12 Most Common Medical Errors (And How to Prevent Them)

Ashley M Jones wrote on the Pharmacy Technician Certification blog the following article on the 12 most common medical errors and how to prevent them.  Many of these errors occur in nursing homes every day.

According to the National Academy of Sciences, medical errors injure millions of people each year and cost billions of dollars annually in increased health costs. And this does not take into account lost wages or productivity costs. If that isn’t frightening enough, the Institute for Healthcare Improvement estimates that more than 238,000 hospital deaths among Medicare patients between 2004 and 2006 were due to medical errors that could have been prevented.

With healthcare reform front and center in political discussions, but little coming from it, patients are left to rely on their overworked physicians and other caregivers for reliable services. To best avoid becoming part of the statistics, become part of the solutions by knowing the 12 most common medical errors and how to prevent them.

1. Medication Errors : The most common of medical errors, luckily it can be one of the most preventable. Errors include assigning a medication due to improper information such as allergies, other medications taken, previous diagnosis, and others. A medication error can also include lack of up to date warning or miscommunication due to poor handwriting. There is also confusion among drugs with similar names or dosage, and this effects all drugs including prescription, over the counter, vaccines, etc. The best way to avoid this medical error is to know what you’re taking, how much, and what you can’t take. If unable to remember, bring all of your medications to the doctor or hospital with you.

2. Bad Communication :  Have you been going to the same doctor for years? That doesn’t mean that he or she knows or will remember everything about you. The second most common medical error results from poor doctor/patient communication. With loads of tests and labs, doctors will not always remember every test you have, so it is up to you. The Agency for Healthcare Research and Quality lists the ten questions every patient should ask their doctor, along with many other useful tips. You can even go there to build your own personalized question list.

3. Infection : They may seem clean, but hospitals are one of the most likely places to receive an infection. Given the high incidence of people with infections, workers who can become contaminated, and the fact that many patients enter the hospital with weakened immune systems, infection can be a serious problem. If staying at a hospital, be sure to avoid a doctor’s tie, ask him or her if they have washed their hands since visiting the last patient, and be sure to wash your own often. This article reports on the incidence of high IV infection rates. If you receive one, be sure to monitor for signs of infection and ask for a new one if suspicious.

4. Falls : Because on so many new drugs, patients cannot predict how they will react to them, causing a fall, which is another leading common medical error. In fact, ten percent of falls for the elderly occur in hospitals. Patients who have other mobility issues like a broken leg, walker, or cane, can also find the clean hospital floors more slippery than those at home. If you think you need assistance standing and walking, contact the nursing staff. Be sure and allow 10-20 minutes for a response, as they may be busy assisting others stand and walk.

5. Surgical Errors : Because surgery is scary enough when everything goes right, it is vital to prevent errors before, during, and after. These can include wrong site, wrong procedure, and even wrong patient surgeries. Although there are new procedures in place to reduce these common medical errors, you can still do your part. Speak to your surgeon about the procedure you are having, why you are having it, and what the surgeon will be doing during the surgery. Also know the rules in place to avoid surgical errors: 1. The surgeon must sign the incision site with the patient awake. 2. Use only a signature and not a confusing “X.” 3. The entire surgery team must stop and perform a checklist before beginning the procedure.

6. Pharmacy Errors : You don’t have to be in a hospital to be a victim of a common medical errors. With dozens of patients each day, pharmacies can also make errors on your medication. In fact, according to this article from CNN, 30 million Americans are the victim of outpatient medication errors each year. Although some are minor and can be caught easily by most patients, others are not. To best prevent medical errors of this sort, know what your doctor prescribed and how much when going to the pharmacy. Also, be sure to be honest with the pharmacist about other medications and drugs you are taking to ensure that there is no harmful interaction.

7. Lab Errors : Another facility with many patients and tests in one spot, common medical errors can occur here as well. These can also be truly devastating by leading to wrong diagnosis and wrong treatment, while the initial disease continues. Types of common errors can include MRI or CT taken incorrectly, samples taken incorrectly, or results misinterpreted. If you feel your lab results are misleading, you are within your rights to ask for another lab test to confirm.

