As the problem of alarm fatigue comes under increased scrutiny, Massachusetts General Hospital has implemented steps to improve the medical staff’s response to patient alarms and avoid unnecessary deaths.
Alarm fatigue at hospitals has received much attention in the past year as it has led to several patient deaths and illnesses throughout Massachusetts. Alarm fatigue is a type of medical malpractice caused when nurses and medical staff work among numerous alarms, many false, and grow desensitized to the many sounds and fail to respond to patients.
At Mass. General Hospital, an 89-year-old man died in January 2010 as he recovered from surgery and awaited implantation of a cardiac pacemaker. State and federal investigators reported 10 nurses on duty said they failed to hear alarms beeping at the central nurses’ station. The nurses also said they never saw ticker signs indicating the patient’s dropping heart rate on three hallway signs.
In April, Mass. General Hospital settled a medical malpractice claim made by the patient’s family for $850,000. After an internal investigation, the Boston hospital also implemented several improvements to reduce this form of medical malpractice, including disabling the off switches of 1,100 cardiac monitors, educating nurses about alarms and installing speakers so alarms are heard more clearly. The medical malpractice settlement was reported today by The Boston Globe on Nov. 28, 2011.
Another medical malpractice lawsuit is pending against Mass. General Hospital after a 47-year-old woman died in the hospital in January 2009. The state Department of Public Health found the patient’s cardiac monitor was not setting off alarms.
Other hospitals experiencing problems with alarm fatigue include UMass Memorial Medical Center in Worcester. In September 2011, The Boston Globe reported the hospital had two wrongful deaths over the past four years due to failure to respond to patient alarms. In one case, nurses failed to respond to alarms for almost an hour. The hospital is now taking steps such as holding monthly drills for medical staff and arranging voluntary seminars and webinars for the hospitals 2,100 nurses.
The hospital has also started sending low-battery warnings to nurses’ cell phones and pagers for life-threatening changes in patients.
Hospitals are not alone in addressing the problem. Last month, the Joint Commission, which accredits hospitals, and the U.S. Food and Drug Administration attended a summit in Washington D.C. In future months, they are expected to make recommendations for the medical community.
Preventable hospital infections are claiming some 100,000 lives a year nationwide and threatening patient safety, despite a renewed focus on cleaning up hospitals, the US Department of Health and Human Services’ Agency for Healthcare Research and Quality has found.
A recent report found in-hospital infections warrant “urgent attention,” with rates of post-operative bloodstream infections and catheter-associated urinary tract infections increasing by 8 and 4 percent respectively. Yet there is good news: the Agency found overall health care quality is slowly improving.
The Agency found hospitals have adopted basic standards for hand hygiene, disinfecting patients, sterile handling of equipment and antibiotic use.
The Secretary of Health and Human Services, Kathleen Sebelius, anticipates a new law will improve the rates for hospital-acquired infections and prevent fatalities. Starting in the 2015 fiscal year, hospitals with high rate of infections will face penalties.
Hospital-acquired infections are pervasive and fatal but also extremely preventable. The Committee to Reduce Infection Death (RID) points to several areas where hospitals can improve: First, over half the time, doctors do not disinfect their hands immediately before touching a patient. Also, many hospitals do not screen incoming patients for MRSA, one of the most pervasive in-hospital infections. Finally, surgery patients may not be advised to shower with chlorhexidine soap daily before the operation, although the practice reduces the risk of infection. RID hypothesizes as evidence of the preventable nature of in-hospital infections grows, so will hospital liability.
For information about different types of hospital-acquired infections and methods to reduce infections, see this guide from the World Health Organization.
The state Attorney General is in the preliminary stage of a systematic review of the Massachusetts healthcare system and has already made some startling discoveries about healthcare costs. Martha Coakley’s office found significant cost variations among hospitals and physicians based on factors other than quality of care. Although the investigation is still ongoing, Attorney General Coakley has expressed concern about affordable and accessible healthcare if the identified systematic failures are not addressed and has urged policymakers to implement cost containtment measures.
As part of the investigation, the Attorney General’s office reviewed documents from insurance companies and healthcare providers representing the bulk of the healthcare market in the state to examine healthcare costs and costs drivers. Specifically, the Attorney General examined insurance contract prices between insurance providers and hospitals between 2004 and 2008. The concern is that although Massachusetts has improved access to the healthcare market–97 percent of the population has healthcare coverage–this improvement could be compromised by cost increases. Attorney General Coakley warned if left unchecked, price disparities in the market could create a provider marketplace dominated by expensive “haves” as lower priced “have-nots” are forced to close down or consolidate with higher priced providers.
The initial findings of the investigation showed that:
- In the same geographic area and across similar levels of service, prices paid by insurance carriers to hospitals and physician groups varied, at the extreme in excess of 200%.
- Price variations are not correlated with quality of care, complexity of the illness or population being served, extent of patients on Medicare or Medicaid, or whether the provider is an academic or research facility.
