Posted on 05/19/2003 5:51:24 AM PDT by GailA
Hospital mistakes killing patients
Usual cause is a string of related mistakes, study says
By CHARLES ORNSTEIN, Los Angeles Times May 19, 2003
LOS ANGELES - Just over a year ago, 16-month-old Delaney Lucille Gonzalez walked with her family into UCLA Medical Center for routine surgery to repair a cleft palate.
Three days later, she was disconnected from life support and died in her mother's arms.
"To bring a healthy child in there for surgery so minor," her mother, Jodi, said recently, clutching a headband she had made for Delaney, "you just don't accept that she's going to die."
The simple explanation is that a breathing tube had been misplaced and had pumped air into the child's stomach rather than her lungs, according to Delaney's medical and autopsy records. Because her body was deprived of oxygen, Delaney's heart stopped. She suffered irreversible brain damage.
The misplaced tube was just the first in a series of errors leading to the child's death, according to California state health inspectors who reviewed the case in response to a complaint from Delaney's mother.
According to their report, the radiology department waited hours before reviewing chest X-rays that would have pinpointed the problem because they were "too busy." In addition, staff members detached and did not replace a carbon-dioxide breathing monitor that they believed to be broken, gave the girl medications that ran counter to doctors' orders and failed to alert supervisors as her condition deteriorated, inspectors said.
"There is absolutely no question that these violations led to the baby's death," said Brenda Klutz, deputy director of licensing and certification at the California Department of Health Services.
Even in the most prestigious hospitals, medical errors sometimes kill patients. According to a landmark report in 1999, 44,000 to 98,000 people die annually in hospitals because of mistakes ranging from performing surgery on the wrong organ to prescribing the wrong type or dosage of medication.
Patients don't usually die from a single mistake. They die from a series of oversights, faulty assumptions and missed opportunities - what some experts refer to as a systemic breakdown.
"One single problem is usually not sufficient. It requires a chain reaction," said Dr. David G. Nichols, a professor of anesthesiology and critical-care medicine and pediatrics at Johns Hopkins University School of Medicine.
(Excerpt) Read more at knoxnews.com ...
How many people does the average Doctor see in a year?
At current HMO requirements, I would guess one every ten minutes, fifty hours per week, for a total of 15,600 per year. Not including the fact that many of these cases are terminal no matter what, that working conditions and resources are restricted, that works out to an error rate of 1 in 91,228. Another way of looking at the number is that the average doctor goes 1/.171 = 5.84 years on average before making a fatal mistake.
Personally, I think I'm doing well if I go 5.84 years in my job without making a mistake! Be glad doctors aren't journalists, who can't seem to go 5.84 column inches without making a fatal mistake. We can't hold medical professionals to a standard that is impossible to keep, punishing them financially when they cannot achieve the impossible. I personally think this type of error rate is fantastic in such a very human, often confusing field.
I am not a doctor, nor do I play one on TV, but I'm glad those who are doctors are persisting in the face of this nonsense. I would have given up long ago. It's already virtually impossible to get an OB in Florida, as insurance rates are $250,000 per year.
The looters and lawyers are at the hospital gates. Paging Dr. Galt, Dr. Jonathon Galt.
"Self-regulating professions"?
Only a State can issue a medical license. Only a State has the legal authority to lay down the requirements for issuing a medical license. Only a State has the legal authority to revoke a medical license.
I am not clear why you describe doctors as a "self-regulating profession".
To claim that a State regulatory board somehow has less than an "equal say" with a doctor's "professional group" is as false as claiming that the American Automobile Association has equal say with the Department of Drivers Licensing in your State.
As Chairman of my hospital's Credentials Committee, the only authority my committee has is to decide whether or not a physician will be allowed to practice medicine in our hospital.
Beyond that, the "bad" physician can set up practice at his own clinic or Surgi-Center and perform brain surgery with plastic forks taken out of the trash bin of a McDonald's restaurant if he so pleases and the only legal thing I can do to stop him is to bring the matter to the attention of the legal authorities of the State of Washington. If the State of Washington decides that brain surgery with ketchup-coated plastic knives is O.K. by them, there is absolutely nothing that I or any other M.D. in the State of Washington can do to revoke that individual's medical license.
If you disagree, could you please cite a single ruling by a State Medical Licensing Board in any State in the Union that has ever been overturned by a medical professional organization.
Can you cite a single medical license that has ever been issued by a medical "professional group"?
Sure you can. It was done in Las Vegas, Nevada.
Yeah, sure, the doctors packed up and moved out of Nevada, Las Vega's trauma hospitals are out of business and a woman in Las Vegas doeas have to drive to Utah to find an obstetrician to deliver her baby but the fact remains that you can do that! < /sarcasm>
No, I'm saying that doctors are fallible human beings and we have to live with unintended consequences of requiring them to be perfect. There is a legal doctrine for this, it's a standard of reasonableness, which is being lost.
i.e.
1) If a state decides that it is going to have doctors pay out millions in the event of a death or disability, that could have, in 20/20 hindsight, been prevented, then it should not be surprised when no one wants to practice medicine there, particularly in high-risk fields.
2) If the legal or medical system tries to reduce risk by creating so many safeguards and backups and high-tech tests to reduce the effective risk to zero, the cost will rise so high that even routine care will become unaffordable.
The net end effect is that no medical care is accessible. Doctors shrug--read Atlas Shrugged. It describes the situation perfectly. Hospitals are required by law to provide costly care to people who cannot pay, at the behest of a goverment who will not cover their costs. The patients will then sue if the outcome is poor. As a result, those who can pay are charged $200 for a Tylenol tablet. But they don't notice because their insurance companies pay on their behalf. They don't notice until their employer moves to Mexico or China because health premiums are approaching 30-50% or salary costs. It's all based on a something-for-nothing looter mentality.
This does not mean that the truly incompetent, the reckless and untalented should not be rooted out and dismissed, they must be. And Doctor's associations have often not all they could to police their own.
We have to accept that we don't, and never will, live in a perfect world.
We should not hold doctors to an unreasonable standard of performance, one that the rest of the working world is not willing, or even able to live up to.
;)
-Jay
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