A hospital is no place to be sick.
—Samuel Goldwyn1
An elderly woman called a particular hospital and said, “Hello, darling, I’d like to talk with the person who gives the information regarding your patients. I want to know if the patient is getting better, doing as expected, or getting worse.”
“What is the patient’s name and room number?” the nurse at the station asked over the phone.
“Sarah Finkel, in room 719,” the woman responded.
“Oh, yes. Mrs. Finkel is doing very well,” the nurse said. “In fact, she’s had two full meals, her blood pressure is fine, and her blood work just came back as normal. She’s going to be taken off the heart monitor in a couple of hours and if she continues this improvement, Dr. Cohen is going to send her home Tuesday at twelve o’clock.”
“Thank God!” the woman said. “That’s fantastic, darling! That’s wonderful news!’
“From your enthusiasm, I take it you must be a close family member or a very close friend,” the nurse said.
“I’m Sarah Finkel in 719!” the woman snapped. “My doctor doesn’t tell me bupkes!”
Hospitals come in many sizes: big, small, private, community, tertiary (specializing in heart surgery, transplantation, etc.), university, and teaching. University and teaching hospitals will give lots of attention to patients, but that attention may consist of repetitive examinations by students, interns, and residents. You can be sure you will have an abundance of specialists available, and they will be preceded by a lot of residents and fellows in training. Conversely, the more rural the hospital, the smaller the hospitals tend to be. Often there are fewer specialists on attending staffs in these smaller, more rural, hospitals, as they are catering to a smaller community of patients. Obviously you want the hospital you pick to be near your home, which may limit your choice. But whatever hospital you choose, big or small, urban or rural, the most important thing to keep in mind is that this is the primary breeding ground of the third leading cause of death in the United States—and the core subject of this book—medical malpractice. To beat a dead horse (one that probably died of natural causes, since animals hopefully suffer less malpractice than humans), medical error is a true public health hazard, a pandemic in a very real sense. It is a danger on the same level as smoking, auto accidents, and pollution. In fact, it occurs in 20 percent of all hospitalized patients.2 That is one in every five patients! So, in the final analysis, choosing the best, and safest, hospital may take priority over choosing the closest.
We covered some of the causes of medical malpractice, which can vary based on many factors. However, they can be categorized as follows:
• Lack of skill of a doctor.
• Overworked and exhausted medical practitioners.
• Injury caused by employees of the doctor or hospital.
• Use of unsafe, untested, or inappropriate drugs or medicines.
• Unsafe hospital procedures or equipment. This includes defective and toxic products, and failure to recall defective defibrillators and pacemakers.
• Hospital-acquired infection. This is one of the worst culprits, yet it is not normally viewed as malpractice. However, considering that the hospital’s main function is to make you better, having conditions that lead to such widespread infection should be considered medical error. As a comparison, if you brought your car in to be repaired and it was running worse as a result of being in the shop, that would be considered the error of the mechanics, right?
The first report sounding the alarm on malpractice was published in 1999 by the Institute of Medicine ([IOM], part of the National Academy of Sciences). At that time it was reported, as already mentioned in the Introduction, that 100,000 patients die annually in American hospitals, and these deaths were attributable to preventable medical errors. The cost to individuals, their families, and society at large for these errors was estimated at $20 to $30 billion annually. In some cases, these figures have been surpassed. One study in Kentucky showed that 1,000 patients die annually in their hospitals due to preventable medical malpractice events.3 The cost borne in Kentucky by residents, patients and their families, and the community at large was greater than $300 million annually. A report on New York hospitals revealed an average of twenty-seven instances, per hospital, of invasive procedures performed on the wrong patient in a one-year period.4 The same review of Florida hospitals found an average of eight patients per hospital.5
Hospitals account for a significant amount of medical malpractice because of the invasive procedures performed. A little-known 1974 study of California hospitals showed that 0.8 percent of hospitalized patients were injured by negligence in the hospital, and, ironically, the patients were in the hospital because of negligent care by their doctors.6 Did you follow that? Patients had to go to the hospital because their doctors had injured them! That amounted to 250,000 injured patients. Another study of New York State hospitalized patients in 1984 revealed 1 percent of patients that year were injured by negligence. This caused the demise of a quarter of these patients. That is a total of 234,000 injuries and 56,000 killed.7 Yes, I said “killed.” Not intentionally, of course. But I think it is important not to soften the blow of these statistics by saying “they died due to complications.” No, they were killed by medical error.
