String of Errors Put Florida Hospital on the Critical List
Diabetic and disabled, 51-year-old Willie King seems an unlikely figurehead for a national uprising over patients’ rights. Two months ago, the retired heavy-equipment operator checked into University Community Hospital here to have his diseased right leg amputated. A doctor cut off his left leg instead.
“When I came to and discovered I lost my good one, it was a shock, a real shock,” King said in a press conference three weeks after the Feb. 20 operation. “I told him: ‘Doctor, that’s the wrong leg.’ ”
Days later, King went across town to another hospital to get the surgery he needed. He is learning to walk now on a pair of donated prosthetic limbs and, after a quick and confidential deal with insurance companies, is financially set.
But King has also become a poignant symbol of a burgeoning consumer movement that its leaders say represents the last unconquered American frontier: patients’ rights. King has lent his name to a proposed bill, now before the Florida Legislature, which would force hospitals to make public patient injury rates and better inform patients about their surgeon’s qualifications.
King, who lives alone in a trailer, is doing fine. “I’ve kind of taken it in stride,” he said.
But University Community Hospital is not. Reeling from a series of medical blunders, including King’s wrong-leg amputation and the death 11 days later of a man whose breathing tube was mistakenly removed, the hospital was stripped of accreditation Thursday, an action that could mean it no longer qualifies for federal Medicare or Medicaid money.
Although the hospital has 20 days to appeal the ruling and remains open, the decision by the Chicago-based Joint Commission on Accreditation of Healthcare Organizations could be a fatal blow to the 420-bed institution on the city’s north side. Last year, University Community took in $52 million in Medicaid and Medicare payments, nearly a third of the hospital’s net patient revenues of $158 million.
The hospital board’s chairman called the commission’s decision unwarranted. “We do not treat these incidents lightly,” Ken Lightfoot said in a statement released late Thursday. “However, by singling out UCH, the industry regulators are refusing to accept the fact that all--repeat, all--hospitals have similar patient incidents.”
In addition to facing lawsuits from several former patients, the hospital is also under investigation by state and federal agencies. A ban on all elective surgeries was imposed last Friday by the Florida Agency for Healthcare Administration, which cited sloppy operating room procedures. That restriction has meant the loss of at least 60 surgeries each day, the hospital said.
On Wednesday the American Medical Assn. called on the accreditation committee to make an example of the Tampa hospital.
“Although human errors are inevitable, . . . systems are supposed to be in place to make the kind of mistakes which apparently occurred virtually impossible,” wrote AMA Executive Vice President James S. Todd. “We know the Tampa hospital may be extraordinary, but we cannot take any chance.”
Although stripping a hospital of its accreditation is extremely rare, the mistakes that occurred there may not be, according to many doctors and malpractice lawyers. “Tampa is not the hotbed of medical malpractice, and patient care is probably no worse at University Community Hospital than anywhere else,” said veteran malpractice attorney Tony Cunningham, who has sued the hospital--as well as this city’s two larger hospitals--many times.
As horrible as King’s wrong-leg amputation is, that is not the only or even the worst medical outrage to take place at the hospital during a nightmarish 26-day spell that threatens to wipe out a reputation for quality patient care that took 26 years to build:
* On March 3, 11 days after a surgeon mistakenly sawed off King’s left leg, Leo Alfonso, a 77-year-old retired electrician, died when a technician mistook him for another patient and pulled a breathing tube from a tracheotomy hole in his throat. With one arm paralyzed and the other held down by restraints, Alfonso slowly suffocated, unable to call for help. Cunningham now represents the Alfonso family.
* On Feb. 15, a doctor performed arthroscopic surgery on the wrong knee of a female patient. After discovering the mistake, the surgeon operated on the other knee.
* On March 16, a woman who gave birth by Cesarean section was partly sterilized before doctors realized that she had not requested or authorized the procedure. Asked immediately by the doctor if she wanted the tubal ligation repaired, the woman consulted with her physician and declined after being assured that she could conceive more children with only one working Fallopian tube.
The events of the last two months, attended by a blistering, worldwide public-image battering, have left the staff demoralized, caused some patients to cancel hospital procedures altogether and turned a once-proud institution into the butt of late-night television jokes.
