Nursefriendly.com: medical errors

Showing posts with label medical errors. Show all posts

Tuesday, June 24, 2014

Worker fatigue cause of health care mistakes, study finds. #Nurseup #HealthcareHarm #Healthcare

Worker fatigue cause of health care mistakes, study finds:"Health care worker fatigue contributed to more than 1,600 incidents reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS), with 37 considered harmful and four resulting in patient deaths, according the Pennsylvania Patient Safety Authority."
http://www.bizjournals.com/pittsburgh/news/2014/06/05/worker-fatigue-cause-of-health-care-mistakes-study.html

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Tuesday, August 16, 2011

amednews: Revealing their medical errors: Why three doctors went public :: Aug. 15, 2011 ... American Medical News

In September 2010, Kimberly Hiatt made a medical error. The critical care nurse at Seattle Children's Hospital miscalculated and gave a fragile 8-month-old baby 1.4 grams of calcium chloride, 10 times the correct dose of 140 milligrams.

The mistake contributed to the death of the child and led to Hiatt's firing and an investigation by the state's nursing commission. In April 2011, devastated by the loss of her job and an infant patient, Hiatt committed suicide.

Hiatt, who had worked as a nurse for more than two decades, was another in a long line of "second victims" of medical error, the term used in medical literature to describe physicians and other health professionals who often feel guilty and depressed after adverse events. Many physicians and other health professionals hold themselves to a standard of perfection, and when things go wrong, they feel alone.

via ama-assn.org

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Nursefriendly, Inc. A New Jersey Corporation.
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Tuesday, April 26, 2011

amednews: 1 in 3 patients harmed during hospital stay :: April 18, 2011 ... American Medical News

By Kevin B. O'Reilly, amednews staff. Posted April 18, 2011.

One-third of hospital patients experience adverse events and about 7% are harmed permanently or die as a result, according to a study that detected patient safety problems at a far higher rate than other methods.

The study, in April's Health Affairs, echoes two reports issued in November 2010 that showed rates of adverse events hovering near 25% among hospitalized Medicare patients nationwide and at 10 North Carolina hospitals.

Detecting adverse events

Links

See related content

The findings draw attention to the safety troubles that have lingered in U.S. hospitals in the 12 years since the Institute of Medicine's headline-grabbing report "To Err is Human." The study cited research estimating that up to 98,000 patients die each year due to preventable medical errors.

"This is one of the best studies that now gives us a sense of how much harm is happening to patients in American hospitals," said Robert Wachter, MD, chief of the medical service at the University of California, San Francisco Medical Center, who was not involved in the research. "There is a tremendous amount of harm befalling patients who are admitted to hospitals and humongous opportunities for improvement."

via ama-assn.org

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Monday, April 18, 2011

Not Running a Hospital: Painfully slow

You can already imagine the responses. "That's just in North Carolina." "Our patients are sicker." "There are problems with the data."
What would prompt that? This New York Times article, citing a forthcoming NEJM study about medical errors in North Carolina. Here's the lede:
Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

via runningahospital.blogspot.com

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Thursday, April 14, 2011

Partnership for Patients - Win, Win, Win for American Healthcare

It's called the Partnership for Patients. (I like it already - it's focused on patients.) It's a program being developed by the federal government, under Secretary of HHS (Health and Human Services) Secretary Kathleen Sebelius, along with CMS (Center for Medicare Services) Dr. Donald Berwick, a man with an impeccable patient safety advocacy record. But they aren't in it alone - they have dozens of private and public organizations backing them, as members of the partnership.

Can this possibly be

A WIN for patients.

A WIN for providers.

And a WIN for payers, too?

via patients.about.com

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Monday, April 11, 2011

Is the US healthcare system too litigious or too careless? | boxcuttersinc

In a recent study published in Health Affairs, researchers at the University of Utah and the Institute for Healthcare Improvement found that errors “occurred in one-third of hospital admissions”. Moreover, they “found at least ten times more confirmed, serious events than … other methods.”

