Medical Bloopers Make Headlines

Edition: February 2003 - Vol 11 Number 02
Article#: 1457
Author: Sheila Dunn

The headlines are outrageous: People contracting hepatitis from their doctor’s office. Patients getting the wrong limb amputated or the wrong kidney removed. Folks undergoing a procedure where the surgical drape catches fire and permanently maims the patient.

More troubling is the underlying question of just how many of these bloopers are going undetected. Are the incidents that are reported just the tip of the iceberg?

When we see these kinds of errors, it’s no wonder that last year the Institute of Medicine ranked hospitalization as the 8th leading cause of death in the United States. But not all of these safety errors occur in the hospital environment – many occur in doctors’ offices and clinics.

You’ve probably seen some of those accidents-waiting-to-happen yourself … like an account sloshing down the hall with a bucketful of specula floating in dishwashing detergent. Or a doctor walking into an exam room with a Styrofoam cup full of liquid nitrogen.

There are just some accounts that don’t get it – and never will until it’s too late. They turn up their noses at the requirement for safety sharps. They haven’t given HIPAA a second thought. They fail to consider that the cheapest and easiest way to do something might have disastrous consequences. These people are just waiting to make headlines.

All of the following stories are true and were reported during the last 12 months. Some are comical – until you consider that people actually lost their lives or were permanently disabled due to the ignorance, thoughtlessness or carelessness of medical personnel.



Man Sues Doctor Who Left Surgery to Cash Check

A Massachusetts man filed a malpractice lawsuit against the orthopedic surgeon who left him on the operating table midway through spinal surgery to cash a check at a nearby bank. The patient suffers permanent disability with severe pain in his legs after David Arndt, M.D., left him for 35 minutes with an open incision in his back during a spinal fusion procedure at a Boston-area hospital. Dr. Arndt, whose license to practice medicine was suspended by the state medical board, has acknowledged that he temporarily abandoned the patient in the operating room during the Jul. 10, 2002 operation at Mount Auburn Hospital in Cambridge, Mass. (Author’s note: This is one of my personal favorites. A more truthful headline could be “OR Nurses Spill Beans on Arrogant Surgeon.”)



Clinic Worker Infects Hundreds of Patients with Hepatitis C

At least 81 cancer patients were infected with hepatitis C at a cancer clinic when a clinic worker used a syringe to administer medicine to a patient who had hepatitis C, then drew more medication from the same vial for the patient with the same syringe. Other patients were then given medicine from the same vial. The clinic, which is now closed, advised over 600 patients to be tested. Hepatitis C has a 2 percent to 10 percent infectivity rate.



Man Sues Over Exposure to Human “Mad Cow”Disease

Six neurosurgery patients at a Denver hospital were possibly exposed to a rare bloodborne pathogen, Creutzfeldt-Jakob (CJD), a fatal brain disease. Surgical instruments used for a brain biopsy on a woman who later died of CJD were used on these patients before physicians knew the cause of the woman’s death. A hospital ethics committee spent two months deciding whether to tell these six people that they might have been exposed to the disease. One of the patients, a 63-year-old man, has filed a lawsuit against the medical center. CJD is the only known disease that can survive the typical surgical instrument sterilization process. Since the Denver incident, the hospital has decided to quarantine instruments that have touched the brain of someone with dementia – an early symptom of CJD – until they know for sure what is wrong with the patient. The suit, however, alleges the policy should have already been in place.



Lifesaving Medical Devices can be Deadly

An 18-year-old worker at an Illinois urology clinic recently was charged with involuntary manslaughter when he accidentally caused a coworker’s death while “playing” with a defibrillator (AED). A member of the cleaning crew, the man picked up the defibrillator and put the paddles on another man’s chest. That man was electrocuted, suffered a seizure, and later died. In a similar story, a child picked up defibrillator paddles, put them on his head, and caused a seizure.



Nurse-anesthetist Caught Reusing Needles

A nurse-anesthetist has admitted to reusing needles previously used to give pain medication to his patients. At least six of the patients have acquired hepatitis C; hundreds more are being tested for hepatitis B, hepatitis C and HIV. Officials said nurse-anesthetist James C. Hill admitted to reusing needles while injecting pain medication to at least 15 patients per day, from Dec. 31, 2001 through Aug. 19, 2002. Both Hill and the supervising physician have been removed from the hospital and have had their privileges revoked. At least one infected patient has filed a lawsuit.



