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The CMG Voice

Medication errors are common after discharge from hospitals

Posted Monday, August 4, 2014 by Tyler Goldberg-Hoss

A new US study highlights how prevalent errors are when patients are discharged from the hospital with instructions to take medications.

Read the full article here:

Medication errors may be common after hospital discharge

The study focused on patients who had been hospitalized for heart related conditions. It found that 20-30% of post-hospitalization prescriptions are never filled, and half are not continued as prescribed.

The study tied errors to a patient’s “health literacy,” defined as a patient’s ability to interpret and act on health information. Patients with a high health literacy were less likely to commit a prescription error, but the percentage difference was surprisingly low: those patients with the highest health literacy scores were only 16% less likely to make an error compared with patients who scored the lowest.

Interestingly, two better predictors for success were gender and relationship status. Women were 40% less likely than men to make a mistake, and single people were almost 70% more likely to make a mistake than married patients.

Patients and health care providers can share responsibility for medication errors. Potential medical malpractice claims can arise when a health care provider, particularly a physician or a nurse, doesn’t act in a reasonably prudent manner in instructing a patient regarding his or her medications, or failing to prescribe necessary medications, and injuries occur.

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Hospitals Feeling the Squeeze on Discharging Patients Too Quickly

Posted Friday, August 1, 2014 by Gene Moen

For years, there has been health insurance pressure on hospitals to more quickly discharge patients once it is felt that intense hospital-based care is no longer needed. We all hear patients and their families complain that patients are being pushed out of hospitals, either to return home or into nursing home or rehab facilities, before they are ready to cope with the aftermath of their illness. But the financial incentives are strong to discharge, and hospitals responded accordingly.

Now there is counter-pressure. A recent article in the Puget Sound Business Journal points out that a provision of the Affordable Care Act penalizes hospitals whose rates of “return” patients are considered too high. The article, titled “Hospitals get help so patients can escape the revolving door of readmissions,” is in the July 28, 2014 issue of the publication. This doesn’t necessarily mean that patients will be kept in the hospital longer, but it does mean that a discharge must take into account the outpatient care that is required to avoid a re-admission of the patient. Part of that may mean an additional day or two in the hospital as a plan is developed with the patient and family for outpatient care after discharge.

The problem of emergency room re-admissions was recently dealt with in a book, Bouncebacks!, by two ER physicians. The book chronicles stories of patients who were admitted to the ER, did not receive adequate diagnosis or care and were later re-admitted with a much more serious condition.

The authors point out that there is always financial pressure on ER personnel to quickly process and discharge patients, but the problem of re-admissions may mean much more in health care costs, both to the individual and to society. There is no question that monetary concerns are now a major driver of health-care decisions, and finding the right balance may be hard to attain. But the pendulum now seems to be moving toward the need for a more careful diagnosis and care plan, even if it means a slightly longer hospital stay, in part to avoid the costs of having patients become sicker and being re-admitted to the hospital.

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“Transparent Accountability” Needed to Prevent Hospital Deaths from Medical Mistakes

Posted Monday, July 28, 2014 by Gene Moen

In 1984, the National Institute of Medicine reported that an estimated 98,000 people died in U.S. hospitals each year as a result of preventable medical errors. That figure shocked many people, but a more current study has now estimated that a more accurate figure would be that 400,000 people die from hospital-based medical errors. The study was published in the Journal of Patient Safety and relied upon four other studies that estimated patient deaths in hospitals.

The author of the study concluded that curtailing this epidemic of patient harm would require, among other things, “transparent accountability for harm” and concerted efforts to correct the root causes of harm. He also pointed out that it doesn’t really matter whether “only” 98,000 people die each year as opposed to 400,000. Even the lowest figure is the equivalent of a jumbo jet crashing every day of the year and killing all on board.

Even one such crash results in a massive effort by the airline industry and the government to determine the cause of the crash and to ensure that actions are taken to prevent another such crash. Yet the medical industry — and the government – tolerates an incredible death toll from medical mistakes in hospitals, and very little is done.

“Transparent accountability” is a laudable goal, but is it realistic to expect that the hospital where an error results in death will tell the family what happened and accept responsibility? Interestingly, other studies have shown that when that occurs – when hospitals accept responsibility – it is much less likely the family will seek legal help to determine why their loved one died.