Commenting on this study, Health Affairs Editor-in-Chief Susan Dentzer said:

Without doubt, we’ve seen improvements in health care over the past decade, and even pockets of excellence, but overall progress has been agonizingly slow. It’s clear that we still have a great deal of work to do in order to achieve a healthcare system that is consistently high-quality–that is, safe, effective, patient-centered, efficient, timely, and devoid of disparities based on race or ethnicity.

Wow, what an indictment of a healthcare system that many consider to be the best in the world!

via boxcuttersinc.wordpress.com

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Thursday, April 7, 2011

Errors still common in U.S. hospitals | Reuters

About one in three people in the United States will encounter some kind of mistake during a hospital stay, U.S. researchers said Thursday.

The finding, which is based on a new tool for measuring hospital errors, is about 10 times higher than estimates using older methods, suggesting much work remains in efforts to improve health quality.
"Without doubt, we've seen improvements in health care over the past decade, and even pockets of excellence, but overall progress has been agonizingly slow," said Susan Dentzer, editor-in-chief of Health Affairs, which published several studies on a special issue on patient safety.
The special issue came 10 years after an influential Institute of Medicine report that found significant gaps in health quality.

via reuters.com

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Wednesday, March 30, 2011

Why Not The Best (Hospital Benchmark Data)

Comparative Health Care
Performance Data

See how well U.S. hospitals perform on measures of evidence-based care, patient experience, readmission and mortality rates, and costs

Compare a hospital's performance with peer organizations and national benchmarks

Find case studies and tools to help improve the quality of care

via whynotthebest.org

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How safe is your hospital? - chicagotribune.com

Just before it was disclosed that a medical error at the University of Chicago led to the death of James Tyree, a well-known financier and philanthropist being treated for cancer, I was putting together a presentation examining the quality of care at some of the area's best-known hospitals.
Using publicly available data, I told a meeting of local health care executives that there were warning flags at several institutions, including the U. of C. Tyree, ironically, would have known about any actual problems in far greater detail. He served on the board of the hospital where he died from an air embolism in a dialysis catheter, and hospital officials said in an interview that they regularly report safety data to board members.
There's an important distinction between great doctoring and great safety. The U. of C. has a reputation for outstanding cancer care. That's likely the reason that Tyree, suffering from stomach cancer and pneumonia, had a relatively good prognosis when he entered the hospital and why his death so shocked his family and friends. But as a wise physician once warned, "Every hospital should have a plaque at its entrance that reads, 'There are some patients whom we cannot help; there are none whom we cannot harm.'"

via chicagotribune.com

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The Epidemic of Preventable Medical Harm, HealthcarePSI.org

The Centers for Disease Control reports that 1.7 million people who enter the hospital this year - for any reason - will contract a Hospital Acquired Infection which is completely unrelated to the condition they entered with, and 99,000 of those patients infected will die within the year. Many thousands more will never fully recover.
The Sepsis Alliance - a physician group studying the condition - states that 215,000 people die each year from sepsis, a blood stream infection. The Alliance also states that half of those deaths could be prevented if hospitals would identify and treat patients in a timely manner.
In November 2010, the Office of the Inspector General released a damning report stating that every month in US hospitals, 15,000 Medicare patients over the age of 65 are killed by preventable medical harm. That's 180,000 needless deaths a year. Another 45,000 Seniors on Medicare are injured every month, but survive their hospitalization.
The three studies above document more than 386,000 preventable deaths a year in US hospitals - and that's only a small glimpse of a problem that has reached epidemic proportions.
The Institutes of Medicine estimates there are 100,000 documented preventable harm deaths per year, however they also reluctantly admit that only 5%-20% of preventable medical harm incidents are ever documented on patient records. That means their figure is badly underestimated. By how much? You do the math.