AANA Reports Rampant Needle Reuse

The American Association of Nurse Anesthetists reports that one out of 100 nurse anesthetists reuse the same needle on multiple patients. Apparently they fail to realize that needles entering IV tubing are, in fact, contaminated with patients’ blood.



Single-use Items Getting Reused at Hospitals

Like many healthcare facilities that face rising health costs and lower reimbursements, a North Carolina hospital collects certain hospital supplies to be sterilized and reconditioned for a second, third or fourth use. They’re targeting costly items, such as cardiac catheters, surgical scissors, blades, saws, bits and shavers.

These incidents come a couple years after a phlebotomist was caught rinsing and reusing butterfly needles on multiple patients in Palo Alto, Calif. None of these incidents have been thought to be malicious, but occurred due to a lack of understanding of the basic principles of infection control.



What’s the Outcome?

These gaffs are appalling. How can anyone with even a rudimentary understanding of healthcare safety make such bone-headed mistakes? You and I both know the troubling reality: These are not just isolated events, and they’re occurring far too often.

So where’s all of this going? The healthcare industry is beginning to take some serious and immediate steps toward assuring quality healthcare at every level. Auditors will enforce the standard of care for every healthcare professional, from training through retirement.

In 2003, expect to see a greater scrutiny of patient and employee safety by healthcare accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO has unveiled the first set of National Patient Safety Goals to give healthcare organizations focused, practical recommendations for reducing specific healthcare errors.

This kind of scrutiny will extend to physician offices. In fact, health systems are creating “Patient Safety Officer” positions in response to the public outcry against medical errors, and the resulting new regulations in several states.



How to Use the Threat of Medical Bloopers as Selling Opportunities

Is it the business of a medical salesperson to hint that unsafe behavior may be dangerous? Absolutely. You are one of the few professionals allowed into the inner chambers of the medical business. People buy from you because they like and trust you. To continue to earn that trust, you need to be honest with them. You need to educate them and provide solutions for their problems.

(Not to mention that you sell customers the supplies that they can misuse, reuse and misuse again.)

It’s never easy or comfortable to change the products people use, or the way they use them, when the only tangible benefit is “safety.” Customers invariably have the “It won’t happen here” attitude. I bet you’ve all heard this one:



“We’ve been giving injections here for five years now and have never had a needle stick. And with reimbursements what they are, Dr. Jones really can’t afford it. Besides, we’ll never get caught.”



Obviously, you can’t say what you’re thinking, which is probably something like:



“Listen, you dumb cluck, you could get stuck tomorrow and die a long, slow death from AIDS. I bet you’d be the first to sue ol’ Doc Jones when that happens! So, is that worth the dime a syringe you’re saving by not switching to safety needles?



“And here’s something else to think about, Ms. Noncompliance: There’s probably one nurse here that’s just waiting until you look at her funny before she calls OSHA and invites them in for a visit. The fines might just put ol’ Doc Jones out of business.”



So, what should you do?



Advise these accounts that they shouldn’t knowingly try to slide by and escape compliance. A disgruntled patient or employee (someone who’s actually witnessed what’s described in the headlines above) could complain to OSHA and hefty fines would follow. It just isn’t worth it.

Or, try appealing to the human aspect of noncompliance, the serious health consequences to employees and patients. These folks could unwittingly be condemned to a living hell – like contracting AIDS or requiring a liver transplant for hepatitis C – because a practice didn’t buy safety devices or use them properly.

Take the customer’s hand and walk them through the regulatory maze with an eye toward risk management. Help them make the product selections that will keep their employees and patients safe. Yes, you’ll be the bearer of bad news at times (these products cost a lot more), but you’ll provide programs or services that go beyond the traditional role of just keeping their products stocked.

Why should you keep slugging away? Why not just give up and move on to a new subject? Because these are selling opportunities – and because it’s the right thing to do.



Dr. Sheila Dunn heads Quality America@, Inc., an Asheville, NC-based regulatory consulting firm working with manufacturers and distributors on point-of-care testing systems. For more information about Quality America’s OSHA compliance products or consulting services, call 800/946-9956, or visit Quality America’s Online Resource center: www.quality-america.com.