JAMA: Outpatient Surgery Centers Suffer from Infection Control Problems

From the Wall Street Journal health blog:

Infection Control Gaps Seen at Outpatient Surgical Centers

The role of hospitals in spreading infections has been the subject of a lot of research. But increasingly, attention is being paid to infection-control practices at outpatient surgical centers — especially given the high-profile 2008 endoscopy-center catastrophe in Las Vegas, which may have exposed 40,000-odd people to the risk of hepatitis and HIV.

Researchers at the CDC surveyed 68 of these ambulatory surgical centers in three states, looking to see how well they complied with infection-control guidelines in five areas, including hand hygiene, injection safety and environmental cleaning practices. In a study published in JAMA, they report that state inspectors noted at least one lapse at 68% of the centers and saw lapses in at least three areas at 18% of the facilities. At 28% of facilities, medications in single-dose vials were used for more than one patient.

Of the 68 facilities, 39 eventually received state citations for infection control deficiencies and 20 for medication administration lapses.

This is all pretty important because, as an accompanying editorial notes, more than 75% of all operations performed are now done on an outpatient basis . . . .

If you or a loved one have been injured due to medical malpractice at an outpatient surgical center, call 888/234-0621 for a free consultation.

Scheduling Surgery? July is Worst Month for Fatal Hospital Errors

From ABCNews.com:

The ‘July Effect’: Worst Month For Fatal Hospital Errors, Study Finds
Study Finds More Fatal Medication Errors in July, Just When New Residents Arrive
By LAUREN COX
June 3, 2010

There is an old saying among some doctors — do not let your friends and family schedule a surgery in July.

July is the month when graduates, fresh out of medical school, report to residencies in teaching hospitals. Anecdotally, at least, it’s been a time when medical errors peak.

A new study decided to see if the so-called “July Effect” was real.

Researchers from the University of California at San Diego investigated more than 62 million U.S. death certificates between 1979 and 2006. Of those, 244,388 deaths were caused by a medication errors in a hospital.

Month to month, the statistics showed a relatively equal chance for a fatal medication error — except at teaching hospitals in the month of July.

The study found that fatal medication errors spiked by 10 percent in July in counties with a high number of teaching hospitals, but stayed the same in areas without teaching hospitals.

The findings appear in the current issue of the Journal of General Internal Medicine . . . .

If you or a loved one have been injured due to a medical error, call the Keating, O’Gara Law Firm at 888/234-0621 for a free initial consultation.

You can watch the ABC report here:

Mother of Toddler Who Died from Medication Error: “That was my purpose in life, to be her mom . . . . “

A tragic story from today’s Omaha World Herald:

Girl dies after medication error
By Juan Perez Jr.
WORLD-HERALD STAFF WRITER

Alicia Coleman was born relatively healthy, her mother said, even though she was three months’ premature and weighed little more than 2 pounds at birth. Things grew worse when Alicia came down with a bowel infection at 12 days old. The infection quickly spread through her intestinal tract and wreaked havoc on her tiny body.

Alicia’s doctors initially gave her a 5 percent chance of survival, said her mother, Dominique Coleman.

Yet Alicia fought through 15 surgical procedures and the battery of medications that marked the first year of her life. She improved to the point where doctors wanted to wean her off her medications. She was learning how to walk.

“We were very optimistic,” said Coleman, 26, of Omaha.

The 19-month-old child suddenly died Saturday while in the care of Children’s Home Healthcare’s World, a pediatric care center at 7815 Farnam Drive. Coleman and hospital authorities said medical staff erroneously injected some of Alicia’s medication into a catheter connected to her jugular vein.

The infant was struck by a seizure and stopped breathing, forcing rescuers to perform CPR as they rushed her to the emergency department at Children’s Hospital & Medical Center. She died after doctors spent an hour trying to revive her, her mother said.

Alicia’s death was at least the second associated with a medication-related error in the city in recent months. In early April, Nebraska Medical Center officials attributed the death of a 23-month-old girl to an overdose of blood thinner.

“One minute I’m fine, the next minute I’m crying,” Coleman said Sunday. “I really don’t know how to start thinking about what life is like without her.

“That was my purpose in life, to be her mom.”

Children’s Home Healthcare’s World is operated by Children’s Hospital & Medical Center. The facility, according to its website, is the area’s only full-service home health care agency focused exclusively on pediatric patients.

In a statement, Children’s officials confirmed that Alicia’s seizure occurred after medication was “improperly routed into the child’s system.”

“Children’s Hospital & Medical Center and Children’s Home Healthcare’s World share deepest condolences with the child’s family,” hospital officials said. “Words fail us at a time like this. Nothing can adequately express the sadness surrounding the loss of a child.”

Coleman knows the feeling. Alicia was her third child, she said. The first two were stillborn.

“She was my last hope,” Coleman said. “She’s made it through so many things and she bounced back, and for something stupid to take her so fast … .”

Coleman’s voice trailed away for a moment, then she said: “I guess I feel cheated.”

Our heart-felt condolences go out to the family of Alicia Coleman.