via healthcarepsi.org

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Monday, March 28, 2011

Nursing Malpractice Case Studies By Date, NursingCaseStudy.com

ShareThis Buzz up!9 votes

Editors Note: The urls to these cases are Permanent and Will Not Change. Feel free to link to any case you feel is helpful. To host any of our cases on your website or reproduce them in your publications, please contact Andrew Lopez, RN
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Physician Dismisses Nursing Assessments, Patient Almost Loses Limb.
Rowe v. Sisters of Pallottine Missionary Society, 2001 WL 1585453 S.E.2e – WV
Summary: The patient was involved in a motorcycle accident in which his bike fell onto and injured his left leg. When the nurses assessing the patient could not detect a pulse in that leg, an ominous sign of circulatory failure. The physician when notified chose to dismiss this fact and discharge the patient. The patient would return soon after with worsening symptoms that would require emergency surgery. Should the nurses have initially pressed for further action, treatment?
http://www.nursefriendly.com/041013
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Extravasation Follows Chemotherapy Administration. Potential Complication or Nursing Negligence:
Iacano v. St. Peter's Medical Center, 334 N. j. Super. 547 – NJ (2000)
Summary: Intravenous therapy has inherent risks and potential complications. When you introduce chemotherapeutic drugs and known vesicants, those risks increase dramatically. In this case, a known risk, extravasation, occurred following administration. The question arises, could the nurses have acted sooner to prevent the extravasation and resulting tissue damage.
http://www.nursefriendly.com/nursing/clinical.cases/040130.htm
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Patient Falls While Ambulating Post-op, Negligence or Medical Malpractice:"One of the most important interventions post-operatively is to get a patient up and walking. It minimizes chances of complications such as DVT, Pneumonia, Pulmonary Emboli and Decubitus Ulcers. In this case, a patient fell while ambulating. It would need to be decided if a case could be made for simple negligence on the part of the staff, or true medical malpractice."
McBee v. HCA Health Services of Tennessee, Inc. 2000 WL 1533000 So.2d – TN
http://www.nursefriendly.com/nursing/clinical.cases/040109.htm
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January 29, 2002: Nurse Sued For "Too Many Sticks" How Many Attempts Is Too Many?:"Starting Intravenous Lines and Performing Venipunctures are basic nursing skills in the Acute Care or Hospital settings. In this case, a female patient would accuse a male nurse of negligence and causing a resulting injury when he needed three attempts to successfully start an intravenous catheter."
Coleman v. East Jefferson General Hosp., 747 So.2d 1044- LA (1999)
http://www.nursefriendly.com/nursing/clinical.cases/020129.htm
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September 4, 2001, Pathologic Fracture, or Patient Injured in Fall:
Summary: The patient in this case had an extensive Oncologic history including multiple metastases and a predisposition to pathological fractures. When the patient fell while transferring a wheelchair, the cause of the broken hip found after the fall was put into question.
http://www.nursefriendly.com/nursing/clinical.cases/2001/090401.htm
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May 13, 2001: Chronically Ill Child or Mother With Munchausens Syndrome
Summary: A child starting at the age of six months was diagnosed with ulcerations of the digestive tract. His treatment and complications would persist well into the age of seven. Identification of Munchausen victims is notoriously difficult under the best of circumstances. In this case, the victim was a child admitted to a Massachusetts Hospital for a Central Venous Catheter, Line infection. The suspicion, diagnosis and treatment were carried out promptly.
Adoption of Keefe, 733 N.E.2D 1075 - MA (2000).
http://www.nursefriendly.com/nursing/clinical.cases/2001/051301.htm
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October 22, 2000: Trauma Patient, In Shock And In Decline, ER Physician Does Not Transfer
Summary: When a patient from a trauma scene arrives at the hospital, initial assessments and evaluations are critical. In this case, a patient involved in a Motor Vehicle Accident was brought in with symptoms indicative of Shock. On evaluation the decision was made to treat the patient on site. The patient then would die soon after admission. Should the ER physician have transferred her?
http://www.nursefriendly.com/nursing/clinical.cases/2000/102200.htm
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October 15, 2000: Physician Restraint Orders Unclear On Transfer, Do You Apply In The Interim?
Summary: The use of Mechanical or Physical Restraints on confused patients is highly controversial. Due to substantial Death & Injury attributed to their use they are considered a last resort measure in providing for the safety of a patient. In this case, orders specifying what restraints and when they were to be used were unclear. In a patient that was clearly at high risk for injury, should they have been applied till the physician could have been contacted?