- Price variations are correlated with the relative market position of the hospital or physician group as compared to hospitals within a geographic region or within a group of academic medical centers.
- Price variations on a per-member, per-month basis are not correlated with the method of payment (e.g. globally or fee-for-service).
- Price increases cause most of the healthcare cost increases in the state.
- Contracting practices distort the commercial healthcare market and reinforce disparities in pricing.
- The report noted that health care costs are increasing much faster than wages.
The investigation is expected to be completed by March 16th and the findings will be presented to the Massachusetts Office of Health and Human Services, Division of Healthcare Finance and Policy.
For more information on Massachusetts’ unique approach to healthcare access, see the following website on the state mandate and statute. If you need to obtain health insurance coverage, see the following guide to choosing a health plan.
The Massachusetts Supreme Judicial Court ruled today that a hospital does not owe a third party a duty of care for injuries arising as a result of hospital treatment of a patient. Accordingly, a police officer who suffered personal injuries in a car accident responding to a pedestrian accident scene, cannot recover against the hospital after its patient was killed in the pedestrian accident.
The case was brought by Leavitt, a police officer for the town of Whitman, MA. He received an emergency call to respond to the scene of an accident where a pedestrian had been struck and killed by a car. On his way to the accident, Leavitt’s cruiser was struck, and he was seriously and permanently injured.
It was determined that the pedestrian had been treated earlier that day at the Brockton Hospital, where he had undergone a colonoscopy. As part of the procedure, he had received narcotic medication. He was allowed to leave the hospital without an escort, which was against hospital policy and, plaintiff alleged, good and accepted medical practice.
The court found that the hospital owed no duty of the plaintiff. Specifically, the court ruled that the theories of general negligence, of a special relationship, and of a voluntary assumption of a duty of care were all without merit. The duty of care in a special relationship is extremely limited in Massachusetts, and there is, the court concluded, simply no duty to control a patient who might be impaired by medication.
Going further, the court also concluded that the incident was outside the foreseeable risk of harm associated with the colonoscopy procedure. The court also rejected the application of the rescue doctrine, deciding that the risk would not reasonably be anticipated to arise from the rescue.
Importantly, the court did not disturb its earlier ruling in the case of Coombes v. Florio, 450 Mass. 543 (2006). In that case, the court held that a doctor may be liable for injuries caused to a third person if it is determined that the physician negligently failed to warn the patient of the effects of treatment. The court distinguished Coombes because no failure to warn was alleged in the case against the Brockton Hospital.
The name of the case is Leavitt v. Brockton Hospital, Inc., SJC-10296 (2009).
Two recent surgical errors, followed by serious medical complications, have led to the closing, at least temorarily, of the pediatric heart surgery unit at the Massachusetts General Hospital. In addition, state public health officials are investigating the circumstances of the errors.
The recent complications included a baby who had surgery in January and one who had surgery in March. Both babies survived, but the baby from the January procedure was reported to have neurological complications. There was also one infant death in the last twenty months.
According to news reports, the Boston hospital opened a specialized pediatric cardiac surgery unit two years ago after hiring a pediatric heart surgeon. The goal was to have a unit that specialized in heart surgery on children, but the program apparently never took off. The unit was performing only four or five surgeries per month, far below the rate considered appropriate to keep a service properly experienced.
The internal investigation at Massachusetts General Hospital may also lead to an on-site investigation by the Department of Public Health, which could lead to recommendations for improvements. The investigations should reveal whether the complications resulted from preventable surgical errors or other medical malpractice.
MGH halts a pediatric program, Boston Globe, April 17, 2009
The Massachusetts Department of Public Health has released its first annual report of Serious Reportable Events at Massachusetts acute care hospitals. The report reveals that there were over 300 serious events resulting in personal injury and at least 19 deaths, including serious surgical errors, falls, and medication errors. The report reflects some aspects of the causes of medical malpractice cases in Massachusetts.
Guidelines for reporting serious events were adopted by the Massachusetts Department of Public Health and implemented in 2008. Under the guidlines, Massachusetts hospitals are required to report six general categories of events, including:
- Surgical errors
- Care management problems (medications errors, pressure ulcers)
- Product or device-related complications
- Patient protection problems (suicide protection)
- Environmental problems, including slips and falls
- Criminal events
Slip and fall injuries, particularly among the elderly, constituted the most frequent problem at hospitals, with over 230 events statewide. These accidents occurred when patients were dizzy from medication, had vision problems, were not protected from falling from their beds, or did not have needed assistance.
Surgical problems continue to occur at shocking rates. The report includes 32 instances of objects being left in surgical patients, 24 wrong site surgeries (for example, wrong leg operated on), 5 wrong procedure injuries, and 1 wrong patient injury.
There were a dozen serious medication errors and a dozen pressure sore problems reported as well.
