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  #1  
Old 01-08-2012, 03:39 PM
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Default Medical errors and "adverse events"

How would you know if your complication (an adverse event) is reported? It's not a trick question -- I'd really like to hear what people have to say about this question. See the article below.

Even the definition of an adverse event is a bit tricky -- here's one from the internet:

"An injury caused by medical management–rather than by the underlying disease–which prolongs hospitalization, produces a disability at the time of discharge, or both Etiology Drug effects, wound infections, technical complications, negligence, diagnostic mishaps, therapeutic mishaps, and events occurring in the emergency room."
_______________________________________

Medical errors go unreported at hospitals
The State Column | Staff | Saturday, January 07, 2012

According to the U.S. Department of Health and Human Services (HHS), the Office of Inspector General (OIG) reported that about 86 percent of hospital medical errors are not reported into the databases of incident reporting system, a system designed to manage and improve the quality of care for patients. Shockingly, 62 percent of adverse and “temporary harm” events are not reported due to staff believing the event does not need to be reported and 25 percent of the medical errors not reported were medical errors that are commonly reported, however were not reported for that instance.

Unreported events included hospital-acquired infections, overused or wrong medications, severe bedsores, and excessive bleeding due to administration of anticoagulants, and in some cases, death. By reporting these events, the hospital administration would be able to identify problems and help improve the care of the patients.

Read more: Medical errors go unreported at hospitals | The State Column
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
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  #2  
Old 01-08-2012, 10:00 PM
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those things mentioned are pounded into the heads of everyone from docs on down the places i've worked...

what i worry about are the much simpler, more common things - like drug dosing errors, wrong patient testing, and wrong patient getting a med. those are the things i've seen and had to rip people's heads off for...
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The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
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  #3  
Old 01-09-2012, 01:25 PM
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I believe you LUD. This is the most concerning to me:

"...62 percent of adverse and “temporary harm” events are not reported due to staff believing the event does not need to be reported..."

Why is this a continuing problem? If a medical staff member is confused, what is the business process to find guidance or seek clarity?

Perhaps part of the problem lies with the FDA or even CDC. Both medical professionals and consumers can report adverse events here:

http://www.fda.gov/Drugs/GuidanceCom...ts/default.htm

But people may get confused as they try to follow the web site navigation and define the medical problem as defined by the web site language. The gov can and should do better IMHO. They known about this problem for many decades.

(see article posted 1-9-12 below)
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate

Last edited by Harrison; 01-09-2012 at 08:53 PM. Reason: added article reference and fixed typos
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  #4  
Old 01-09-2012, 06:56 PM
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some of these things are hospital dependent. as far as hospital acquired infections and decubitus ulcers... i know most places are VERY diligent about documenting the presence of infection or ulcers on admission, b/c if they're deemed to be hospital-acquired, they may not get paid!

the way the FDA site is worded, those things to report have to do w/ MEDICAL DEVICES... not a behavior or personal error.

this leads to having multiple types of errors to be reported, and to be honest, i don't know 100% of what i'd have to "report". usually it's the nurse who comes to me and says hey, sign this form b/c Mrs Smith fell off the stretcher and bruised her knee. more of an incident than an error... most places i've been, the charge nurse is ultimately responsible for knowing what happens and making sure the paperwork gets done.
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US non-spine MD - laid up no more!!!
had recurrent annular tear L5/S1, failed everything
M6L done 10/19/11 w/ Dr Clavel getting back to my old self more and more every week!
laidupdoc@gmail.com if my PM box is full

The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
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  #5  
Old 01-09-2012, 08:52 PM
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Harm in Hospitals Seldom Reported, OIG Says

By Emily P. Walker, Washington Correspondent, MedPage Today
Published: January 06, 2012

WASHINGTON -- Most hospital errors that result in harm to Medicare patients go unreported, and even when they are, hospitals rarely change the way they operate in order to prevent similar errors in the future, according to a new report from the Department of Health and Human Service's Office of the Inspector General (OIG).

The OIG found that hospital staff did not report 86% of adverse events, whether errors or accidents. Hospital administrators interviewed for the report suggested that doctors and nurses are unclear about what constitutes a reportable adverse event.

For their report, investigators selected 420 adverse events from an earlier OIG review on hospital errors and had physicians review the medical records on those cases.

