Senate Panel Researches Medical Mistakes Problem

Dr. Karl Shipman merely broke his wrist, but it killed him.

Bacteria set in during surgery to set his wrist, and a staph infection ultimately raged through his body. The Denver physician’s fellow doctors did not pick it up.

It’s neck strain, an orthopedic specialist said as the pain spread to Shipman’s spinal column. Try physical therapy, another suggested. When Shipman went to his own hospital a week later, antibiotics still weren’t administered for 12 hours. An intern just months out of medical school was in charge of the intensive care unit, and by the time experienced physicians arrived the next morning, Shipman was in shock and respiratory failure.

He soon died.

Shipman’s daughter, Debra Mallone, described that string of medical mistakes Monday as a senator opened hearings on a stunning problem: a report that medical errors kill between 44,000 and 98,000 hospitalized Americans every year.

“Those numbers if anything are on the low side,” said Dr. John Eisenberg, director of the federal Agency for Healthcare Research and Quality, which is studying what hospitals and doctors can do to prevent mistakes.

The Institute of Medicine revealed the problem last month and recommended an end to medicine’s “culture of secrecy” about it. The institute urged health workers to talk about mistakes so they can learn how to avoid them. It set as a minimum goal a 50% reduction in medical errors within five years.

Only about a third of the states require that hospitals report serious errors, and those that do keep much of the information secret, experts and patients told a Senate health subcommittee Monday.

Consequently, one of the Institute of Medicine’s recommendations is a mandatory national reporting system, so that experts can seek out patterns and take action.

The American Medical Assn. opposes such a system, saying doctors will continue to keep mistakes secret if they fear discussing them can lead to punishment or lawsuits. Plus, if consumers see data on mistakes, they must be put in context--told, for example, that some of the best hospitals get sued because they care for the sickest patients, those most likely to die, former American Medical Assn. President Dr. Nancy Dickey said.

“I would respectfully disagree with you about the need for a mandatory federal reporting system,” responded Sen. Arlen Specter (R-Pa.), noting several lawmakers already are considering legislation.

Without such information, patients are powerless to pick a good doctor, said Ray McEachern of Tampa, Fla., who started a patient advocacy group after his wife was injured in 1992.

Patricia McEachern needed an examination of an artery leading to her brain. She testified that without her knowledge or approval, her physician allowed a resident--a doctor-in-training who had never performed such a procedure--to thread a catheter into the artery. The catheter became tangled and caused a stroke that left her right arm and leg paralyzed, she said.

Six months earlier, her doctor had been sued for allowing another untrained resident to perform a catheterization, but he never reported the incident, McEachern said.

xFO Ray McEachern of Tampa, Fla., testifies with his wife, who was partially paralyzed after a procedure by an inexperienced resident.