There can be little doubt that this report reflects only a portion of the serious medical events that should be reported. We say that for a couple of reasons. First, this was the first year of reporting, and hospital administrators are still learning what needs to be reported. Some hospitals have no doubt been more transparent and vigilant in their reporting and their efforts to reduce error. (Beth Israel Hospital under Dr. Paul Levy is the leader in this respect.) It is unlikely that the bed sores have been accurately reported, given the low number (12) versus the enormous patient population.
Transparency and accident reporting are two keys to improving patient safety at hospitals. Reduction in medical malpractice from surgical errors can be achieved with more time spent among the surgical staff double-checking to ensure the correct patient, the correct procedure, and the correct site of the surgery. We have previously discussed how surgical safety checklists reduce the rate of medical malpractice, including the rate of serious injuries and wrongful death.
If you are traveling on an airplane, you can be comforted by the fact that the pilots and co-pilots run through pre-flight and pre-landing checklists designed to prevent accidents and injuries. So wouldn’t you think the same techniques would be used in hospitals for critical surgical procedures? Well. . . not necessarily.
In an article published in the New England Journal of Medicine today, researchers demonstrated that the use of a simple checklist for surgical procedures cuts the rate of complication by 36%. The checklist reduced the rate of infection, wrong site surgery, the need for re-operation, post-operative complications, and death. The study demonstrated improvements in each of the eight countries involved in the study. If implemented properly, the number of injuries and wrongful deaths caused by medical malpractice would decline.
The authors report that roughly half of surgical complications are avoidable. The authors utilized a 19-step checklist to improve verification, to require surgical team members to introduce themselves and share patient concerns, to verify antibiotic coverage, and to document concerns regarding the post-operative recovery period. The first part of the list is designed to reduce wrong patient, wrong operation, wrong site complications which are still remarkably common. Requiring the team members to introduce themselves to each other increased teamwork and also reduced mistakes.
With such obvious improvements so readily available, one would think that hospitals and doctors would be jumping quickly onto this bandwagon. Not necessarily. Why not? Would a little more paperwork and a little extra time cut into profits? When patients’ lives, health and safety are at stake, one would hope that hospitals would instead rush to implement these guidelines immediately. Implementing checklists are clearly one way to reduce injuries, death, and medical malpractice claims.
What you can do: The 19-step checklist has been been published on-line by the World Health Organization. Print a copy for yourself, and if you are going to be having surgery, make sure your doctors use either your form, or are already using one just like it.
Thanks to an excellent series of articles in the Boston Globe, we now have some clear insight into what is driving the unconscionable increases in health insurance in Massachusetts: Secret agreements between the Partners HealthCare system and insurance companies. And while doctors and their insurance companies are quick to blame medical malpractice cases for exploding health care costs, the real increases can easily be blamed on the profit-driven expansion at Partners and increases in profits for insurance companies.
As the Globe has reported in a series of articles on the power and growth of Partners, the hospital corporation is now so large and powerful that it can freely bully insurance companies. The first up, Blue Cross and Blue Shield, which freely agreed to the demands of Partners in a “gentlemen’s agreement” sealed with a handshake. A handshake? Yup, their lawyers were apparently too nervous to put the deal in writing.
The result: an increase of 70% in Blue Cross insurance rates over the last eight year. Not surpisingly, their profits have soared. If you are like most Massachusetts residents, you have not seen pay increases approaching anything like that. And most hospitals that compete with the Partners affiliates have not seen similar increases, instead suffering blows to their bottom lines.
Using its clout, according to the Globe report, Partners also whipped other insurance companies into line, threatening to stop accepting patients insured by Tufts Health Plan, and others, unless they gave Partners a major boost in reimbursement rates.
Where is the money going? Partners keeps its profit margin low by spending hundreds of millions on expansions. The cost of the new cardiac center at the Brigham and Women’s Hospital was $382 million. A new building is popping up at Massachusetts General Hospital at the price of $686 million. These numbers all dwarf the costs of medical malpractice claims in Massachusetts. (And whatever happened to the notion that these giant health care corporations were supposed to be “non-profit”?)
What does this mean for Massachusetts consumers? Your health insurance costs will continue to skyrocket, Partners will continue to corner the market for medical care in Massachusetts, their doctors will earn more, but the quality of your care will be no better and community hospitals will be threatened by Partners juggernaut. That’s right, you pay more but get care that is no better than average, and lose health care choices in the bargain.
It is time for our legislators, the Governor, and our Attorney General to crack down on costs of health care that are driving Massachusetts consumers towards bankruptcy.
At Breakstone, White & Gluck we are concerned about health care quality, health care costs, and the truth about medical malpractice in Massachusetts. If you have a malpractice matter you would like to discuss with an experienced attorney, please contact us, toll free, at 800-379-1244.
A handshake that made medical history, Boston Globe, December 28, 2008 (third article in series)