Jay Leno weighed in on the “Tonight Show,” and “Late Night’s” David Letterman mentioned Florida last month when he introduced the “Top 10 Signs You’re in a Bad Hospital.” “No. 10: You go in for routine surgery, you come out with a tail.”
“It’s been rough, no doubt,” John Andreas, the hospital’s administrative director for corporate communications, said earlier this week. “This is a calling to people like nurses, doctors, respiratory technicians. They come here to do a good job, not to hurt people. It is tough to see the place where you have worked, built your career, in the news, on the front page every day.”
Indeed, what happened at University Community Hospital? Are the 326 doctors licensed to practice there more careless than doctors elsewhere? Are the respiratory technicians and other staff members poorly trained or supervised? Is checking into this hospital for surgery any riskier than entering any other American hospital?
Predictably, hospital President Norm Stein says no. While admitting that the four highly publicized mistakes at University Community were caused by human error, Stein went on to suggest that the hospital had run into a streak of bad luck: “It just seems to be a timing issue, where lightning seems to strike here without relief. I don’t wish this on any other hospital.”
In fact, according to a report last month in the Tampa Tribune newspaper, University Community pays malpractice claims at a somewhat higher rate than Tampa’s two other major hospitals, Tampa General and St. Joseph’s. In the last five years, for example, Tampa General--a public hospital that gets the bulk of the city’s trauma cases--paid a claim to one out of every 7,225 patients, compared to University Community’s payout rate of one for every 5,507 patients, according to the Tribune report.
Less predictably, many of Tampa’s malpractice attorneys, who regularly sue University Community and the city’s two larger hospitals, agree with Stein. Says attorney Peter J. Brudny, who engineered King’s settlement with the hospital: “They are no worse than any other hospital, maybe better. But like every hospital I deal with, they have to be pushed to be safer; they won’t do it on their own.
“Unfortunately, UCH, like every hospital, tries to live in a very secretive environment, where employees are threatened with firing if they go public. They are schooled in cover-up.”
In fact, it was an anonymous hospital staff member who first breached what Brudny calls a widespread code of secrecy in hospitals, leaking word of King’s wrong-leg amputation to a local television station. But it was not until March 1, nine days after the amputation and four days after the first news reports surfaced, that Stein officially acknowledged the incident.
“Simply put, this event took place because of human error,” he said in a statement. “We apologize to Mr. King.”
While taking responsibility, hospital officials also tried to explain how surgeon Rolando Sanchez--who had been involved in a wrong-site hernia operation in 1992--could have cut off the wrong leg.
“Our review indicates that sometime between the time the surgical consent form was signed and surgery occurred, there was a breakdown in procedure,” said Carl Hakanson, hospital medical director. “As a result, the right leg was never identified; the left leg was scrubbed and prepared for surgery. That leg, which showed advanced signs of disease, (was) removed.”
With federal and state inspectors on their way to Tampa, the hospital also announced new safety procedures, including a requirement that in cases involving a left-right limb or organ, the word “No” is to be written in felt-tip pen on the site that is not to be operated on.
But the bad news continued to break. Two days after that press conference, a respiratory technician just back from a six-week maternity leave failed to check an identification bracelet and pulled the ventilator tube from Alfonso’s throat. Moreover, in what appears to have been an attempt to cover up the mistake, the death certificate indicated that Alfonso had died of natural causes.
His March 3 death was not made public until nine days later, and at the medical examiner’s request, the body was exhumed for an autopsy. “This was a tragic incident,” the hospital said in a statement.
Within hours federal health officials had ordered an emergency investigation of hospital practices, and the administration turned to the firm of Hill & Knowlton for public relations help. “We’re in a crisis,” Andreas said.
Despite bipartisan support, the proposed Willie King Hospital Safety Act is not expected to pass this year. “The doctors’ lobby is too strong,” said Ray McEachern, a Tampa dry cleaner who helped draft the bill after his wife, Patricia, was partially paralyzed in 1992 after a surgical mistake at another local hospital. “But now, people are listening. Victims of medical negligence are coming together. This is a start.”
Researcher Anna M. Virtue contributed to this story from Miami.