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.

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:

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.

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.

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.

“Nobody bothered to let us know,” Tina said of a report released to the media.

Nobody had told them staffers had stopped giving Olivia her seizure medicine. And although normally they’d get a call even when she had the sniffles or scraped her hand, nobody called when she began having seizures at 11:30 p.m. Jan. 15.

They weren’t told an ambulance picked her up two hours after the episode began. Once in the hospital, she was found to have pneumonia and a fever of 106 degrees.

Nobody had told the Maneses that no one checked Olivia’s vital signs while she was thrashing and seizing at the developmental center.

Tina breaks down when she thinks of her daughter suffering for hours “fighting for her life.”

Nobody called them to be with her daughter.

Nobody told them any of those things.

“We have never once gotten a call from BSDC,” Tina said. “Olivia was happy and healthy and besides having her syndrome, hasn’t had a seizure for 10 years.”

Last weekend, they got a phone call from Gov. David Heineman. He apologized that they had to learn the details of their daughter’s death on the news.

David said he talked to Heineman for about 90 minutes, explaining how he doesn’t blame the staff. He blames administrators for not properly training staff or being qualified to run the center.

He doesn’t think Heineman realized how severely disabled some of the people in Beatrice are.

“It seemed to me that he was out of touch,” David said.

He told the governor he thinks Beatrice should stay open and that group homes cannot provide the kind of services people like Olivia need.

The Maneses didn’t know until after Olivia died that the center had cut nursing staff on the night shift. They didn’t know, until they read a state investigation into her death, that not all staff was trained to handle seizures, even though 17 of the 18 people in Olivia’s unit had a history of them.

Despite all the negative publicity surrounding the Beatrice center “especially in recent years” the Maneses say they never saw the kind of abuse and neglect alleged by advocacy groups and inspectors.

The center is on the verge of losing $29 million annually in federal Medicaid funds due to abuse and neglect and failure to meet federal standards.

The Maneses used to pop in unannounced to make sure Olivia was being properly cared for and never saw problems.

“They were like family to us,” Tina said. “They’ve lost their little girl just like we have.”

And although they were often asked if they’d like to transfer Olivia to a group home or other community program, they always declined. They didn’t feel she would get the therapy and services she needed.

They believe the state made another mistake by removing 45 “medically fragile” Beatrice residents in the wake of Olivia’s death. Now those residents aren’t getting the kind of non-medical services they need, the Maneses say.

David’s brother still lives at the Beatrice center where he’s lived for 42 years. And that’s exactly where they want him to stay.

A jury awarded $25.8 million Friday to the family of a cancer patient who was given a wrong prescription, had a stroke and died several years later, lawyers said.

Beth Hippely was prescribed Warfarin, a blood thinner, in 2002 to treat breast cancer. The prescription filled at a Walgreens pharmacy was 10 times what her doctor prescribed, court documents said.

The Polk County Circuit Court jury found the prescription error caused a cerebral hemorrhage resulting in permanent bodily injury, disability and physical pain. The mother of three died in January at the age of 46.

A 19-year-old pharmacy technician, with little training, misfiled the prescription, according to court documents.

If you or a loved one have been injured due to a medication error, please call Keating, O’Gara, Nedved & Peter at 888/234-0621 or fill out the contact form on this site. Your first consultation is free and we handle cases on a contingency fee basis.

Arielle Newman, a cross-country runner at Notre Dame Academy on Staten Island, died after her body absorbed high levels of methyl salicylate, an anti-inflammatory found in sports creams such as Bengay and Icy Hot, the New York City medical examiner said Friday.

The medical examiner’s spokeswoman, Ellen Borakove, said the teen used “topical medication to excess.” She said it was the first time that her office had reported a death from using a sports cream.

If you or a loved one have been injured due to the negligence of another, please call Keating, O’Gara, Nedved & Peter at 888/234-0621 or fill out the contact form on this site. Your first consultation is free and we handle cases on a contingency fee basis.

A federal jury on Tuesday awarded $5.5 million to the father of a man who died while wearing a drug patch made by two Johnson & Johnson subsidiaries.

The jury in Federal District Court in West Palm Beach found that Janssen Pharmaceutica Products and the Alza Corporation, both based in New Jersey, were liable in the death of Adam Hendelson, 28, who died in 2003 while wearing the companies’ Duragesic patch.

The patch delivers controlled doses of the powerful painkiller fentanyl.

If you or a loved one have been injured due to medical negligence, please call Keating, O’Gara, Nedved & Peter at 888/234-0621 or fill out the contact form on this site. Your first consultation is free and we handle cases on a contingency fee basis.

The widespread use of electronic systems to send prescriptions from doctors to pharmacies promises to prevent thousands of life-threatening medical errors, save billions of dollars in health care costs and even drive more business to drug stores.

Still, the vast majority of U.S. physicians have yet to adopt electronic prescribing, or e-prescribing, for the estimated 4 billion prescriptions they write annually, a situation that a phalanx of corporations and the government are working to change. One coalition promoting e-prescribing estimates that as many as 20 percent of the 550,000 practicing U.S. physicians had the technology to send e-prescriptions, but that only 5 percent actually have been using it.

With e-prescribing, physicians can use hand-held or desktop computers or “smart” mobile phones to send patient drug prescriptions to pharmacy computers.

Beyond conveying prescriptions, systems can alert doctors to potential drug interactions or dosing problems, eliminate handwriting errors, automate the time-consuming renewal process, provide data on a patient’s drug plan, and potentially cut thousands of pharmacy calls to doctors. Hospitals, insurers, technology companies, regional collaboratives and pharmacies have been working to advance adoption of e-prescribing.

If you or a loved one have been injured due to a medical error, please call Keating, O’Gara, Nedved & Peter at 888/234-0621 or fill out the contact form on this site. Your first consultation is free and we handle cases on a contingency fee basis.

Gawande is a general surgeon at the Brigham and Women’s Hospital in Boston and assistant professor at Harvard Medical School. And he still makes mistakes. It’s this uncomfortable wound that he has opened up, first in Complications – his bestselling book that was shortlisted for the National Book prize in the US and became the inspiration for the TV series Grey’s Anatomy – and now in his follow-up, Better.

“What I’m interested in is failure,” he says, “as it’s the one area of medicine with which the professionals are often reluctant to engage because the stakes we are playing for are so high. We can fail by putting a decimal point in the wrong place and by not asking the right questions. If you ask any doctor when he or she last made a misdiagnosis, the truthful answer would always be in the last month. We get things wrong and we try to put them right. And, of course, we can fail with a slip of the hand. I once performed an emergency trachaeotomy in which I did everything wrong. I had the wrong knife, the wrong lights and I made the wrong incision. There was blood everywhere and the patient would have died if a colleague hadn’t stepped in to help. It was horrific.

If you or a loved one have been injured due to a medical mistake, please call Keating, O’Gara, Nedved & Peter at 888/234-0621 or fill out the contact form on this site. Your first consultation is free and we handle cases on a contingency fee basis.