Tousignant v. St. Louis County, 602 N.W.2d 882 - MN (1999)
http://www.nursefriendly.com/nursing/clinical.cases/2000/101500.htm
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February 16, 2000 Nurse Advises "Reconsider Choice of Physicians" An Nurse's Ethical Dilemma.
In this case the nurse providing patient care noted a decline in the patient's condition, evidenced by weight loss, hallucinations, psychiatric symptoms, and acute distress. The findings were documented and attempts were made to contact the attending physician. The attending physician, however, failed to return any of telephone messages.
Deerman v. Beverly California Corp., 518 S.E.2d 804 - NC (1999)
http://www.nursefriendly.com/nursing/clinical.cases/2000/021600.htm
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January 13, 1999: Cytomegalovirus Test Result, Misinterpreted By Nurse. Did Negligence Lead to Child With Birth Defects?
Summary: Nurses access and report confidential and sensitive test results to case managers, insurance companies, physicians and other nurses as a matter of course each day. It is commonly accepted that only a physician can interpret what a test result implies for a specific patient. Nurses by training have a general knowledge of basic lab values and what they may represent. In this case, a pregnant woman with an active Cytomegalovirus infection was misinformed by a nurse reporting a result. Had an accurate explanation been given, a therapeutic abortion might have been performed.
Duplan v. Harper, 188 F.3d 1195 OK - (1999).
http://www.nursefriendly.com/nursing/clinical.cases/011300.htm
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October 17, 1999: Psychiatric Nurses "Miss" Festering Wound Infection? Is She Held To The Same Standard?
Summary: Registered Nurses in their training cover each of the accepted areas that a new graduate might be expected to work in. Once in the field, it is expected that additional and specific training to a Department or Specialty will be obtained. In this case, the Psychiatric nurses did not pick up on a festering infection in a patient that had tried to commit suicide. Was the fact that they were Psychiatric nurses a valid excuse?
Latshaw v. MT. Carmel Hospital, 53 F. Supp. KL - (1999)
http://www.nursefriendly.com/nursing/clinical.cases/101799.htm
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October 10, 1999: Nursing Malpractice Alleged When Suspected Breast Cancer Patient Doesn't Follow Up
Summary: Breast Cancer is a well-defined and treatable if not always curable disease process. Once suspicious findings-lumps, nodules, nipple discharge or other telltale signs of a problem are noted-prompt evaluation and follow-up care is essential. In this case, a patient with a family history of breast cancer presented with a "mass" and was evaluated. She did not follow-up as directed and when she later died of breast cancer, her estate would sue for "failure to diagnose, treat."
Michigan Ave. Not. Bank v. County of Cook, 714 N.E.2d 1013 - IL (1999)
http://www.nursefriendly.com/nursing/clinical.cases/101099.htm
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October 3, 1999: Grand Mal Seizure Follows Cervical Myelogram, Anticipated Risk or Nursing Negligence?
Cascio v. St. Joseph Hosp., 734 So.2d 1099 - FL (1999)
Summary: With a proper Informed Consent obtained, it is accepted that a patient is aware of potential risks & complications prior to a procedure. In this case, following a cervical myelogram, a patient developed seizures and suffered an injury. The physician would blame the nursing staff for causing an "increased risk" by not following procedures.
http://www.nursefriendly.com/nursing/clinical.cases/100399.htm
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September 26, 1999: Nursing Assistants Leave Client Alone, Patient Receives Second Degree Burns During Bath.
Registered and Licensed Practical Nurses frequently delegate responsibilities and tasks to Certified Nursing Assistants and Unlicensed Assistive Personnel. It is clearly recognized that they are responsible for the actions/inactions of those they supervise. In this case, two nursing assistants recognized injuries to a patient while giving a bath. When they failed to notify the nurse of the injuries, they would be reported and lose their certifications.
http://www.nursefriendly.com/nursing/clinical.cases/092699.htm
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September 19, 1999: Abusive Psychiatric Patient Restrained, Placed In Seclusion For Angering Nursing & Medical Staff?
Summary: In dealing with violent, abusive or angry psychiatric patients, the safety of the patient and staff are the priority concerns. When restraints or seclusion are deemed necessary, justification for the measures must be documented concisely. In this case, an unruly patient angered the nurse caring for him. When leather restraints were applied and maintained for a prolonged period of time, the patient would object and later sue for damages.
Alt v. John Umstead hospital 479 S.E. 2d 800
http://www.nursefriendly.com/nursing/clinical.cases/091999.htm
