Hospital Mistakes Not Being Reported

David Mittleman
Attorney
(866) 735-1102 Ext 430
Posted by David MittlemanSeptember 19, 2008 3:26 PM

Hospitals and physicians not only have a duty to provide competent care, but also to notify the patients if they have been harmed by their negligence. Unfortunately, studies have found that hospitals are putting patients at risk by failing to report medical errors that range from drug overdose to leaving objects inside the patient’s body. It is disturbing to know that patients risk harm from at least one preventable medication error for each day they spend in a hospital bed.

26 states have passed laws requiring hospitals to report mistakes, but the problem appears unresolved because medical errors are still out of control. For example, New Jersey’s 2004 law requires that hospitals report serious incidents, based on "never events" - a list of 28 problems that should never happen. It includes surgery on the wrong patient, an infant discharged to the incorrect person, serious injury from incompatible blood transfusions, and death or serious injury due to a medication error. New Jersey’s health department has received only 1,600 reports since reporting began. Experts have expressed concerns about the lack of reporting by hospitals to reflect the real number of major adverse events. So, how many should be reported? Well, according to the Institute for Healthcare Improvement in Cambridge, Mass., a review of 100 patient medical charts reveals 40 instances of harm on average.

Pennsylvania, on the other hand, established the Patient Safety Authority and requires hospitals to report events that result in death or an "unanticipated" harm, and near misses. Regardless of state law, mistakes at the hospitals still go unreported. For example, 2 patients required additional surgery last summer after objects were accidentally left inside their bodies, 3 patients had to be sent back to OR to stop excessive postoperative bleeding, and an elderly woman developed 2 open bedsores for being left on a bedpan for at least 4 ½ hours after recovering from a broken hip surgery. Surprisingly, none of these problems were reported by the hospital. Only 4 hospitals have been cited for noncompliance since the Pennsylvania law went into effect. However, none was fined because the state elected not to impose a $1000-a-day penalty for each failure to report. One reason why hospitals are unwilling to report these mishaps is because the law also requires that patients be informed in writing within a week of such problem. So, it seems like hospitals are more inclined to violate the law by not reporting their mistakes just so they save the trouble of notifying the patients - could this be the hospitals’ way of evading lawsuits at the expense of patients’ well-being?

1 Comment

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michelle kolarich
Posted by michelle kolarich
October 18, 2008 8:45 PM

Hello Sir/Madam,

My husband asked me to obtain some information about bed pressure sores for his dad who is currently hospitalized.

He is in a western pa. hospital, in the intensive care unit.

We went to visit him and in a "3-day span" these are incidents that occurred. Only God knows what else goes on!

My father-in-law was on oxygen for days without a humidifier, and his nose was clogged. When we entered his room, he asked us if we could unclog his nose for him. It was sore to the touch, very dry and it started to bleed. When my husband asked one of the nurses about his nasal condition, the nurse said "oh he needs a humidifier, and my husband asked her if she could install one for him.

In the meanwhile, whilst we were waiting for the installation of same, my husband took his chapstick out of his pocker, and he took a little bit of the gel off, and he applied it to his nose to provide some temporary lubrication. Another nurse saw what he was doing and she said don't use that, he needs somee lubricating gel. She went to her supply room, and she gave him three (3) packets of lubricating gel.

The next day when we visited my father-in-law, he said that his nose was still clogged, and he wanted more gel. My husband asked the nurse for some, and she gave him some tripple strength antibiotic gel. My husband looked at it, and he said that he does not believe that he should put that up his father's nose, he showed it to another nurse, and she said no way, throw it out, you need lubricating gel.

Another day we went to see my father-in-law, and my sister-in-law was already sitting in the room and I heard her shouting saying "you cannot give him that he would choke". A nurse was just about to give him his medication the wrong way, by mouth, instead of his tube.

I went and I wrote on their blackboard, "NO WATER FOR PATIENT. MEDICINE SHOULD BE GIVEN VIA TUBE".

I found that incident very strange because if there was no hosiptal mandate for the nurse to follow, then how would she know to tend to the patient accordingly. Strange!!!

Our main concern is that my father-in-law has bed sores that are getting worse, and he is in excruciating pain, and he has had these bed sores for months now. We were told that they are applying some salve/balm, but it does not seem like he is being rotated, so they are not healing.

What do you suggest we do?

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