The Carnage Continues, Part 2

Medical errors include misdiag- nosis, hospital acquired infections, medication error—both inpatient and outpatient—excessive radiation, unnecessary surgeries, nursing home diarrhea, medical error, and blood clots. Medical errors have become the leading cause of death to Americans, exceeding heart disease and cancer with over 800,000 deaths attributed to error—or 2,191 deaths per day.

The New York Times (July 12, 2012) reported on the case of Rory Staunton, a 12-year-old boy who fell down, cut his arm, went to NYU Lagone Medical Center emergency room several times, his pediatrician several times, and was misdiagnosed at all levels. His blood tests were mislaid and he subsequently died of sepsis a couple of days after falling. This was a systemic death caused by a health care system.

The Times covered it as if it was an individual case of misconduct, instead of a national epidemic. Several days later the Times published an announcement by the hospital that they had developed a “checklist” to prevent such events in the future. Checklists are considered “low hanging fruit solutions,” as they cost almost nothing and allow institutions to march forward without making the systemic changes necessary to prevent such error-induced deaths. The systemic causes are:

• for profit care 
• staffing ratios 
• shiftwork 
• non-accountability to following
  policies and procedures
• legal issues that conflict with
  patient safety
• lack of root cause analysis

A recent op-ed piece in the Times (August 1, 2012) by Dr. Sanjay Gupta symbolizes in part how the mainstream media and members of the medical profession can distort the reality of medical error. In his piece, Gupta underestimates the number of deaths due to medical error by over 600,000, alluding to 200,000 deaths. He also never mentions the systemic causes and mostly attributes the blame to individual doctors or healthcare workers making mistakes.

Free Market Medicine

Free market medicine, or for-profit care, exacerbates adverse events. For-profit hospitals have 2 to 4 times the medical error rate as not-for-profit facilities. The healthcare system as it has evolved in the U.S. treats patients as economic objects, commodities to be traded in the market system, with customers that are defined as representatives of profit and loss. Himmelstein (JAMA 1999) found in a study that 56 percent of all HMOs that are for-profit had lower quality of care as measured by such health indicators as beta blockers after a myocardial infarction and lower incidence of providing eye exams to diabetics. In a meta review of 15 studies and 26,000 hospitals, for-profits were shown to have shorter lengths of stay and less staffing, a 6 percent higher mortality rate, 9 percent higher mortality rate in perinatal settings, and fewer skilled staff.

In the end, the U.S. has created an epidemic of harm for both mortality (+800,000 deaths) and morbidity (millions of injured due to medical care) or one out of three who enter the healthcare system suffer an adverse event—according to the latest study by Health Affairs—and is considered 37th in the world for quality of care. According to a recent report by Health and Human Services, Dr. Lee Adler, a leading physician and researcher, writes hospitals see medical errors as “the normal risk of doing business.” Obamacare, for all its controversies, will not address the contradictions in our healthcare delivery system vis-a-vis medical error. It leaves intact the for-profits, the insurance companies, and other bureaucratic delivery systems that maintain rather than change the systemic causes.

There are two areas that need immediate attention if the numbers of patients harmed is to be reduced in the near term. One area is staffing ratios for clinical care personnel and the second area is ratios of auxilliary personnel who clean the hospitals. The good news is that if both of these categories were brought up to scientific standards, it would greatly impact the data on medical error and infections.

STAFFING. The linkage between low staffing ratios and patient harm has been in the scientific literature for decades. Linda Aiken pointed out in her articles published in Peer Review the connection between higher ratios and higher patient mortality in 2002. She wrote that each patient above a 1:4 ratio produced an increase of 7 percent mortalilty and a ratio of 1:8 increases  patient mortality by 38 percent. Maintaining an RN ratio of 1:4 saves 72,000 lives annually according to Rothenberg in a journal article published in 2005. Despite this scientific proof that staffing ratios of 1:3 or 1:4 save lives, only one state in the U.S. has a ratio law, California, which mandates 1:2 in an ICU and 1:3 in a medical unit. Every year many states introduce regulatory language on ratios, only to see them die due to lobbying by State Hospital Associations, an employer association instituted to protect hospitals against unwarranted regulations. In a free market economy labor costs are considered expenditures. Increases in net profit are directly linked to labor costs and numbers of employees. However, healthcare is not a steel mill and the economic designs and paradigms have to be created using different metrics and cost benefit math. If healthcare, a scientific industry, is not reading or complying with its own scientific studies where data clearly shows the relationship between safety and ratios and that prevention is clearly cheaper than paying for the downstream error or infection, then even the language that healthcare is now applying about austerity makes no scientific sense.