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September 12, 1999: Sleep Apnea Monitor Turned off or Ignored By Nursing Staff, Patient's Coding Goes Unnoticed.
Monitors and Monitored patients present special challenges to practicing nurses. Like a call bell, when alarms on a monitor are activated, they can signal benign or life-threatening events. In this case, a patient's monitors did not alarm as expected. The patient was in distress and would be found without respirations and pulseless by the nurse on duty.
Odom v. State Dept. of Health and Hosp., 322 So. 2d 91 -LA (1999)
http://www.nursefriendly.com/nursing/clinical.cases/091299.htm
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September 5, 1999: Sealed "Rape Kit" Reopened By Nurse. Evidence Inadmissible?
Documentation of observations and findings are basic to nursing practice. Our practice is governed by standards of practice and "protocols" to be followed. In this case, a nurse admitting a rape victim collected and placed in a "rape kit" DNA samples, evidence to be submitted for laboratory analysis. The evidence submission protocol would inadvertently be broken by the nurse. The defense for the rapist would argue this breach made the evidence inadmissible.
State v. Southern, 980 P.2d 3 - MT (1999)
http://www.nursefriendly.com/nursing/clinical.cases/090599.htm
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August 29, 1999: Surgeon "Loses Clamp" Behind Patient's Heart During Bypass.
Nurse's Responsibility To Pick Up?
Summary: During any surgical operation, there is an inherent "duty" owed to
the patient that the operation will be carried out competently. This
includes carrying out specified procedures and taking measures to prevent
"foreign" objects from being left in the body cavity. In this case, during a
coronary artery bypass grafting, a clamp slipped from the surgeon's sight.
It would be found on x-ray later sitting behind the patient's heart.
http://www.nursefriendly.com/nursing/clinical.cases/082999.htm
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August 22, 1999: Psychiatric Nurse, Sued By hospital After Developing Relationship With Client?
Wright v. Mercy Hosp. Of Janesville - 557 N.W. 2d 846 - WI (1996)
Summary: Doctors and Nurses by nature of their positions deal with patients when they are vulnerable, off-balance and emotionally needy. When the population includes the psychiatric patient, the potential exists for a client to develop "feelings" for the caregiver. In this case, a sexually abused mother of three was admitted for multiple mental disturbances. During the course of the treatment, a relationship developed and led to sexual encounters following discharge. When it came to light, the patient successfully sued. The hospital would attempt to recover damages against the nurse following her testimony in defense of the facility. This is commonly called a Subrogation action.
http://www.nursefriendly.com/nursing/clinical.cases/082299.htm
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August 15, 1999: Violent Psychiatric Patient Attacks Nurse,
No Legal Recourse Against Facility or Psychiatrist?
Charleston v. Larson, 696 N.E. 2d 793 – IL 1998
Summary: It would seem absurd, that if a physician admits and facility assigns a nurse to care for a known violent patient, that it has no legal obligation to protect that nurse against violence. In this case, a psychiatric patient sought admission to facility. On admission, he threatened to attack a nurse. When the patient would follow through on his threat, the nurse was denied legal recourse against the psychiatrist who could have taken precautions against the attack.
http://www.nursefriendly.com/nursing/clinical.cases/081599.htm
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August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage, Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 –ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm
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August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
http://www.nursefriendly.com/nursing/clinical.cases/080199.htm
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July 25, 1999: Premature Child of Cocaine Addicted Mother Survives Abortion. Physician Order: Leave To Die?
The premature birth of a child under normal circumstances requires highly skilled nursing and medical care if the child is to survive. The birth of a premature child to a known Cocaine addicted mother greatly increased the risks of mortality. In this case, a child intended to be aborted is born alive. When the physician orders that the child be to left to die, it miraculously survives on its own. Were the nurses liable for "following orders?"
Hartsell v. Fort Sanders Reg. Med. Ctr. 905 S.W. 2d 944 - TN (1995).
http://www.nursefriendly.com/nursing/clinical.cases/072599.htm
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July 18, 1999: Good Samaritan Laws & Acts. Do They Cover Nurses Volunteering Nursing Care When A Citizen Goes Anaphylactic.
"Off-duty" healthcare professionals renderingEmergency aid are in most cases "covered" by the Good Samaritan Acts. These are laws enacted in each state that provide some degree of immunity from liability for good faith efforts in giving emergency care. In this case, a nurse and physician were sued for providing assistance in a volunteer function at a "first-aid" station. Good Samaritan "immunity" was not recognized by the courts.
