Health | Local | Vital Signs

Local Hospitals Trying To Reduce Medical Mistakes

OPB | March 4, 2012 10:39 p.m. | Updated: June 7, 2013 10:25 a.m. | Portland, OR

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As part of the health care overhaul, the federal government is trying to reduce the number of medical mistakes made by hospitals.

The Centers for Disease Control and Prevention estimates that out of every 20 people who are hospitalized, one will suffer as a result of a medical mistake. They could get the wrong drugs, or contract an infection, or experience a fall.

The hope is to reduce mistakes by 40 percent, saving some 60,000 lives over a period of three years.

Kristian Foden-Vencil visited The Kaiser Permanente Sunnyside Medical Center to see what their staff is doing.

 

Nurse Amanda Sutliff stands outside a cubicle in the ICU. Inside a man is recovering from open-heart surgery. Standing in a circle around Sutliff are 21 medical experts including the surgeon, the social worker, the pharmacist, the nurse practitioner and the care coordinator. They want to know the patient’s glucose level, how much he’s eaten, and whether he’s been to the bathroom.

Kaiser workers meet to help avoid mistakes.

 

Nurse Sutliff wants to know why he still has what’s called a “Foley catheter” in his bladder three days after the surgery.

Afterwards, Chief Medical Officer Doctor Kathy Crispell, explains the nurse was making sure it wasn’t left in by mistake.

Crispell said, “Any tube or line, anything that is in the body, is a potential site of infection. And so to help reduce hospital acquired infection you need to get those things out as soon as possible. The usual practice is to try and get that catheter out the day after surgery. He’s had some unique problems, not necessarily related to the surgery that requires him to have the catheter stay in. So that was part of that discussion and you heard the nurse Amanda ask the question, why do we need to keep the Foley in.”

Kristian Foden-Vencil: “In the old days, would that have been presumptuous for a nurse to say, hey Doc. why are we doing this?”

Kathy Crispell: “Yes although this type of practice has been going on for a long time.”

Central lines are another potential site of infection. A central line is the plastic tube a patient has running into his or her chest — so blood can be drawn and medication administered. Doctors didn’t use to dress up in all their scrubs to insert the line. But now most hospitals have adopted the best practice of complete scrubs on the doctor and patient.

Crispell said, “There wasn’t a single unified standardized way of putting in these lines. And what we’ve learned is that if we standardize this whole process, so that everyone follows these ‘x’ number of steps, that we get better outcomes. In matter of fact great outcomes, because we haven’t had any line infection in our medical intensive care unit since we started this project.”

That was two years ago.

Scattered around the hospital are a number of other reminders about ways to reduce mistakes. There are signs outside the rooms of particularly shaky patients warning about falls.

How big are the problems associated with medical mistakes? The CDC estimates that 100,000 people die from medical mistakes every year. And reducing those mistakes by 40 percent could save 60,000 lives over a three-year period that ends in 2013.

Diane Waldo said, “It’s a big hairy audacious goal!”

Waldo is the director of quality for the Oregon Association of Hospitals and Health Systems. She says the feds will come up with a list of best practices — like having all doctors dress up in full sterile garb when they put in a central line.

Waldo says there are lots of ideas out there for the feds to choose from. Take this idea, for making sure nurses give the right medication to the right patient.

Waldo explained, “One hospital even put, like a red vest on the medication nurse as she went around. So everyone knew, don’t interupt Diane because she’s giving medications. So don’t ask her about 16 other things.”

Hospitals are even putting up white boards in each patient’s room — so their medical issues are in plain sight and there don’t have to be innumerable conversations as shifts change.

Waldo said “So it would include things like diet, activity, last pain medications, IV fluids. Things that you would need to know right away when you walk into that room. Is that patient on fall precautions? Am I safe to get this patient up by myself? Or should I be using a walker with them or calling for help or whatever.”

Some hospitals also encourage nurses and doctors to have conversations in front of their patients, so a patient can speak up if he or she notices a mistake.

For some people, this is a change that has taken too long.

Kaiser workers

Dee Dee Vallier sits on Oregon’s Health Care Acquired Infection Advisory Committee. It’s a statutorily mandated committee that helps oversee a program for reporting infections acquired because of mistakes in hospitals. Eleven years ago, her husband fell off the roof while cleaning the gutters. He broke his leg. But while in hospital she says he acquired infections in his blood and spine that left him disabled.

She explained, “Every time I asked somebody, “How did he get these infections, what happened?” And at the time, nobody would talk about it.”

After her experience, she says she read about the very basic ways patients can acquire such infections: like doctors or nurses not washing their hands thoroughly; or medical equipment not being left in too long. The CDC says those are some of the most common ways that hospital staff can spread infections to patients, even if the patients had no sign of infection when they arrived.

Vallier thinks hospitals haven’t worked as hard as say banks to get rid of human errors, because they don’t have the financial incentives to do so.

She said, “The hospitals that are doing good are essentially penalized because they aren’t making money off of treating these infections. But the hospitals that are bad are actually getting rewarded for it.”

But now, the Obama Administration’s health care overhaul is trying to change those financial incentives. Under the new health care law, hospitals that have to re-admit patients may not be compensated for the follow-up care.

The administration has also created what it calls a “Partnership for Patients.” That’s scheduled to have a list of best practices for hospitals by the end of next year.


This story is part of a project on health care in the states, a partnership of OPB, NPR and Kaiser Health News.

Kaiser Health News is a nonprofit news service covering health policy and politics. It is an editorially-independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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