CLEANING OR LACK THEREOF. The epidemic of hospital acquired infections (100,000 deaths annually) is also a direct result of the staffing levels of cleaners provided in each facility. New data presented in April at the annual meeting of the Society for Healthcare Epidemiology of America documented the lack of hygiene in hospitals. Boston University researchers, who examined 49 operating rooms, found more than half the objects that should have been disinfected were overlooked.

A study of patient rooms in 20 hospitals in Connecticut, Massachusetts, and Washington DC found that more than half the surfaces that should have been cleaned for new patients were left dirty. The report added that, “As long as hospitals are inadequately cleaned, doctors’ and nurses’ hands will be recontaminated seconds after they are washed—when they touch a keyboard, open a supply chest, pull open a privacy curtain.”

A recent Johns Hopkins study said that 26 percent of supply cabinets were contaminated with a dangerous bacterium, MRSA, and 21 percent with Vancomycin Resistant Enterococcus (VRE). Stethoscopes, blood pressure cuffs, and EKG wires were used on patients without being cleaned.

Studies published as long ago as 1978 warn that blood pressure cuffs frequently carry live bacteria, including MRSA, and are a source of infection. In a newly released British report, one-third of blood pressure cuffs were found to be contaminated with Clostridium difficile, a germ that can cause lethal diarrhea if it enters via the mouth.

By cutting cleaning staffs, reducing time spent cleaning and testing surfaces, and then paying for infections, the system cheats itself, paying more money post infections than it would spend preventing infections. By nearly doubling cleaning staff hours on one ward, a hospital in Dorchester reduced the spread of MRSA by 90 percent, saving 312 times the added cleaning costs. Hospitals in the U.S. once tested surfaces for bacteria, but in 1970 the CDC and the American Hospital Association advised them to stop, saying testing was unnecessary and not cost effective. MRSA infections since then have increased 32-fold and numerous studies have linked unclean hospital equipment and rooms to infections.

REPORTING ERROR. Hospitals have been and continue to be reluctant to gather reliable data and then release the numbers to the public domain. Of the 27 states that have reporting laws, Health and Human Services, in a newly released study, reports that there is little or no compliance and few consequences for non-reporting. Most of these state bills were underfunded and few accountability clauses for not reporting were built into the legislation. Chamberland in a 2012 study found that 50 to 96 percent of errors go unreported. Roehk in his study says hospitals only capture 14 percent of adverse events. Non-reporting can be considered a symbol of a system that prefers its own created image rather than a realistic look at medical error.

ADMINSTRATIVE EVIL. How can we explain the seemingly paradoxical circumstances where health care delivery poses a risk to those that require these services? One analytical tool is a perspective called Administrative Evil. The authors of a book called Unmasking Administrative Evil (2004) studied the role of evil in the field of public administration—historically and within our current structures. Evil in this context is a constructed reality. In other words, we have created structures within our society that permit evil acts to be done by our public administrators, often in the guise of efficiencies or improvements.

For example, an administrator might decide to reduce staff in a particular department to provide for more urgent care in another—leaving patients vulnerable in the understaffed area. A decision such as this, which, on closer examination, is really unethical, is being made by someone who is acting within his or her role as others would expect them to—from an organizational or policy perspective. Other more ethical options might not even have been considered.

In this state of “inverted morality,” what appears to be good is actually bad; what looks like it is right is wrong.

Concluding Thoughts

Health care is operating unsafely. It is injuring millions of healthcare workers (one in ten apply for worker compensation every year) and killing and injuring millions of patients. It is a badly designed system that does not even read, apply, or implement recommendations and findings of its own science. The cost of injuring millions of patients and healthcare workers is staggering. If even a certain percentage of these injuries were prevented each year, it would pay for the systemic changes that are at the very heart of the problem.

A redesign of the healthcare system is what is needed. In the short term, every state must pass a ratio law to provide the needed number of nurses and other clinicians and the ratio laws must include provision for the correct number of hospital cleaners to prevent infections. The regulatory process must be supported by labor and civilian groups such as the AARP (many of the victims of medical error are the elderly, especially for medication error), and other social groups. They must push past the lobbying efforts of the hospital associations that are in business to prevent any such change.

Accordingly, reporting laws must be re-written to assure accountability and a standardized method must be produced to compare apples to apples. Shiftwork regulations must change and actually follow the science, transparency must become the code word for an industry with habits of secrecy, hierarchical relationships that produce bullying and tension between classes of health care workers must be addressed and so on. It is not an easy task, but healthcare will never be safe unless we begin to address the systemic causes involved in 95 percent of all errors if a rigorous root cause analysis is done. 

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William Charney, an occupational health scientist, is editor of Epidemic of Medical Errors and Hospital-Acquired Infections.