Boccasile v. Cajun Music Ltd. 694 A 2d 686 - RI (1997)
http://www.nursefriendly.com/nursing/clinical.cases/071899.htm
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July 11, 1999: Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
Nursing homes are frequently a patient's destination for rehabilitation following surgery. Common conditions fitting this bill include large bone fractures, hip replacements and stroke. Following these acute episodes, the patients are too unstable to go home and not "sick" enough to have their hospital stays reimbursed by insurance companies. The purpose of admission to a nursing home is to help the patient regain lost function, strength and health. In this case, the patient would remain in the Nursing Home till her death of complications.
Lloyd v. County of Du Page, 707 NE.2d 1252 - IL (1999)
http://www.nursefriendly.com/nursing/clinical.cases/071199.htm
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July 4, 1999: Diabetic Coronary Artery Bypass Patient, Septic & Noncompliant. Nursing Duty and Responsibility Questioned.
Patient noncompliance can present serious challenges to nurses and physicians providing care. If aware of the proper measures to be taken, what happens when the patient does not agree or comply with the course of treatment? In this case, a patient after having a coronary artery bypass grafting developed a sternal infection. When advised by a nurse to return for treatment, the patient refused.
Kind v. State Ex Rel. Dept. of Health, 728 S.o. 2d 1027 -LA (1999).
http://www.nursefriendly.com/nursing/clinical.cases/070499.htm
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June 27, 1999: Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse?
As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes. When a family member is placed in a facility, a certain standard of care is expected. In this case, a resident was injured repeatedly while under their care. When the patient died a few days after being "dropped" the family sued.
Brickey v. Concerned Care of Midwest Ince. 988 S.W. 2d 592 MO (1999)
http://www.nursefriendly.com/nursing/clinical.cases/062799.htm
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June 20, 1999: Organ Donation Informed Consent, Is A Single Parent's Sufficient?
Organ donors are in high demand. Frequently intended recipients can wait a lifetime for the critical matching organ. In this case, two nurses obtained a consent from a child's mother. When the father later expressed his disagreement, the child's corneas had been harvested and it was too late.
Andrews v. Alabama Eye Bank, 727 S. 2d 62 –AL (1999)
http://www.nursefriendly.com/nursing/clinical.cases/062099.htm
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June 13, 1999: Felony Child Abuse Conviction, Made Possible Thanks to Nurse's Documentation.
Child abuse is a "reportable" crime. This means when a healthcare worker suspects in the course of their duties that a child has been abused, it must be reported. Procedures are in place in hospitals and other facilities for the reporting of abused children. In this case, it was the expert documentation of a child's statements by a nurse, physician and field agent that made the conviction of an abuser possible.
State v. Gillard, 936 S.W. 2d 194 - MO (1999).
http://www.nursefriendly.com/nursing/clinical.cases/061399.htm
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June 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Official tolerance for verbal abuse and sexual harassment is approaching zero. It is clear that both are still prevalent in healthcare settings today. Enforcing and reporting instances of abuse are critical to an end being put to the situation. In this case, a physician had a "history" of verbal abuse in the facility involved. It was the documentation of previous events that made formal action and administration of a suspension feasible.
Gordon v. Lewiston Hospital, 714 A.2d 539 – PA (1998)
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm
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May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
http://www.nursefriendly.com/nursing/clinical.cases/053099.htm
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May 23, 1999: Sponge Count Off, Patient Develops Sepsis, Surgeon Blames Nurse.
Sponge Counts are a basic and critical safety measure during a surgical operation. In this case, the standard three counts were not performed. A sponge was left in the patient that would later lead to infection. When the issue went to court, the surgeon claimed "it was not his responsibility" to keep track of the sponges.
Johnston v. Southwest Louisiana Assn. 693 So. 2d 1195 –LA (1997)
http://www.nursefriendly.com/nursing/clinical.cases/052399.htm
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Editors Note: The urls to these cases are Permanent and Will Not Change. Feel free to link to any case you feel is helpful. To host any of our cases on your website or reproduce them in your publications, please contact Andrew Lopez, RN
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Malpractice Cases By Date Posted (Twenty Nine Cases Total)