8. Treatment Errors : If you feel your diagnosis was reached correctly, a common medical error can still happen during treatment. Because many doctors have been practicing for decades, it is not unusual for them to be using outdated procedures. Be sure to ask why you are having the treatment, how long the doctor has been doing them, and if there are any alternatives. This website is full of guidelines for treating many common illnesses.

9. Follow Up Care : When discharged from the hospital or clinic, be sure and know what your follow up care is and what to expect from it. If you are given a specific amount of medication and told to take it all, take it all. Just because you feel better halfway through, doesn’t mean you are better. Ask the facility who to contact if you have follow up questions on your at home care. This link also has more on what to do.

10. Birth Injuries : It may be the most joyous time in your life, but birthing a child can also lead to medical errors. The most common can result in serious injuries such as cerebral palsy and paralysis. Women who are most at risk include those with large babies, prematurity, prolonged labor, and more. To best avoid these injuries, do research on the place you would like to have your baby in. Check several hospitals in and outside of your area. See the incidence of birth injury and, if possible, read reviews by other mothers who gave birth there.

11. Bring Family : This is vital to avoiding common medical errors. If you are too ill to answer or too tired to protest, an informed family member is your best bet to sidestepping a common medical error. They can answer questions about medications, do reviews of your current and future care, and lift spirits. Make sure they also read these 12 most common medical errors and how to prevent them. Click on this link to get more rules for family members visiting at a hospital.

12. Don’t Wait Until It’s Too Late : With healthcare costs on the rise, many patients believe they can save money by putting off the doctor’s visit. However, this can actually have the opposite effect as the worse a disease gets, the harder and more expensive it is to treat. This decision can also be deadly with the wrong disease going undiagnosed or treated. If you have no insurance, find a Take Care Clinic. Visits start at $65, which is far cheaper than many primary care visits out of pocket. They are also doing free blood glucose testing for the month of February.

If you have any questions regarding the above 12 most common medical errors and how to prevent them, ask your physician. The best way to not become lost in a system like so many million before you is to be your own best advocate. Know your rights both as a patient and an insurance holder. If you don’t have insurance, there are still many resources for you, along with many useful tips for those who do have it.
 

Use of Antipsychotics

McKnight's also ran an article about the recent studies that prove the off label use and over use of dangerous antipsychotics to elderly and vulnerable patients. Antipsychotic medication use is still widespread in nursing homes, even after the federal government issued a “black box” warning on the drugs in 2005 according to two new studies.

The drugs in question include clozapine, risperidone, olanzapine and paliperidone. Doctors prescribe these drugs, which are designed to treat bipolar disorder and schizophrenia, off-label for residents with dementia. Both studies appeared in Monday's issue of the Archives of Internal Medicine.
 

Medication error leads to rectal bleeding

The Madison and St. Clair Record had an article about a lawsuit filed against a nursing home for giving a resident a blood thinner that caused rectal bleeding.  Ron Matikitis filed a lawsuit in Madison County Circuit Court on behalf of Ann Matikitis against Bravo Care of Edwardsville. Ron Matikitis claims nurses at Rosewood Care Center in Edwardsville - a nursing home licensed by Bravo Care - administered 4 milligrams of Coumadin to Ann Matikitis on Sept. 24, 2008, despite the fact that her physician had ordered her prescription to be held because of an elevated PT/INR lab result. The drug, usually used to prevent blood clots, ended up causing Ann Matikitis to experience massive rectal bleeding and to be hospitalized.

In addition to her injuries, Ann Matikitis suffered a marked deterioration of her prior physical condition, incurred substantial medical bills and suffered great pain and anguish. In addition she suffered a severe and permanent disability.

Ron Matikitis blames Bravo and its employees for failing to properly consult with Ann Matikitis' physician and her family members about her deteriorating condition, for failing to timely report the medication error, for failing to provide appropriate general nursing, for failing to record the medication error and for failing to comply with a physician's orders. In addition, employees negligently failed to record the care provided and Ann Matikitis' reaction to the prescription and violated resident care policies, according to the complaint.