We all get calls from potential clients who say that after the bad outcome, the providers seemed to disappear or, on occasion, someone from “risk management” appears on the scene and explains how important it is to the hospital to listen to patient complaints so that care can be improved. Follow-up, however, seldom happens and a polite and bland letter is usually the most the family will receive. Often the major motivation for a potential client calling a malpractice attorney is to make sure the same thing doesn’t happen to some other patient.

Medical malpractice claims may be a crude and certainly imperfect means of holding a hospital accountable for a death from medical error, but it may be the only effective way to do that. Hospitals don’t like lawsuits, and insurance companies don’t like paying money for someone’s mistakes, so the cumulative effect – hopefully – is to ensure that someone is actually trying to avoid those events.

Malpractice attorneys all know of cases where very specific corrective steps were taken as a result of a lawsuit being brought, and there are probably many others where changes are made that we never learn about. Achieving accountability for medical malpractice is the goal, but that process may also involve needed changes to prevent yet more deaths.

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Aging Surgeons and Malpractice

Posted Wednesday, July 23, 2014 by Tyler Goldberg-Hoss

Recently a surgeon friend of mine contacted me. He was calling because a colleague of his was worried about something he heard at a seminar focused on surgical liability: that surgeons are easier to sue once they turn 70 years old.

My friend was concerned enough for his friend that he called and asked for my opinion. I tried to think of the issue with common sense, and I concluded that no such hard and fast rule made any sense. There are likely many excellent surgeons who are past 70. It seemed to me that if the surgeon came across to a jury as competent and able, it would only backfire on me and my client to imply or assert that the surgeon was negligent just because he was older than some magical age.

Interestingly, a recent article came across my desk that considers this very issue. It will be printed in the August 2014 edition of Annals of Surgery and is titled “The Aging Surgeon.” It’s available here (for a fee):

The Aging Surgeon

The article takes what I believe to be a balanced look at the issues surrounding aging surgeons. It is still a potential patient safety problem, as there are now approximately 20,000 surgeons over the age of 70 actively practicing in the United States. The article cites studies that show increased incidence of complications relative to age, including in coronary artery bypass grafts, laparoscopic procedures, and other surgeries. Anecdotally, one surgeon was found to have fallen asleep during a complex procedure.

Addressing the problem is difficult, as these people are esteemed members of their surgical communities, often training those surgeons who are now acting as their chiefs. Mandatory retirement, the article concludes, is not the answer, since that would prevent otherwise very competent surgeons from continuing to practice.

The article advocates for The Aging Surgeon Program as a method by which the surgical community can police itself. It is a two-day comprehensive evaluation of a surgeon’s physical and cognitive abilities. Its goal is to strike a balance, between patient safety and liability risk on one hand, and the dignity of the surgeon and his benefit to his surgical community.

While I’m unsure exactly what solution is best, I am glad to see surgeons balancing their own interests with those of their patients.

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University of Washington Medical Center Ranked 11th Among U.S. Hospitals

Posted Monday, July 21, 2014 by Gene Moen

In a recent report by U.S. News and World Report, the U.W. Medical Center was ranked 11th overall among all U.S. hospitals. In certain areas, its ranking was even higher: 4th in rehabilitation medicine, 6th in oncology, and 10th in diabetes. Nationally, the highest ranking hospitals were Mayo Clinic in Minnesota, Johns Hopkins, Massachusetts General, and UCLA.

The report, just released, ranked nearly 5,000 hospitals in 16 adult specialty categories using surveys from more than 9,500 physicians. Hospitals that are consistently featured high up on the list are seen as some of the best in the nation.

The rankings were based on physician surveys of hospital quality, and those views may be based on research and scholarly publications as much as on direct patient care. What happens to a patient while in the hospital may have little relation to the quality of research done by senior faculty members. Indeed, much of the care in a teaching hospital is done by residents and by nurses, although faculty members may supervise that care. Residents are graduates of medical schools and are doctors, but they are doing specialized training at a teaching hospital such as the U.W.

In our experience, most of the medical malpractice cases we handle against the U.W. or Harborview involve poor decisions by first year residents, nurses, or technicians. Another common area of liability has to do with systems errors, such as failure to have procedures for follow-up of adverse tests or imaging results. As with any large medical institution, patient decisions can be less than optimal when there are numerous providers involved in a particular patient’s care. In teaching hospitals, there are often numerous residents involved, many of them making recommendations or issuing orders. The more “hand-offs” of care between providers, the more room for mistakes to occur.

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