Health Care Harm
Health care mistakes are the 3rd leading cause of death in the United States. A landmark 1999 report by the Institute of Medicine showed that 100,000 deaths occur in the US each year as a result of health care harm. A 2007 CDC Control report said that an additional 99,000 people die annually from hospital-acquired infections.
There have been more than 80 reported deaths in the United States linked to the use of contaminated Heparin (produced by Baxter International). Most of the deaths occurred among patients that were administrated with a contaminated batch of Baxter Heparin supplied by a Chinese facility. The contaminated Heparin caused a severe allergic reaction that led to many deaths. In February 2008, Baxter International recalled their entire Heparin supply.
In April of 2008 I traveled to Seattle, Washington to see renowned Thoracic and Esophageal surgeon, Dr. Ralph Aye. He performed the Hill Posterior Gastropexy on me, which is a surgery to correct severe acid reflux. It is not the more common surgery called a Nissen Fundoplication done by most general surgeons. The Hill requires a more skilled surgeon and is done laparoscopically. I spent only 24 hours in the hospital and had few if any side effects during the 6 week recovery. During the night of my 24 hour stay, the nurse came in three times to give me a shot of Heparin. Because my husband and I were well aware of the dangers of Baxter Heparin, we made sure that was not what the nurse was administering. Let me say that Swedish Medical Center was the finest facility I have ever been in and the care was top rate. I’ve been well ever since, thanks to Dr. Aye’s surgical skill. Sadly this is not the case in all healthcare facilities.
On the afternoon of November 17, 2007 actor Dennis Quaid and his wife noticed a sore on their twin son’s umbilical cord. Their daughter had a similar irritation on one of her fingers. The couple’s pediatrician sent them to Cedars-Sinai. (Remember I wrote about Cedars-Sinai and CT scans in Part 8 of this series.) Both children, only 12 days old, were diagnosed with staph. The parents would not leave their children’s sides. They even watched the next morning as a nurse dispensed a substance into their IVs. She explained that it was Hep-Lock, routinely used to prevent blood clots at IV sites. Without knowing it the new parents had just witnessed the first of two massive overdoses of heparin, another being given several hours later when the IV bags were changed. Finally that night the exhausted parents went home to rest. At 6 a.m. the next morning when they returned to Cedars-Sinai, they learned of the overdose. They rushed to their children and were intercepted by representatives from the risk-management division of Cedars-Sinai. The hospital was of course worried about liability rather than the health and welfare of the children. It outraged Quaid and his wife.
When they later looked into the frequency of medical errors, they learned that U.S. hospitals (and probably around the world) are not required to publically report errors, and that caregivers often conceal mistakes to avoid malpractice lawsuits.
Cal Sheridan, now 15, was insufficiently treated for jaundice as an infant and now suffers from a plethora of illnesses — cerebral palsy and auditory and vision impairment. Four years after Cal failed to be properly treated, his father, Patrick, was diagnosed with a benign brain tumor; a follow-up pathology report indicating that the tumor was malignant was misfiled and Patrick, late to begin treatment, lost his battle with cancer in 2002. Cal’s mother, Sue Sheridan now heads up two non-profit organizations to address medical errors.
But back to the Quaid children. After launching an investigation in how the overdose to the twins happened, Quaid learned that the nurses had twice mistakenly given each infant a 10,000 unit dose of heparin, used to treat illnesses in adults, instead of the similarly packaged 10 unit dose called Hep-Lock, appropriate for use in IVs for infants. Three infants at Methodist Hospital in Indianapolis had died a year earlier from the exact same overdose. I know Methodist well as my daughter was treated there as a young girl.
Baxter soon changed how it packaged the two dosages. Instead of being identical in size and similar in color, the higher dose would now carry an orange label and warning. However, the company FAILED TO RECALL THE EXISTING BOTTLES! As Quaid said, “Companies recall dog food! Why weren’t they recalled?”
Yes, the Quaids have sued Baxter for negligence and the case is pending. As for Cedars-Sinai, the hospital agreed to make changes to prevent an overdose from occurring again. As part of the settlement with the Quaids, Cedars spent millions on electronic record keeping, bedside bar coding, computerized physician order entry systems. So, the Quaids are happy with this result. I wonder if they know about the 200 patients that received 8 times the normal dosage levels in CT scans at Cedars-Sinai.