Ron Matikitis seeks a judgment of more than $50,000, plus costs and other relief the court deems just.

Robert H. Gregory of the Law Office of Robert H. Gregory in East Alton will be representing him.
 

Incorrect transcription of doctor's order leads to stroke/death

The Star-Tribune had an interesting article about the massive stroke and death of a resident caused by a nursing home failing to give a medication despite a physician's order.  State investigators say a woman recovering from spine surgery died of a massive stroke in June after a nursing home in Faribault, Minn., failed to give her a medication prescribed to prevent blood clots.

The doctor's order was incorrectly transcribed by a nurse at Faribault Commons Nursing and Rehabilitation, and the home did not have adequate checks to spot the error, its administrator acknowledged Monday. The home was cited for neglect.

The report, made public last week by the department's Office of Health Facility Complaints, said this is what happened:

The unidentified patient was moved from a hospital to Faribault Commons on June 2 for rehabilitation therapy with orders for the daily Lovenox injection.  She was given the drug for three days, mistakenly did not get it on the weekend, then got it again for four days.  Then the treatment was stopped because a nurse mistakenly had written that it was to end on June 11, instead of July 11 as ordered.  The patient had a massive stroke on June 17 and was sent to the hospital, but returned to the nursing home two days later for end-of-life care. She died on June 24.

 

Regulating "off label" use of anti-psychotics

The Chicago Tribune had a good article about the use of anti-psychotic medications being overprescribed and over used in nursing homes.  Health advocates are calling for tough new rules on the use of anti-psychotic drugs in Illinois nursing homes, including tighter controls on doctors who prescribe the powerful medications. "Medical care should help you get better, not get worse," said Wendy Meltzer of Illinois Citizens for Better Care, an advocacy group for nursing home residents.

A Tribune investigation recently showed how many frail and vulnerable Illinois nursing home residents have been unnecessarily dosed with anti-psychotics, leading to harm and an increased risk of death. One psychiatrist, the Tribune found in a joint investigation with ProPublica, provided assembly-line care to thousands of mentally ill patients.

The FDA has approved anti-psychotic drugs to treat serious mental illnesses, such as schizophrenia, but doctors also prescribe them to geriatric patients with other conditions, such as dementia, in a common but controversial practice called "off-label" use. Meltzer said one way to stop nursing home doctors from using the drugs to "chemically restrain" residents is for the state to refuse to pay for certain medications.  Documents show that hundreds of nursing residents have been given psychotropics without their permission since 2001. 

Nursing homes, Meltzer said, should have a formal process of explaining the benefits and risks of taking psychotropics. Right now, she said, the goal of many nursing homes is to simply get residents to sign the forms as opposed to explain the options.

Advocates also said Illinois should require drugmakers to publicly disclose payments to doctors so that their patients can be aware of possible conflicts of interest. One pharmaceutical company gave Reinstein nearly $500,000 to promote a drug that Medicaid records suggest he prescribed 41,000 times.

 

Nurses steal pain medication from residents

The Middleton Journal had an article about two different employees of a nursing home, acting separately, stole narcotics from residents for years, and altered the residents' charts to make it look like residents actually received the need pain medication.  How could they not have been caught earlier?  didn't the residents complain that they were still in pain? 

Deborah Renee Richardson and Denise “Bells” Holtkamp are both accused of stealing Oxycodone from the Lebanon Country Manor nursing facility in Ohio.  Both nurses separately altered patient records so they could steal the addictive painkiller for their own use.

Both women were indicted by a Warren County Grand Jury on two counts of illegal processing of drug documents, a fourth-degree felony; two counts of theft of drugs, a fourth-degree felony; and two counts of aggravated possession of drugs, a fifth-degree felony.