The doctors identified 302 events of preventable harm to patients, 128 of which were considered serious, including a death from septic shock and four deaths from excessive bleeding after administration of anticoagulants.

To determine which of the 302 events were actually reported in hospital error-reporting systems, the OIG requested error reporting data from the hospitals where the selected adverse events occurred.

The OIG investigators also interviewed hospital administrators about the specific events and why they weren't reported. All of the hospitals involved had reporting systems in place and said they expected staff to report errors that resulted in patient harm, but none had a standardized list of which events should be reported.

The administrators told OIG investigators that the most common reasons that errors went unreported were that no clear error occurred leading up to the adverse event, that the event was thought to be a common side effect to the treatment, and that the event occurred so frequently that it was considered too common to report.

For instance, only one of 17 catheter-related infections -- a common event in Medicare beneficiaries -- was reported.

In his conclusion, report author Inspector General Daniel Levinson wrote that it is crucial that the adverse event reporting systems do what they're supposed to and said that the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) are in the best position to provide hospitals with guidance and incentives to better use reporting systems.

Specifically, AHRQ and CMS should create and promote an adverse event list to be used by hospitals, other healthcare providers, and medical and nursing schools. The list would detail the full range of patient harm that can occur in hospitals so hospital workers would have a clearer idea of what events should be reported.

CMS and AHRQ agreed with the recommendations, according to OIG.

Levinson also recommended that CMS provide guidance to accreditors on how to better assess hospital efforts to track and analyze adverse events. As a condition of participation in Medicare, hospitals must go through an accreditation process that proves they are tracking events that result in patients being harmed.

The OIG report on which the current analysis was based was done in 2010. It found that nearly 14% of hospitalized Medicare beneficiaries experienced a preventable adverse event that resulted in extended hospitalization, required life-sustaining intervention, caused permanent disability, or resulted in death.

An additional 13.5% experienced events that required some sort of additional treatment, but were not life-threatening, the 2010 report showed.

The idea of doing a better job of tracking patient harm as a result of medical treatment gained popularity after the Institute of Medicine's 1999 landmark report "To Err is Human: Building a Safer Health System." That report argued that hospitals can only address patient safety problems if adverse events are identified and adequately described.
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #6  
Old 01-09-2012, 09:07 PM
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if CMS gets involved, no one will get paid for anything that could even be construed as an honest error... there's always a fine line between having standards and getting the gov't involved (see EMTALA, HIPPA, JCAHO, and pretty much anything else tied to gov't healthcare $$).... take care of it before they tell you how and won't give you any money to pay for it...
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US non-spine MD - laid up no more!!!
had recurrent annular tear L5/S1, failed everything
M6L done 10/19/11 w/ Dr Clavel getting back to my old self more and more every week!
laidupdoc@gmail.com if my PM box is full

The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
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  #7  
Old 01-09-2012, 10:34 PM
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CMMS has been involved for decades (see this org chart) The Department of Health and Human Service's Office's job is to communicate among the various govt. agencies. A simple list started in 1999 (see original report) would have been a good starting solution. Why did CMS and AHRQ drop the ball?

Kick the can down the road -- at the patients' expense. How very sad. How inept.

I've talked and interviewed govt. employees (some are in the film to be released), and they really are good, bright people. But accountability and efficiency are lacking in the various orgs that are supposed to be taking care of us:

HHS Organizational Directory

With all those tax dollars, and tens of thousands of employees, I would expect them to do more. We already know that Medicare is in deep, deep trouble. How can we as patients help?

That said, I've really tried hard and I am sorry to say, I've given up. It's ugly. Some of this sentiment is expressed in my film and in the interviews I published on biofilmcommunity.org.
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #8  
Old 01-10-2012, 12:20 AM
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i don't have the answers man, but having the federal gov't take care of it is rarely the answer to any real problem.

the advice i give everyone is - have someone with you when you are in the hospital, particularly if you are going to be of unsound mind during any of the stay. have them ask questions. lots of them. write everything down.
__________________
US non-spine MD - laid up no more!!!
had recurrent annular tear L5/S1, failed everything
M6L done 10/19/11 w/ Dr Clavel getting back to my old self more and more every week!
laidupdoc@gmail.com if my PM box is full

The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
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