Medical Errors

April 18, 2019

Most Common Sentinel Events of 2018

The Joint Commission released its report on the top sentinel events of 2018 and, unsurprisingly, patient falls and “unintended retention of a foreign body” took the top spot for another year. According to the Joint Commission, a sentinel event is “an unexpected event in a healthcare setting that results in death or serious injury to a patient.” While the overall number of sentinel events has declined in the last decade, some hospitals have seen a sharp increase.

Overall, these are the top ten sentinel events recorded in 2018 followed by the number of events self-reported to The Joint Commission:

Falls (111)

March 23, 2019

Hospitals Wrongly Blame Mother for Birth Complications

by Gallivan & Gallivan

America has one of the highest maternity mortality rates in the developed world and, sadly, that rate is only increasing each year. According to hospitals, these ever-increasing number of childbirth complications are primarily caused by demographic and financial considerations out of their control – poor access to healthcare compounded by pre-existing health problems which commonly afflict low-income mothers. A recent analysis by USA Today, however, shows a different cause and puts the primary blame on the hospitals, not the mothers.

According to the newspaper, many of the hospitals with a high rate of childbirth complications are “training hospitals” for medical students. The newspaper delves into several stories of women receiving poor care while delivering their child at the hands of these physicians-in-training. In one instance, Felicia West slipped in the bathroom and fell on her six-month pregnant belly. After being admitted to Touro hospital in New Orleans she suffered a seizure and went into respiratory arrested. The doctors performed a C-section on West’s child and, while the baby was fine, the mother’s health continued to deteriorate. The doctors misdiagnosed her with a rare blood disorder and in the following days, her blood pressure continued to increase. According to the American College of Obstetricians, a blood pressure reading over 160 is the “most important factor” of a coming stroke in pregnant women and new moms. Strokes that are not “treated expeditiously can result in maternal death.”

March 19, 2019

Hospitals Search for Best Way to Ensure Aging Surgeons are Safe to Operate

by Gallivan & Gallivan

With Americans living even longer, hospitals have begun evaluating the best methods to ensure elderly surgeons are safe and competent in the operating room. Unlike other industries, such as aviation where commercial pilots are required to retire at 65, doctors and surgeons are not obligated to put down the scalpel and leave the operating room upon reaching a certain age. Given the precision and high stakes of performing an operation, health care experts worry whether this is a good idea – especially when studies show that doctors are not accurate judges of their own abilities.

Research has unambiguously shown that cognitive and physical abilities decline with age and surgeons must possess exceptional skills in both these areas to remain effective. The consequences of a delayed reaction or a minor slip of the forceps can be the difference between a patient living or dying. Studies on the mortality rate of patients with elderly surgeons have been mixed, however, with some studies showing a higher rate of patient deaths for surgeons over the age of 60 and other studies showing a lower rate. Speaking to The New York Times, Dr. E. Patchen Dellinger, an expert on aging physicians, said that the older surgeons bring to the operating room may outweigh his or her decline in abilities. In his opinion, there “are sharp, wonderful doctors, and those who need to stop” which he estimated to be approximately 5 to 10 percent of doctors over the age of 75.

March 13, 2019

Patient Care Declines After Hospital Mergers

by Gallivan & Gallivan

After a decade of rapid consolidation in the healthcare industry, researchers are now analyzing the effect of hospital mergers and the results show lower-quality care and higher prices for patients. According to an analysis by The New York Times, hospitals see an increase in both patient mortality rates and “patients with major health setbacks” after merging with another hospital. With one less competitor in the geographic area competing for patients, the higher price for medical care after a merger should not be surprising. However, hospitals and healthcare systems have often rallied public support for their mergers by touting improved patient care as one of the tangible benefits. Given the increased breadth of healthcare offered by larger hospitals and a supposedly synergistic benefit from having a single healthcare provider, hospitals reasoned that larger and more capable hospital systems would lead to better outcomes for their patients.

While touting better care for patients may be an effective tool for helping hospitals receive approval for their merger, the evidence on the subject points in a different direction. Several Medicare studies show hospital competition “results in lower rates of mortality from heart attacks and pneumonia.” A national study on cardiologists measured whether market concentration, or the number of cardiologists competing against each other for patients, effected patient care. The results showed that patients in areas with a “highly concentrated market,” where the majority of cardiologists worked for the same hospital or employer, are more likely to “have heart attacks, visit the emergency department, be readmitted to the hospital or die.” The author notes these increases “are large” – a cardiology practice that increased its market share from 40 percent to 60 percent would see heart attack rates increase by 5 to 7 percent.

February 18, 2019

Families Demand Answers from Doctor and Hospital Responsible for 28 Fatal Opioid Overdoses

by Gallivan & Gallivan

A stunning and heartbreaking story about the unnecessary deaths of 28 emergency room patients caused by lethal doses of opiates prescribed by a single emergency room doctor has left families with two questions: Was the doctor woefully incompetent or intentionally murdering his patients? And, just as shockingly, how did a hospital allow the doctor to prescribe and administer a deadly dose of fentanyl to so many patients?

According to NBC News, Dr. William Husel, an intensive care doctor, is responsible for the deaths of 34 patients between 2015 and 2018. According to a hospital investigation, 28 of these patients died after receiving a dose of fentanyl 10 times higher than normal. In some circumstances, pain medication was unnecessary and administered without the patient’s permission. Dr. Husel’s medical license was suspended permanently last week without a hearing, a rare action depicting the gravity of his barbarous actions. Before the Ohio Medical Board’s action, the attorney general for the state called Dr. Husel “a serial killer on the loose with a medical license and access to fentanyl.” A criminal investigation is currently underway, but no homicide charges have been filed against the deadly doctor.

