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April 8, 2008, 11:45 am
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By JoNel Aleccia

High-profile medical errors such as operating on the wrong body part or receiving a mistaken dose of drugs should take a back seat to a far more common and insidious mistake, a new report reveals.

For the fifth straight year, an analysis of errors in the nation’s hospitals found that the most reported patient safety risk is a little-known but always-fatal problem called “failure to rescue.”

The term refers to cases where caregivers fail to notice or respond when a patient is dying of preventable complications in a hospital.

Between 2004 and 2006, failure to rescue claimed more than 188,000 lives, amounting to about 128 deaths for every 1,000 patients at risk of complications, according to the latest report from HealthGrades, a health care ratings organization.

That’s far more than any other measure found in the new study, which detected 1.12 million safety problems during nearly 41 million hospital stays logged by the country’s Medicare recipients. The mistakes, tracked in 16 areas, accounted for more than 238,000 preventable deaths over three years and an estimated $8.8 billion in unnecessary medical costs, the report showed.

The numbers included 6-year-old Christian Padilla of Fort Wayne, Ind., who sailed through a successful heart surgery to correct a birth defect in 2005, only to die days later from the preventable complications that characterize a failure to rescue case.

“The nurse didn’t recognize his symptoms as something of concern,” said the boy’s father, Jim Padilla, 38, an assistant professor at a local university. “She described him in her medical notes as ‘acting fidgety.’”

In reality, the child was unconscious and suffering seizures as a result of the brain swelling that killed him, said Padilla, who received a $1.25 million combined settlement from the Indiana Patient’s Compensation Fund and Riley Children’s Hospital, according to the Indiana Department of Insurance.

It's not clear whether a drug reaction or another problem caused the swelling, said Padilla, who was at his son's side, frantic, throughout the ordeal.

"We got to the point where I had asked multiple times: 'Should he be sleeping so long?'" he said. "Over and over, I was told this was normal.'"

The nurse’s failure to notice Christian’s subtle but increasing symptoms of distress is a key element of this measure of how well hospitals respond to unexpected complications — or don’t, said Dr. Samantha Collier, chief medical officer for HealthGrades.

“As an example, somebody comes in for an elective surgery like a knee replacement and turns up with vague symptoms, like shortness of breath, and the next thing you know, somebody dies,” explained Collier. “It’s obvious that if you go in for a knee surgery, you shouldn’t die.”

When simple procedures go wrong

Failure to rescue is a marker that should concern anyone who’s ever been a patient in a hospital. It predicts whether even simple procedures suddenly could go wrong, said Dr. Michael DeVita, a professor of critical care medicine at the University of Pittsburgh School of Medicine.

“It’s before Code Blue,” he said, referring to the common term for patients in acute distress. “Somewhere between two-thirds and fourth-fifths of Code Blue incidents are preceded by this.”

Every year, at least 61,000 people die from failure to rescue mistakes, the report showed. The deaths have decreased by more than 11 percent since 2004, a bright spot in a study where about half of the patient safety indicators improved, but the rest didn’t. Four important post-operative indicators got worse: respiratory failure, pulmonary embolism or deep vein thrombosis, sepsis and abdominal wounds that split open after surgery.

Overall, the rate of patient safety problems has remained steady at about 3 percent of Medicare hospitalizations, the report indicated. The percent of patients who died after enduring one or more mistakes dropped by nearly 5 percent, to about 26 percent.

Although HealthGrades has been measuring failure to rescue since 2002, when it counted some 200,000 cases during a three-year reporting period, the agency has changed how it analyzes data from the federal Agency for Healthcare Research and Quality, Collier said.

Critics charged that the agency was including patients who might have been predisposed to complications, artificially inflating the results, but Collier said those patients have been excluded from the new analysis.

Still, even 11 percent improvement isn’t nearly enough in a condition that should be preventable, said Sean Clarke, associate director for the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia.

“Failure to rescue is not whether you get the wrong IV in the first place,” said Clarke. “It’s how fast do people pick up that you’re going south and turn it around?”

Too often, overworked, overwhelmed and inexperienced nurses and other hospital workers fail to notice basic problems, or to accurately interpret their meanings, said Clarke.

Surgery, painkillers raise risk

The two trickiest situations involve patients who’ve just come from surgery, or those who are taking medications for pain, Clarke said. In each case, subtle reactions can escalate from mild concern to near catastrophe within a matter of hours.

“It’s the basics. It’s about breathing, it’s about circulation, it’s about bleeding. Breathing issues are a huge, huge, huge deal,” he said.

The situation is hardly new. The term “failure to rescue” was first coined in the early 1990s by Dr. Jeffrey H. Silber, director of the Center for Health Outcomes and Policy Research. He was looking for a way to characterize the matrix of institutional and individual errors that contribute to patient deaths.

Source: http://www.msnbc.msn.com/id/24002334/

It is never good to leave someone in the hospital alone no matter how minor the surgery or procedure. If you have someone there, they might not know what’s wrong, but it is a constant eye of supervision.

I'll make this pretty fast...In 2005, I suffered a major stroke in my hotel room after a wedding. Fortunately, I was able to be coherent enough to call my brother, who summoned an ambulance.

I was left in a hallway on a gurney for hours, as they were busy. I reportedly fell off of the gurney twice (I was out of it). When I talked to attorneys later about negligence, they said that as of the year before, a law change stated that any negligence claims had to be deemed malicious to have merit, which is hard to prove. That was that.

The law change was obviously enacted to protect ER physicians, hospitals, and their staffs. Granted, they work in a chaotic and stressful environment; they seem to, however, take advantage of the fact that they now have

(cont.) a lot of freedom to neglect patients until treatment is convenient. Perhaps a few nursing students or volunteers could be retained in ERs to monitor waiting patients. This way, experience is gained, cost is minimal, and, above all, care is improved. Mistakes will still be made, but negligence is more unlikely.

I believe they see so many severe cases they become complacent and lose touch of the severity of each case. I made this post because last week I lost my cousin to diabetes, and the circumstances were very unusual. I hate to say this, but some of the people are just there pulling a paycheck.

I agree with you brother. I hate to say this but doctors are busy and if you don't have someone watching after you or taking notes you could very well lose your life.

I have seen this happen twice with my own eyes:

1.) My grandfather - He had lymphoma and was actively going through Chemotherapy and because no one paid attention to him, he developed a minor infection and died.

2.) My mother-in-law almost died because she is diabetic and her blood sugar was really low and the doctors were taking really long time accessing her situation and if my father-in-law hadn't been there she would have probably died because they forgot to give her food and a drink.

3.) Before my cousin died she almost overdosed because the hospital she was in at the time gave her double the amount of medication they gave her. She actually flat-lined and they had to bring her back.

Something must be wrong with our system because all of these incidents happened within my family and in the last 5 years.

I believe doctors should be on a pay-per-performance where the doctor gets bonuses from our government for getting a patient better; very similar the Canada's Healthcare system.

I agree, something has to be done!

I have found that emergency rooms are too dangerous to go to. The last Emergency room I was in was under the thumb of a head nurse who spent more time shoutintg bloody murder, complaining that she was overworked than she did tending to any patients. She even complained that two of the patients there were screamers.

My sister was one of the screamers and the nurse did nothing to help her pain. We later found out that a cancerous tumor had eaten its way through her intestine and had created a pool of infection in her abdomen. The other screamer was a woman with an infected gall bladder after her surgery. This nurse didn't even try to stop the pain they were on, all she did was to stop everyone who came into the room and screamed that she was overworked. I didn't see her help anyone all the hours I was there holding onto my sister's hand praying she would survive.

It was a nightmare.