The medical system has played a large role in undermining the health of Americans. According to several research studies in the last decade, a total of 225,000 Americans per year have died as a result of their medical treatments:
- 12,000 deaths per year due to unnecessary surgery
- 7000 deaths per year due to medication errors in hospitals
- 20,000 deaths per year due to other errors in hospitals
- 80,000 deaths per year due to infections in hospitals
- 106,000 deaths per year due to negative effects of drugs Thus, America’s healthcare-system-induced deaths are the third leading cause of the death in the U.S., after heart disease and cancer.
Medical mistakes seem to be a leading cause of death because most physicians and dentists are so rushed to see a certain number of patients in a day, that they rarely take time to read a patient’s full chart. The only physician that ever read all 50 some pages of my medical history (I keep my own history on my computer) was Dr. Aye of Swedish Medical Center. It really didn’t used to be like this.
A 15 year old autistic boy, Michael Blankenship, was brought into the dental clinic in a hospital that specialized in treating children. When Michael was discharged the hospital’s chief pediatric dentist made a fatal mistake. She prescribed a Fentanyl “pain patch” because Michael’s mother informed the hospital that her son could not, or would not, ingest oral medication due to his autism. This fact had also been recorded in Michael’s chart years earlier. The pharmacist that filled the script failed to catch the error as well. That evening, Michael’s mother put the patch on her son at bedtime. Michael was found dead the next morning. The Fentanyl patch delivered so much of the narcotic to Michael’s system that it caused respiratory arrest and this caused his death.
The FDA has been warning since 2005 against misuse of the patch system, which was designed for use only by patients who have developed a tolerance for opium-derived painkillers such as morphine. In a recent public health advisory, the agency warned against prescribing the patch in circumstances identical to those that Blankenship found himself in. Michael had never ever been exposed to narcotics. One would think a script for a liquid painkiller would have been much more appropriate for a tooth extraction.
The FDA, according to the statement, “continues to receive reports of death and life-threatening side effects in patients who use the Fentanyl patch.”
“The reports indicate that doctors have inappropriately prescribed the Fentanyl patch to patients for acute pain following surgery, for headaches, occasional or mild pain, and other indications for which a Fentanyl patch should not be prescribed,” the warning’s authors said, according to the FDA Web site.
In Blankenship’s case, he was given a patch designed to release 100 micrograms of the drug per hour — which was the maximum dose available. His dentists, according to the allegations, had not previously prescribed the drug to any of their patients. There are countless stories like this that are simply heartbreaking. One thing I’ve learned before taking any prescribed medication is to check out the side effects and any negative reactions with other medications. As well, we can check the physicians and the hospitals. One of the 20 or so questions I asked Dr. Aye in our phone consult prior to traveling to Seattle was what the infection rate was at Swedish Medical for Staph, MRSA, Clostridium Difficile Colitis, etc. etc. ad nauseum. I was pleased with the answer. You will find however, that in today’s hospitals, the doctors and surgeons will readily tell you to go home as quickly as possible in order to stay well.
There are many reasons for mistakes and for infections from hospitals, nursing homes, clinics, and other health care facilities, but with the advent of the unstoppable Obama care, we all need to be our own best advocates for all facets of our health care.
As for “tort reform,” what is your father, mother, sister, brother, child, husband, or wife worth? The advocates of tort reform want to limit the amount paid out to $250 thousand. As seen in the Quaid case, they could have sued the hospital for millions, but instead chose to have them spend the money to keep it from happening again. If tort reform had been in place, would they have bothered to change anything knowing the limit the Quaid’s could collect was $250,000? Who is tort reform good for? Certainly not the patient that loses their life or has damages that destroy the quality of life.
And one last point, the horrible mistake that happened to the Quaid children leaked out to the media. Hundreds of thousands of people prayed for the 12 day old twins. Dennis Quaid and his wife, Kimberly openly admit that those prayers saved their children. God does answer prayers.