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By Topic: Nurse Abuse, Nursing Documentation, Restraints, Sepsis, Sexual Harrassment, Sponge Counts, Verbal Abuse

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Send comments and mail to Andrew Lopez, RN
Last updated by Andrew Lopez, RN on Monday, February 28, 2011

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Sunday, March 27, 2011

Admitting harm protects patients - Sunday, March 27, 2011 | 2 a.m. - Las Vegas Sun

As Nevada legislators debate this week whether to require hospitals to publicly report when they harm patients, they could learn a lot from Paul Levy’s experience in pulling back the veil of hospital secrecy.

Levy became a revolutionary figure in medicine when, as CEO of Beth Israel Deaconess — then the weak sibling among Harvard University’s teaching hospitals — he began blogging about injuries and infections suffered by his hospital’s patients. His competitors eventually followed suit and now, with Massachusetts law imposing transparency, they acknowledge openness has brought greater accountability and a more focused commitment to protecting patients.

“It’s not just fear of public embarrassment” that drives the improvements, said Dr. Ken Sands, chairman of Beth Israel Deaconess Medical Center’s health care quality department. “It’s an easy way to show something is a priority and is deserving of attention.”

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Wednesday, March 2, 2011

Texas Senate panel advances bill to protect nurses | AP Texas News | Chron.com - Houston Chronicle

A Texas Senate committee approved legislation Tuesday aimed at strengthening protection for nurses who report abuse by doctors.

The bill filed by state Sen. Jane Nelson, R-Flower Mound, protects nurses from being fired, discriminated against or punished. Nurses would be immune from criminal prosecution under the bill.

The bill now goes to the full Senate. If enacted, doctors would be fined up to $25,000 if convicted of retaliation.

Lawmakers saw a need for a more stringent law after two West Texas nurses were fired and criminally charged after reporting a doctor for allegedly practicing bad medicine.

The charges were dropped against Winkler County nurse Vicki Galle, but Anne Mitchell was prosecuted for "misuse of official information" and threatened with 10 years in prison.

Galle and Mitchell anonymously filed their complaint against Dr. Rolando Arafiles with the Texas Medical Board in 2009. But with help from the sheriff, Arafiles found out who the nurses were.

Despite Mitchell's acquittal, the case stirred outrage from medical communities nationwide. Nursing advocates want to ensure nurses can report malpractice without fear of retaliation.

"Patients are best served when nurses can advocate on their behalf," Nelson said. "The case of the Winkler County nurses highlighted the need for additional protection for nurses."

Mitchell said the decision to report Arafiles was carefully considered, and one she felt she had to make on behalf of her patients.

But the price she paid was high. She said her nursing career is over, her income has been cut in half and she continues to endure the effects of being labeled a whistleblower.

"That label basically reads 'don't hire me'," she said. "Nurses are frequently the last safety net for patients. If our voices are stifled, our patients will suffer. My hope is that the passage of this bill will prevent other nurses from having to go through what we went through."

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e-Autopsy: Kaiser Hospitals Dig In to Data to Assess Mortality

You've heard the macabre joke that hospitals and doctors "bury their mistakes." Well, here's an interesting twist: At Kaiser Permanente hospitals in Southern California, doctors are doing precisely the opposite. They're rolling back time in the death process – exhuming their unknown mistakes so to speak – to see what, if anything, they can learn in order to save similar patients the next time around.

But they're not doing it the old way through invasive autopsies. Those are expensive, increasingly unpopular with families, forbidden by some religions, and often don't reveal that much about errors in the process of hospital care.

Kaiser has a new concept, the e-Autopsy.