Near Fatal Medication Error Results in Lawsuit by Actor Dennis Quaid

Actor Dennis Quaid has sued Baxter Healthcare Corp., the manuracturer of Heparin, for negligence in not properly labeling its product. From the Contra Costa Times:

Actor Dennis Quaid sues drug maker

Actor Dennis Quaid and his wife Kimberly have filed a lawsuit against a drug maker alleging similar labels for the blood thinner Heparin and a less potent drug caused a mix-up at Cedars-Sinai Medical Center threatening the lives of his newborn twins in 2007.

Quaid filed the lawsuit Friday in Los Angeles Superior Court on behalf of his children against Baxter Healthcare Corp. The suit seeks unspecified damages.

Both Heparin and the lower dose version, Hep-lock, are packaged in similar vials with blue backgrounds and very small print on both labels, according to the complaint.

Quaid’s twins, who were born in November 2007, were both administered multiple near-fatal doses of Heparin to treat staph infections, according to the lawsuit.

The children, Zoe Grace and Thomas Boone, were given 10,000 units of Heparin, rather than the 10 units of Hep-Lock they were prescribed, according to the complaint.

Baxter Healthcare should have recalled the vials of Heparin containing 10,000 units because the company knew infants had died because of similar medication errors, according to the lawsuit.

The company also was obligated to warn healthcare providers of the previous medication mistakes, the suit states.

The children suffered internal injuries and shock, but the extent of what happened to them will probably not be known for years, according to the suit.

Newborns and infants are often given Hep-Lock to flush their prevent clotting because their intravenous lines are so small . . . .

The twins’ overdose is just one of the estimated 100,000 fatalities stemming from medical errors that occur every year in American hospitals and from pharmaceuticals. If you or a loved one have been injured by medical malpractice or through a medication errorand would like to talk with an experienced Nebraska defective drug lawyer, call the Keating, O’Gara Law Firm at 888/234-0621 for a free consultation.

Lincoln Journal Star Covers Keating, O’Gara Tort Claim Filing for Death of Olivia Manes

manes-family.jpg
Olivia Manes, seated between her parents, Tina and David Manes, and pictured with older sister Suzanne, age 20, and brother Jesse, age 14, at Christmas time.

From the Lincoln Journal Star:

Parents sue state to get answers in daughter’s death
By DEENA WINTER
Lincoln Journal Star
Friday, Feb 13, 2009

At first, she was known only as Client 1.

An 18-year-old Beatrice State Developmental Center client had died.

Three hours after going into a seizure, she was dead.

She hadn’t had a seizure since 1999, when she began taking Klonopin to control them.

Her parents didn’t know it, but three days earlier, Beatrice staff had stopped giving her the medication, triggering what their attorney calls “a cascading series of medical errors.”

At about 3 a.m. on Jan. 16, her parents were awakened by the Pawnee County sheriff.

Client 1, as she was referred to in a state investigation, was dead.

But she had a name: Olivia Manes.

On Thursday, Tina and David Manes filed a $1.75 million claim against the state for wrongful death and the “pre-death terror, pain and suffering” of their daughter Olivia. They alleged at least 10 errors in her care.

A spokeswoman for the state declined to comment on the filing.

Tina and David learned Olivia had Dandy-Walker Syndrome when she was 2 months old. She was blind and mentally retarded. She never walked. She had 15 to 20 seizures per day.

They kept her home until she was 6 and it became clear they could no longer care for her. She had difficulty swallowing. Feeding her took a couple of hours. She wasn’t getting enough fluids.

Immediately, they knew where they wanted her to live.

David’s older brother, Mark, had Down Syndrome and lived at the Beatrice center.

“I grew up out there,” said David, a Beatrice native.

Tina said she felt guilty because she had “selfishly” kept Olivia at home longer than perhaps she should have. When she went to Beatrice, she was so small and possibly malnourished they could carry her like a toddler.

In Beatrice, she learned to eat, drink and swallow properly. She came to love eating.

She thrived, particularly after she began taking one tablet of seizure medicine daily. It was her lifeline.

She loved music especially Shania Twain and Christmas songs. She loved feeling the breeze on her face when someone pushed her wheelchair outside.

The Maneses and their son and another daughter live 39 miles away from Beatrice, in Steinauer. They visited Olivia at least weekly.

When she heard their voices, her mother said, she would light up and reach her hands out for a bear hug that could give you whiplash.

She loved to nestle her cheek next to yours, Tina said, crying at the memory.

They felt like she was meant to spread joy at Beatrice.

When they got the call telling them she’d died, they couldn’t understand how their girl, who hadn’t had a seizure since 1999, could be gone.

Two weeks after burying their daughter, the Maneses learned some of the heartbreaking details of Olivia’s death while watching the evening news.


From offices in Lincoln, Nebraska, attorneys at Keating, O'Gara, Nedved & Peter, P.C., L.L.O. serve clients in Lincoln, Grand Island, Kearney, Omaha, Hastings, Norfolk, Fremont, Beatrice, Broken Bow, Valentine, Lexington, North Platte, McCook, Ainsworth, O' Neill, Wayne, Norfolk, Fairbury, Kimball, Sidney, Seward, York, Aurora, Columbus, and communities throughout Lancaster County, Adams, Buffalo, Custer, Gage, Hall, Lincoln and Red Willow Counties, and those injured in traffic accidents on Interstate Highway 80, and Nebraska state highways 81, 83, 183, and 281.