February 8, 2019

The Rate of Women Dying During Birth Continues to Increase in America

by Gallivan & Gallivan

America is one of only two countries in the world where the rate of deaths during pregnancy increased between 1990 and 2018. In an exhaustive expose in National Geographic, the news magazine details the causes of the country’s high rate of death for pregnant women, the widening racial disparity, and the progress meant to help alleviate the unnecessary and tragic problem. Given the increased attention to the issue in recent years, public health advocates are hopeful the trend will begin reversing itself in the next few years.

Overall, 700 women die each year giving birth in the United States – a rate of approximately 14 deaths per 100,000 births. However, this data does not show the wide racial disparities in the maternal death rate. For black Americans, the likelihood of dying during birth is more than three times higher than the average at 47 maternal deaths per 100,000 births. Native Americans also have a higher maternal death rate at almost 39 per 100,000. Comparatively, Hispanic and Asian American women have a lower-than-average rate of maternal deaths at 12.2 and 11.6, respectively. Researchers and public health advocates say the high maternal death rates are directly linked to a woman’s ability to access adequate prenatal healthcare – with almost 9 percent of black Americans receiving no prenatal care before giving birth. The research found a full 60 percent of the maternal deaths last year were fully preventable. Continue reading

February 5, 2019

New HBO Documentary “Bleed Out” Shines Light on Medical Errors

by Gallivan & Gallivan

The new documentary “Bleed Out” provides an infuriating first-hand account of a routine surgery that went horribly wrong and changed a woman’s life. The documentary, which was released on HBO this month, dives into the third most common killer of Americans – preventable medical errors. According to a study released by Johns Hopkins University, medical errors kill 250,000 Americans each year.

The harrowing documentary follows Judie Burrows, who went in for a routine hip replacement surgery almost a decade ago and is now unable to speak, broke, and suicidal. According to her son, Steve Burrows, comedian and documentarian, his mother fell down in November 2009 and broke her hip. After spending eight days in a Wisconsin hospital without any plan of care, the hospital finally performed X-rays and rushed the woman into heart surgery. Unfortunately, the doctors in charge of caring for Judie did not consider her daily blood-thinner medication and the patient ended up losing half of her blood during the surgery.

February 4, 2019

NY Doctor Failed to Diagnose Glaucoma Resulting in Blindness

by Gallivan & Gallivan

A Brooklyn jury returned a $15 million verdict in a lawsuit against a Brooklyn hospital after the patient’s doctor at the hospital failed to diagnose glaucoma on several different occasions, according to the Associated Press. After complaining of blurred vision and pressure around her eyes, both symptoms of the degenerative disease, Amanda Velasquez set up an appointment with her obstetrician. Dr. Reginald Ruiz, at Woodhull Medical Center. Dr. Ruiz told Velasquez, who was seven months pregnant at the time of the appointment, that her eye problems were related to her pregnancy and she should not be concerned.

With her vision continuing to decline, Velasquez complained about her vision and the pressure around her eyes at six different appointments with Dr. Ruiz over the following two months. According to her testimony before the New York Supreme Court, the lowest court in the state, Velasquez knew something was seriously wrong after she gave birth and could not see the child on her lap. She immediately made an appointment at New York Eye and Ear Infirmary, where she was diagnosed with glaucoma. By the time Velasquez could undergo surgery, she was already 90 percent blind and the damage to her vision was irreversible.

December 26, 2018

After Committing Medical Malpractice in Another State, Doctors Can Still Practice in New York

by Gallivan & Gallivan

Doctors accused of medical malpractice or other unprofessional conduct in another state may still be able to practice in New York State. In a report analyzing 250 doctors accused of professional misconduct, USA Today found that doctors accused of running pill mills, were found liable for medical malpractice, and engaging in inappropriate relationships with their patients, are still practicing medicine – just in a different state. In most states, including New York, a doctor who voluntarily surrenders his license in a different state is not automatically disqualified from practicing medicine.

Unlike most states, however, New York even allows some doctors with felony convictions to practice medicine. Under New York’s licensing scheme for doctors, a medical board is allowed to approve or deny a doctor’s license to practice medicine in the state based on their own criteria. In circumstances where a doctor voluntarily relinquishes his or her license in another state, there is rarely a “paper trail” describing any misconduct. According to LoHud.com, some states do not track allegations of misconduct against doctors and other states do not make the information available to licensing boards in other states. This haphazard system undoubtedly endangers these doctor’s patients.

December 22, 2018

Patient Safety Ratings at New York Hospitals Drop

by Gallivan & Gallivan

Continuing the state’s decade-long decline, New York ranked a dismal 48^th in overall patient safety. The rankings, which are released twice each year by the non-profit organization Leapfrog Group, compile data from hospitals across the country and measure the rate of medical errors, infections and injuries, and patient satisfaction, to determine each hospital’s ranking. Since Leapfrog Group began ranking patient safety in 2012, New York has fallen from 40^th worst state in the country to 48^th. In the tri-state area, Connecticut also ranks low for patient safety while New Jersey ranks among the best states in the country.

According to Leapfrog, the worst hospitals in the state are located in New York City and upstate. In fact, five of the 20 hospitals across the country that received an “F” from Leapfrog are located in the five boroughs. In the Hudson Valley, the hospital results were mixed. Here are Leapfrog’s patient safety ratings for the local-area hospitals:

A