Kaiser's hybrid manual and electronic mortality review uses storytelling and specialists' scrutiny to study medical charts of patients who died in the hospital. The process builds a precise timeline of what happened. The goal is to prevent death and/or improve end-of-life care by looking for places to improve—from ambulatory settings prior to admission to the inpatient bedside.

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Tuesday, March 1, 2011

HHS Releases National Plan to Improve Health Literacy | HHS.gov

Today, the United States Department of Health and Human Services released The National Action Plan to Improve Health Literacy aimed at making health information and services easier to understand and use. The plan calls for improving the jargon-filled language, dense writing, and complex explanations that often fill patient handouts, medical forms, health web sites, and recommendations to the public.
According to the report, efforts to improve the health literacy skills of both the public and health professionals are needed to achieve a health literate society—a critical need as health reform generates more demand for consumer and patient information that is easy-to-understand and culturally and linguistically appropriate.
According to research from the U.S. Department of Education, only 12 percent of English-speaking adults in the United States have proficient health literacy skills. The overwhelming majority of adults have difficulty understanding and using everyday health information that comes from many sources, including the media, web sites, nutrition and medicine labels, and health professionals.
“Health literacy is needed to make health reform a reality,” said HHS Secretary Kathleen Sebelius. “Without health information that makes sense to them, people can’t access cost effective, safe, and high quality health services. But, HHS can’t do it alone,” she added. “We need payers and providers of health care services to communicate clearly and make the necessary changes to improve their communication with consumers, patients, and beneficiaries. Today’s plan is only the beginning of a long-term process with our many partners in all sectors that we hope will result in a society that encourages people to live longer, healthier lives.”

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Thursday, February 24, 2011

Nearly 60% of paid home caregivers make medication errors, study finds - McKnight's Long Term Care News

One-third of paid caregivers who work for clients who live in their own homes had difficulty reading and understanding health-related information and instructions. Furthermore, 60% of them made medication errors involving their clients, according to Northwestern University researchers, who say the study is the first of its kind.

Investigators at the university recruited 100 paid, non-family caregivers in the Chicago area and evaluated their literacy with health-related tasks and knowledge. While researchers emphasized that the majority of caregivers are good people who are trying to support their families, medication-error levels are a serious cause of concern.

They found that most paid caregivers are women with an average age of 50 years old. Many are foreign born with limited schooling. They are usually paid about $9 an hour, though almost one-third earns less than minimum wage.

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Nursefriendly.com

Tuesday, June 24, 2014

Worker fatigue cause of health care mistakes, study finds. #Nurseup #HealthcareHarm #Healthcare

Tuesday, August 16, 2011

amednews: Revealing their medical errors: Why three doctors went public :: Aug. 15, 2011 ... American Medical News

Tuesday, April 26, 2011

amednews: 1 in 3 patients harmed during hospital stay :: April 18, 2011 ... American Medical News

Monday, April 18, 2011

Not Running a Hospital: Painfully slow

Thursday, April 14, 2011

Partnership for Patients - Win, Win, Win for American Healthcare

Monday, April 11, 2011

Is the US healthcare system too litigious or too careless? | boxcuttersinc

Thursday, April 7, 2011

Errors still common in U.S. hospitals | Reuters

Wednesday, March 30, 2011

Why Not The Best (Hospital Benchmark Data)

Comparative Health Care
Performance Data

How safe is your hospital? - chicagotribune.com

The Epidemic of Preventable Medical Harm, HealthcarePSI.org

Monday, March 28, 2011

Nursing Malpractice Case Studies By Date, NursingCaseStudy.com

Sunday, March 27, 2011

Admitting harm protects patients - Sunday, March 27, 2011 | 2 a.m. - Las Vegas Sun

Wednesday, March 2, 2011

Texas Senate panel advances bill to protect nurses | AP Texas News | Chron.com - Houston Chronicle

e-Autopsy: Kaiser Hospitals Dig In to Data to Assess Mortality

Tuesday, March 1, 2011

HHS Releases National Plan to Improve Health Literacy | HHS.gov

Thursday, February 24, 2011

Nearly 60% of paid home caregivers make medication errors, study finds - McKnight's Long Term Care News

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