Has a different ring to it, doesn’t it? Hopefully it is more of a wail than a ring, like an alarm going off. Interestingly, only one malpractice claim was (and is still) made for every 7.6 hospital-induced negligent injuries.
HealthGrades, Inc., originally found that 195,000 patients in the United States died due to potentially preventable “in-hospital” medical errors every year (for 2000, 2001, and 2002).8 That is even worse than the opening statistics of this book. That is more than one jumbo jet full of people crashing and killing everyone on board—every day of the year. In fact, it is the equivalent of 390 jumbo jets full of people dying each year due to preventable “in-hospital” medical errors. The HealthGrades report was published in July 2004. It cited the 1999 Institute of Medicine’s report as too low (90,000 deaths was too low; that is us Americans, always trying to top ourselves). HealthGrades is the leading health care ratings organization, providing ratings and profiles of hospitals, nursing homes, and physicians. Millions of consumers and many of the nation’s largest employers, health plans, and hospitals rely on HealthGrades’s independent ratings.9
The IOM’s 1999 report called for a 50 percent reduction in errors over the next five years. Unfortunately, this error rate has increased instead of decreased. Some of the IOM’s recommendations were:
• Keeping patients safe (this one was a real revelation!).
• Transforming the work environment of nurses.
• Identifying solutions to problems in hospitals, nursing homes, and other health care organizations’ work environments that threaten patient safety through their effect on nursing care. (Why didn’t I think of that?)
• Achieving a new standard of care.
• Giving a detailed plan to facilitate data standards.
• Establishing a national standard.
• Creating comprehensive patient safety programs in health care organizations.
One major cause of medical malpractice causing morbidity and mortality in hospital patients, as previously indicated, is infection. Approximately 3 million hospitalized patients a year, 10 percent, will contract hospital-related infections. According to the Centers for Disease Control and Prevention, 90,000 of these patients who contract in-hospital infections will die every year.10 Not all of these are caused by medical malpractice, but the majority of them seem to be. The recent increase in antibody-resistant bacteria and the mounting cost of caring for these patients add $4.5 billion annually to our health care bill.
To further complicate matters, many physicians give antibiotics to potentially ill patients without first adequately culturing the infected area. Oftentimes surface bacteria are cultured rather than getting deep into a wound for a culture. This misuse of antibiotics can obscure an infection and fool the physician into thinking he or she used the right antibiotic, only to hide the more serious infection (such as that of the heart or bone). I have frequently had to tell patients to stop their course of antibiotics for a week or more in order to allow the proper culturing and identification of their infections.
The Chicago Tribune reported in 2002 that 75,000 Americans die yearly from hospital-acquired nosocomial (Greek for “our house”) infections that were preventable.11 They reported that not enough hand washing and changing of scrubs were the major causes. Interestingly, but, based on the logic of the medical industry so far, not surprisingly, since 1995, American hospitals have pared down their cleaning staffs by close to 30 percent.12 Is it just me, or are things going in the opposite direction? It is like realizing you are driving on the wrong side of the freeway—so you speed up! Have we fallen down the rabbit hole and not realized it? A recent study showed that doctors washed their hands, in between seeing each patient, only 44 percent of the time if nobody was looking. If they knew they were being watched, then 61 percent washed up.13
Adding to the list of causes for medical malpractice is the growing shortage of nurses. Low nurse staffing directly affects patient outcomes, resulting in problems such as resistant urinary tract infections, shock, and gastrointestinal bleeding. This was reported in 2001 by a study done by Harvard and Vanderbilt professors. Studies show that patients in hospitals where nurses had heavier workloads also had a higher risk of dying. Each additional patient per nurse corresponds to a 7 percent increase in patient morbidity and deaths following complications. Nevertheless, nursing shortages persist.14
As this book was going to press HealthGrades issued two important studies reviewing 41 million Medicare patient records at 5,000 hospitals over a three-year period. The first study was the HealthGrades eleventh annual Hospital Quality Study. Based on the study, HealthGrades made available on their Web site quality ratings for all nonfederal hospitals in the country. Full reports on death rate trends in each of the fifty states are available in the study. And the report includes hospital death rates for the nation’s fifteen largest metropolitan statistical areas.
The astounding revelation was that patients had a 70 percent lower chance of dying at the nation’s top-rated hospitals compared with the lowest-rated hospitals. This was determined by studying seventeen procedures and conditions. While overall death rates declined slightly from 2005 to 2007, the nation’s best-performing hospitals were able to reduce their death rates at a much faster rate than poorly performing hospitals, resulting in large state, regional, and hospital-to-hospital variations in the quality of patient care.