 

ADON sentenced for stealing medication at nursing home

The Franklin News-Post had a story about a nursing home employee--the assistant director of nursing-- getting only three years for the distribution of prescription drugs she took from residents at her facility.  Linda Sloan Quick was also sentenced to three years probation, following her prison sentence, and she was ordered to be on good behavior for 25 years.  There was no mention if she would lose her license to practice nursing or if she was reported to the Board of Nursing.

Court records show that the drugs taken from the nursing home by Quick had either expired or had been prescribed for patients who had died or had been transferred to another health facility.  The sheriff's department received anonymous information that a nursing home employee was selling prescription drugs, and investigators got Quick's name from a confidential informant.

Quick was sentenced to 10 years for distribution of Fentanyl, but seven years of the sentence were suspended.  Quick was also sentenced to three years on each of the three counts of distribution of Hydrocodone. All nine years were suspended.



 

How complaints are handled by state agencies

Stephanie Flemmons at sflemmons@acnpapers.com had a great article in the Plano Courier.  The article discusses how a complaint was handled by the state agency responsible for investigating nursing home resident's complaints.  Richard Ward was a resident who received a serious medication error that could have killed him.  The Texas Department of Aging and Disability Services ruled not to take any action against a facility that almost killed him.

“It strikes me as, you may have made a medication error that could have killed someone, but oh well,” Ward said. “We are not working on cars here, we are working on people.”

Ward’s formal complaint stated that the Life Care Center of Plano failed to administer the proper medication, which almost caused a fatal heart attack.  When Ward admitted himself to Life Care, he provided the nursing staff with an itemized list of the types of medications he was required to take, what the dosages were and the actual medications.

Ward said the nursing staff failed to administer his Coumadin.  He became aware days later when his physician conducted her examination.  “When the doctor conducted her physical it was almost too late,” Ward said. “She panicked after the results from an INR test came back normal. A normal level for a person with my heart conditions is a dangerous place.”

The physician immediately ordered Lovenox injections and Coumadin.  “I felt like I was on the brink of death,” Ward said. “I panicked.”

That night on May 28, Ward received his required Coumadin.  The next day the errors kept occurring. He received his Lovenox the next morning, but did not receive it that night.

“Medication time is at 9 p.m. and I waited until 10:30 p.m. to ask the nurses,” Ward said. “They argued with me. I had to force them to look it up.”   Ward said they realized they made a mistake, but at that point he had had enough.  “I thought these people were going to kill me,” Ward said. “That was their last chance.”

The state agency ruled this claim as unsubstantiated or unverified.

“I am flabbergasted,” Ward said. “I brought them a typed list of every medication that I picked up from the Medical Center of Plano before I admitted myself.”   Ward discharged himself from Life Care.  He reviewed his medical records.  The typed list was no longer in the records.

“They took it out because it showed blatant negligence,” Ward said. “All they had to do was lose one piece of paper and they wouldn’t look so bad.”

Ward’s second complaint alleged that the facility failed to maintain accurate clinical records.  DADS did find that the facility did have his name incorrect, but they did not issue a citation.

“How would they know who they were giving medicine to if they did not have the patient’s correct name?” Ward said. “At some point they gave me medicine, without the correct name on my records.”

Ward wrote prescriptions for 20 years in the Army and as a civilian.  He is concerned that the state agency’s rulings on both claims proves future such rulings could take the life of an innocent person.  “You just can’t make a mistake like this and not have any repercussions,” Ward said. “If they are doing this to someone who is awake and alert and knows how to read medical records, I’m sure they are doing this to someone else. I’m not an isolated case.”

Ward said they never contacted any of his family members or even asked him many questions regarding the claim.   According to DADS annual report, medication errors are No. 8 in their top 10 list for complaints.

 

Nurse steals narcotics from residents

Vermont's WCAX.com had an article about another employee of a nursing home stealing resident's pills.  There seems to be an epidemic of nurses stealing narcotics and other medications to ingest or sell on the black market.  Should they routinely drug test nursing home workers? 

Dawn Ash was indicted for possession and theft of the narcotics. She worked as a nurse at a New London, N.H., nursing home.   Investigators suspect her of stealing Percocet and Vicodin from residents at the William P. Clough Center. It's a 58-bed nursing home attached to New London Hospital.

