn accreditation from the Joint Commission on Accreditation of Healthcare Organizations unless they have rigorous safety programs. Among other things, the JCAHO requires that hospitals tell patients about errors that occur, that all patients be positively identified before receiving medications, and that all patients should be encouraged to be actively involved in their own care. Since, in rare cases, surgeons have been known to amputate the wrong limb or remove the wrong kidney, the commission also requires that all surgical sites be clearly marked on the patient ahead of time. If you’re a patient about to undergo a major operation, make sure the area of your body designated for surgery is marked beforehand.

There are many other steps patients can take to protect themselves from errors. Patients should find out what to expect before undergoing surgery. This includes asking who will be performing the surgery and how many of these operations the surgeon has performed in advance. Feel free to voice your concerns and to seek a second opinion if necessary.

The National Patient Safety Foundation also suggests that you ask health workers to check your identification bracelet or armband that lists your allergies to medications before dispensing drugs, taking tests, or putting anything in an intravenous tube. And even if you’ve already given one to your doctor, make a list of all the medications you’re taking as well as your drug allergies and bring it to the surgeons, anesthesiologists, and nurses who’ll be participating in the surgery.

Patients can also make sure they’re protected after surgery. Infections can spread when health workers don’t wash their hands after handling dressings and intravenous tubes. The National Patient Safety Foundation advises you not to feel shy about asking a health worker or doctor to wash his or her hands before touching you.

In the best-case scenario, safety will be on the mind of every person who enters a hospital room: doctors, nurses, medical technicians, the relative sitting by the bedside, and, most of all, the person lying in bed. Entering a hospital without thinking about safety is like crossing a street without looking both ways. As Passaro and his parents found out, it’s all too easy to get blindsided.

*This name has been changed.


Interview with Anthony Passaro Jr., retired postal worker.

Interview with Mark Graber, MD, chief of medicine at the Veteran’s Administration Hospital in Northport, New York.

HealthGrades Quality Study: Second Annual Patient Safety in American Hospitals Report, May 2005, HealthGrades.

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The Institute of Medicine. To err is human: building a better health system. November 1999.

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Agency for Healthcare Research and Quality. Patient Fact Sheet: 20 tips to help prevent medical errors.

Flores, Glenn MD et al. Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters. Pediatrics, Vol. 111 No. 1. January 2003, pp. 6-14

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Retained Surgical Instrument. Dembitzer, A. et al. New England Journal of Medicine. Vol. 348 January 16, 2003 No. 3

FDA. FDA Rule Requires Bar Codes on Drugs and Blood to Help Reduce Errors.

Institute of Medicine. Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually; Report Offers Comprehensive Strategies for reducing Drug-Related Mistakes. July 2006.

Journal of the American Medical Association. Bar Codes Mandated for Hospital Meds. 291 (14): 1685-1686. April 2004.

New England Journal of Medicine. Gawande AA et al. Risk Factors for Retained Instruments and Sponges after Surgery. Volume 348:229-235. Number 3. January 2003.

Agency for Healthcare Research and Quality. Morbidity and Mortality Rounds on the Web: Language Barrier. April 2006.

The Joint Commission on Accreditation of Healthcare Organizations. 2009 National Patient Safety Goals.

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