Hospitals Are Writing Prescriptions for Patient Safety

Thirteen years have passed since Bob Fauber went to an emergency room with chest pain and was almost mistaken for another patient scheduled to watch a video on sex after a heart attack.

Fauber was being stabilized in a Hartford-area hospital room when a nurse arrived with a wheelchair to take him to the film.

“I said, ‘You have the wrong patient,’” Fauber’s wife, Gloria, told the nurse. The nurse apologized and left the room.

It was the only comical error in a series of medical mistakes that caused Fauber months of unnecessary suffering and may have contributed to his death in 1989 after bypass surgery.

Gloria Fauber can laugh about that one incident now. But her husband’s experience still stings. And it amazes her that only now are hospitals beginning to acknowledge that mistakes occur all the time--sometimes with fatal consequences.

“Close calls are what you want to look at,” said James P. Bagian, a physician and former astronaut who is director of the Veterans’ Administration National Center for Patient Safety.

But while industries such as aviation use mistakes and close calls as opportunities to improve safety, the medical profession had traditionally reacted to errors with denial and shame, Bagian said.

And that has cost lives.

In 1999, the Institute of Medicine, a research arm of the National Academy of Sciences, estimated that 44,000 to 98,000 people die each year and many more are injured from preventable mistakes made in hospitals.

Three years later, hospitals across the country are beginning to acknowledge that accidents happen and that only by recognizing that can patients be made safer in the future.

“We’re trying to come to grips with the idea that there is more harm being done to patients than we ever realized or cared to realize,” said Dr. Michael L. Therrien, a cardiologist at St. Francis Hospital and Medical Center in Hartford.

One focus of the St. Francis effort is to encourage doctors, nurses and other health-care workers to report mistakes and close calls so similar incidents can be prevented.

At Yale-New Haven Hospital, one goal of a 2-year-old patient-safety initiative is to triple the rate of reported errors--not by making more mistakes but by being honest about those that occur, said Dr. Harlan M. Krumholz, co-chairman of the initiative.

Krumholz, a cardiologist, said a myth that physicians are invincible super-humans who do not need checks and balances or written reminders is at the root of the secrecy that often masks preventable errors.

Like Bagian, Krumholz would like to borrow a page from the airline industry. “Pilots are very tough and macho, yet you don’t think any less of a pilot who has to go through a checklist before taking off,” Krumholz said. “Up until recently, you would raise questions about a doctor who does that.”

Yale-New Haven has identified four areas of vulnerability and has made changes. The hospital also has set up anonymous hotlines for reporting errors and close calls and is teaching patients how to look out for themselves.

To avoid misidentification of patients, such as the mix-up that almost sent Fauber’s critically ill husband to a sex film, Yale-New Haven now makes sure that all patients have an ID band from the time they come through the front door.

Blood handling is also a potential minefield for errors, said Sally Roumanis, who co-chairs the patient safety effort. It was not uncommon at Yale-New Haven, Roumanis said, for the wrong patient’s blood to be sent to the lab for testing. More consistent use of ID bands reduced mix-ups, she said.

In addition, blood might be ruined en route to the lab because a nurse or technician forgot to put it on ice. Sometimes the wrong tests are ordered. Now, each blood vial gets a computer-generated label that contains handling directions and patient information.

Perhaps the most dreaded and infamous hospital errors involve surgery on the wrong body part. To prevent that, Yale-New Haven and other hospitals now mark the correct spot with an indelible marker.

Recently, a doctor scrawled a circle with the word “yes” on Andrea Wyckoff’s right foot. She was in the day surgery center to have the crooked joints in her toes repaired. Wyckoff already had the toes on her left foot straightened, so she said the gnarled condition of the right toes should have made the surgical site obvious. Still, she said she was comforted by the hospital’s attention to detail.

Yale-New Haven also has tried to get patients more involved. Each patient is given a flier acknowledging that accidents happen and urging patients to help prevent them.

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Hilary Waldman is a reporter for the Hartford Courant, a Tribune company.