Last April, shortly before she was hired at the Clough Center, the state of Vermont suspended Ash's nursing license. She was accused in Vermont of illegally obtaining regulated substances with false prescriptions.
 

How in the world was she hired at a nursing home? Why didn't the nursing home check to make sure she had a license?  I wonder how many residents had to suffer in pain because this nurse took their pain medication.  I hope they throw the book at her.

Patient allergic to morphine dies after being given morphine

The Post-Tribune had an article written by Mark Taylor about the negligent care provided to a resident in a hospital.  The article described the resident, Donna Durham, as an active, energetic widow with sparkling green eyes and silver hair who worked as a top real estate agent and home appraiser until June 12, the day she arrived at  the hospital for surgery. 

Prior to the surgery, the Dunham family had apprised hospital staff of their mother’s allergy to codeine and morphine.  It was entered in her medical chart.  It was identified on the red tag she wore on her wrist. And in the final presurgery meeting with physicians, Dunham’s children say they reminded anesthesiologist Dr. Nageswar Yelavarthi that their mother was allergic to morphine.

In spite of those warnings he allegedly ordered a nurse to administer the potent narcotic to which Dunham was allergic, according to Pinnacle medical records obtained by Dunham family attorney George Galanos. Yelavarthi allegedly told the nurse that he and the staff could deal with the expected allergic reactions, such as nausea and vomiting, a nurse’s note states.

By 12:08 p.m., Dunham was in respiratory arrest and having difficulty breathing.  Medical records indicate Pinnacle staff attempted to stabilize Dunham and around 12:30 p.m. began attempts to transfer her to an acute-care hospital. 

Dunham's doctor, Dr. Kucharzyk,  did not complete a spine fellowship and does not have the additional training required to perform spinal procedures.  According to the Patient Compensation Fund of the Indiana Department of Insurance, Kucharzyk has been named in at least 14 medical malpractice lawsuits.  Kucharzyk never disclosed this information to the family.

Nonetheless, Kucharzyk held surgical privileges in back surgery at Pinnacle.

After Dunham went into respiratory distress at 12:08 pm., Pinnacle staff connected her to a ventilator to breathe for her.   Anesthesiologist Yelavarthi gave her an antidote to the morphine, but it didn’t work.

Kucharzyk was enlisted to attempt to transfer Dunham to Methodist or Saint Anthony. But he said he did not hold full privileges at Methodist or Saint Anthony and wasn’t successful in arranging a transfer. Kucharzyk soon after told Pinnacle staff, “He would not be following the patient,” according to Dunham’s medical records.

Khalid contacted Methodist to alert staff there about Dunham’s condition and the sequence of events, and at 1:01 p.m. Superior Ambulance arrived at Pinnacle to transport Dunham to Methodist.  Again at 1:20 p.m., Pinnacle staff contacted Methodist and were told that Methodist could not accept Dunham until case management reviewed her insurance “to make sure she was not a (patient) ‘dump’,” hospital slang for a patient unable to pay, according to Pinnacle records.

Patient dumping is when a hospital transfers a patient to another health-care facility because of the person’s inability to pay. It’s a practice that is illegal, as is delaying care while considering payment or insurance information.

The Pinnacle staff continued working on Dunham even as they attempted to transfer her to Methodist, a hospital with an intensive-care unit better equipped to handle such emergencies.

Finally at 2:30 p.m., nearly 150 minutes after Dunham had gone into respiratory distress, Superior transported her to Methodist.  Dunham arrived at Methodist still in distress and deteriorated rapidly.

Methodist’s ER staff worked on her until 3:30 p.m., when she was pronounced dead of heart failure.  A Methodist ER nurse asked the family if Pinnacle ever explained their mother’s condition when it transferred her.

Cheryl Harrell said Kucharzyk phoned that evening.   “He asked what happened and acted like he didn’t know anything had gone wrong,” she said. “He said when he left she was fine.”

 

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