The study concluded that if all hospitals performed at the level of those five-star–rated hospitals, 237,420 Medicare deaths could have been prevented over that three-year period. That is to say 80,000 Medicare patients could have been saved every year. Large gaps persist between the best and the worst hospitals across all procedures and diagnoses studied. Five-star–rated hospitals had significantly lower risk-adjusted mortality across all three years studied. Across all procedures and diagnoses studied, there was a 70 percent lower chance of dying in a five-star–rated hospital compared to a one-star hospital (as noted above). However, across all procedures and diagnoses studied, there was a 50 percent lower chance of dying in a five-star hospital compared to the U.S. hospital average. Interestingly, the region with the lowest overall risk adjusted mortality rates was the east northcentral region (Illinois, Indiana, Michigan, Ohio, and Wisconsin). This region had the highest percentage of best performing hospitals, at 26 percent. Less than 7 percent of hospitals within the New England region were top performing hospitals. Out of the 5,000 hospitals studied by HealthGrades, how many hospitals do you think were considered five star? Twenty-five percent? Perhaps 20 percent? A mere 250 hospitals got the top rating. That is 5 percent of the hospitals. That does not include veteran’s or military hospitals. No other federal hospitals were included, so the percentage of best care hospitals goes down to much less than 5 percent.15
The second study issued by HealthGrades was the fourth annual Patient Safety in American Hospitals Study. This study, like the previous one, used the same database of 41 million Medicare patients in 5,000 hospitals but during a different three-year period, from 2003 to 2005. The definition of patient safety for the study was “freedom from accidental injury due to medical care, or medical errors.” They defined medical error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim, including problems in practice, products, procedures, and systems.
The study showed that 1.16 million total patient safety incidents occurred in over 40 million hospitalizations in the Medicare population, which is almost a 3 percent incident rate. These incidents were associated with $8.6 billion of excess cost during 2003 through 2005. The total patient safety incident rate worsened by an additional 2 percent of incidents per 1,000 hospitalizations in 2005 compared to 2003. Of the 284,798 deaths that occurred among patients who developed one or more patient safety incidents, 247,662 were potentially preventable. Furthermore, Medicare beneficiaries that developed one or more patient safety incidents had a one in four chance of dying during the hospitalization during 2003 to 2005. As with the first study, there were wide, highly significant gaps in individual safety incidents and overall performance between the rated “Distinguished Hospitals for Patient Safety” and the bottom ranked hospital. Medicare patients in these Distinguished Hospitals for Patient Safety had a 40 percent lower occurrence of experiencing one or more safety incidents compared to the bottom ranked hospitals. Failure to rescue is shorthand for failure to prevent deterioration, such as death or permanent disability from an underlying illness. The patient safety indicators with the highest incidence rates were decubitus ulcers (bed sores), failure to rescue, and postoperative respiratory failure. If all hospitals performed at the level of the Distinguished Hospitals for Patient Safety, 206,298 patient safety incidents and 34,393 Medicare deaths could have been prevented while saving the United States $1.74 billion during the 2003 to 2005 study period.16
These reports did not cover other causes of injury to patients. One of the most common causes of injury, in a hospital setting, is falling. Patients fall because they are weak, feel faint, or become dizzy due to medications. Patients likely to fall are supposed to be identified at the time of admission and also reevaluated during their confinement. Are the patients stuporous, prone to falling, or dizzy? Do they have a history of falling? The hospital has to have a written manual that details a plan to prevent such falls. Should patients who are dizzy be restrained? At the very least, and what is recommended, is that patients who are prone to fall be placed in rooms just in front of the nurse’s station, so that there can be better observation. At least 50 percent of physical injuries in hospitals occur from falling from either a bed or a chair. I once testified against a physician who ordered 20 milligrams of a sleep medication for his patient. The medication was ordered for an 80-year-old man who had difficulty in sleeping. The Physicians’ Desk Reference, a guide for prescribing nurses and physicians, specifically states, in emboldened letters, that no more than 5 milligrams of that particular drug should be dispensed to any person over the age of 65. One would reason that if 5 milligrams would help put one to sleep, that 20 milligrams would do a better job? As it turns out, 10 or 20 milligrams does not do any better than 5 milligrams, it just increases the chances of unwanted side effects. In the case of this hallucinogenic drug, the incidence of dizziness and falling rises tremendously. Why this particular pharmaceutical company offers the higher dosages, knowing these facts (they print them in the Physician’s Desk Reference), is beyond me. Why this particular physician ordered the 20 milligram dose (which is never indicated) is also beyond me. The elderly patient was found confused, lying on the hospital floor, with a fractured hip. His roommate stated that the patient was mumbling, fighting to get out of bed, tripped and fell. All this time, the roommate was ringing on his bedside call button, but nobody came to his aid.
The HealthGrades reports also did not cover medication errors, transfusion errors, or surgical errors, which I cover in another section of this book.
So that, my friends, is a snapshot of our current hospital situation in America. Not a pretty picture. Not a place that you would want to get a room at any time soon. Unfortunately, many people won’t have that option. So what are you to do if you find yourself booking a stay at Sickness Central? First of all, don’t go in scared. Despite all the negative statistics in this book, the fact still remains that plenty of people check in to hospitals and check out “all better.” The minority of doctors and medical practitioners are responsible for the vast majority of malpractice incidents that occur. Nevertheless, to deny this growing problem would be like turning a blind eye to those jumbo jets crashing every day of the year. Remember, my intention is not to make you more frightened of the medical world, just more informed about it. The purpose of telling it like it is is to make sure that you do not take anything for granted and make sure that you take control of your health care experience.
Just as with the doctor visits, when you stay at the hospital, you are dealing with human beings: nurses, doctors, and other staff members who are dealing with their own issues—not the least of which are an abundance of bureaucratic, political, and workplace problems. I know that you are there because you are sick and need help. I know that they should be thinking only about how they can make your experience the best it can possibly be. I know that they should make sure that you heal in the quickest, most painless way possible. And I believe that, for most health care practitioners, that is what they wish, too. But, alas, that isn’t the way things often are. And all of us physicians do make mistakes. So that once again puts the ball squarely in your court.
So what are you going to serve back to the medical practitioners working with you? As best as possible, you want to treat them with as much kindness and respect as you can. Thank them when they help you. Share personal things about yourself and seek to get to know them as well. The more personal you become with them, the closer your working health care relationship with them can be. The more you respect, validate, and appreciate them, the more they are likely to return the favor. Now is not the time to be proud. Swallow your pride. You can cough it up later, when you have made it out of the hospital, alive and well!
As always, do your research. If you have followed the guidance of this book, you investigated the hospital before you checked in, and you know the statistics for the particular procedure you are going in for. You have Googled until your fingers are sore. You have written out your questions and concerns, discussed them all with your doctor, and had every question answered completely. You have gotten a second—and sometimes even a third—opinion. You have brought along a friend or family member to crucial doctor appointments, before committing to the hospital stay, to be your objective witness.
Of course, depending on your location and insurance status, you may not have unlimited choice as to which hospital, doctor, or level of facilities you will have access to. This is, unfortunately, just the reality for some of us. Nevertheless, having a thorough knowledge of the hospital statistics, the doctor’s track record, and a comprehensive list of questions and concerns that have been fully addressed—as well as an alert, proactive stance while in the hospital—will dramatically increase your chances of having a successful medical experience, regardless of the particular hospital and medical team you find yourself working with.
As you go through the experience of your stay, leading up to the particular procedure for which you are entering the hospital, make sure once again that every medication you take is the right one. Check and double check against any allergies you may have had. Ask the doctor exactly why you are taking it and what, if any, alternatives there are. What possible side effects and drug interactions are there? This goes for all tests as well. If the thought of being this assertive makes you want to curl up into a ball—snap out of it! But if you can’t, enlist a good friend or caring family member to be your patient advocate. While you are staying in the hospital, as well as before, during, and after the day of any major procedures, it is also a good idea to have someone there to be an extra pair of eyes and ears.
Recently I received a phone call from a former classmate and similar specialist in infectious diseases. He had decided to practice medicine in Israel and is quite well known in his field. He had a problem. His only sibling, his sister, was in and out of a small community hospital in Long Island. He could not get the physician caring for his sister to speak with him and, to his dismay, she had already been in the hospital for a total of six weeks. The family had not even been told of any diagnosis. What he did know was that after she was in the hospital for about two weeks, she was sent home, where she would then collapse and have to be taken back to the hospital the next day. This cycle occurred on three separate occasions. Obviously, something was amiss. I spoke with the brother-in-law and obtained the physician’s name and number. When I phoned, the doctor’s nurse said that he does not speak to other doctors and would not come to the phone. That was a tip-off that he probably did not know what was wrong with my friend’s sister. I next phoned the administrator of the hospital, who was in a meeting, and got the sympathy of his secretary. So far I am following the script I would have prescribed for you. One half hour later, the physician called. He was not apologizing, but he also had no clue as to what was going on. He shared no information with me so I called the husband and strongly suggested that, if it was okay with him, I would arrange for a transfer to a university hospital a half mile away. He was delighted. The chief of medicine at the university hospital agreed to the transfer, but there was a delay for a few days, as the insurance company objected to both the transfer and having to pay for the ambulance ride. On the day of transfer, the husband called to say that his wife had suffered a heart attack (so he was told) and needed heart surgery. What had actually happened was that she had had low-grade fevers, never had blood cultures taken, and was, unknowingly, suffering from endocarditis (an infection of the valves of the heart). She needed her heart valve repaired. If a doctor isn’t forthcoming, or if he cannot come up with a reasonable answer, it is your duty to obtain a second opinion, sooner rather than later.
Of course if you are entering a hospital as the result of an accident, you may not have been able to do all the necessary preparation (the hopeful exception being if your accident occurs locally, and you have already scouted the hospitals in your area). If this is the case, fear not. As soon as you have presence of mind, that is the time to begin asking questions and making sure that you get answers. From that point on, question everything, kindly, but firmly. And get that patient advocate in there by your side.
Prescription
• Research the hospitals in your area or wherever you may be staying for an extended period of time. Check statistics, doctors, specialists, and technical equipment quality.
• After reading the HealthGrades reports, it makes sense to be admitted to a five-star–rated hospital (which is usually also a Distinguished Hospital for Patient Safety) if it is possible. Odds are in your favor for a safer outcome and the chance you will leave that hospital in good shape. That doesn’t mean that nothing can happen to you. One of my patients was recently in a five-star hospital. While in the intensive care unit the doctor told the nurse that my patient needed potassium. Instead of putting the potassium in the I.V. solution, she injected it directly into his vein. He screamed out because of severe burning and his blood pressure dropped to 50 as he went into shock. He did, however, survive.
• Get all your questions answered from your doctor, surgeon, anesthesiologist, and anyone else who will be on the medical team before entering the hospital and before any major procedures.
• To limit your susceptibility to acquiring hospital infections, make sure anyone who touches you washes their hands first. Infectious agents are commonly carried from one patient to another. In the old days before antibiotics, many unfortunate women died of puerperal sepsis (birthing mothers dying of rampant infection). Fortunately, a quite brilliant physician realized that midwives and physicians who were not washing their hands were probably passing the strep infection that was killing these women from one patient to the next. So he posted nurses, stationing them at the end of each ward. Their job was to blow a whistle at anyone who attempted entering a room without first washing his or her hands. This simple procedure ended the outbreak of a terrible human-induced disease and went on to save thousands of future lives.
• Cross-infection can occur frequently, such as when a nurse changes one catheter that is infected and then changes another without washing his or her hands. Be alert to these incidents and do not hesitate to point it out.
• Intravenous sites and catheters have to be changed every two to three days to prevent phlebitis and infection. If you suspect that you will be in and out of a drowsy state as you recuperate, let your friend or family member know that these are things to watch out for, and let them be your eyes while yours are resting
• Ask your physician daily if the intravenous line or catheter is still necessary. The longer they stay in, the greater the odds of getting an infection.
• Urinary catheters can and should be hooked up to triple lumen catheters, which allow sterile liquids to irrigate your bladder continually.
• When urinary catheters are removed, the nurse should first insert a few ounces of 0.25 percent solution acidic acid into your bladder to kill off the bacteria that will remain behind.
• Preoperative patients should be shaved with a clipper and not a razor. Abraded and scratched skin can become infected more easily.
• Do not accept an antibiotic unless the wound, urine, or blood was adequately cultured. You do not want to take the wrong antibiotic, which could mask the real culprit.
• As with outpatient procedures, get your surgery done first thing in the morning. The operating room is presumed to be the most sterile and not yet contaminated by a previous case. The surgeon and operating team are bright-eyed and bushy-tailed. I reviewed a case where a patient was the second one of the day to have a dilation and curettage (D&C) for a stillborn. The first patient had had a similar procedure done, but she also had hepatitis C. Unfortunately, the second patient came down with the same strain of hepatitis C six weeks later.
• Call the hospital’s quality control, risk management, or infection control nurse and get the infection statistics for your physician as compared to his or her peers as well as the general risk compared to other hospitals.
• Check out the hospital on Web sites that compare hospitals’ national averages.17
• Medical workers favor institutions that attract nurses. The American Nurses Association’s Web site lists “magnet hospitals,” those most attractive to nurses.
• Call the hospital’s nursing supervisor and find out the nurse-to-patient ratio.