A few decades ago the aviation industry began to encourage a different system of reporting errors. Instead of an error being used to shame and blame a pilot or other professional, the error began being used as a learning tool for the industry.
This shift in error reporting is seen as one of the reasons for the improved
aviation safety record in this country over the past few decades.

Now, Medicare and others want to bring the same system of communication and learning from adverse events to the medical profession. Yet, recent data released by the Agency for Healthcare Research and Quality indicates that we still have a way to go before that is accomplished. The Agency found that most hospitals are still more interested in punishing medical professionals who commit an error than learning from those mistakes.

It is important to note that what Medicare and others are talking about are internal hospital and medical care procedures – not medical malpractice lawsuits. Patients who are harmed by medical errors, or their survivors, would still have the right to file medical malpractice claims for their injuries.

What do you think? Does fear of blame and shame prevent medical professionals from learning from their mistakes? Please leave a comment and share your thoughts with us.

Decades ago we used to worry about the possibility of infection or of tainted blood entering our bodies during blood transfusions. Better screening procedures and careful testing have reduced the risk of blood transfusion infections. However, blood transfusions are still not free of risk
for patients.

Many of the risks presented by blood transfusions today are caused by negligence or medical
malpractice. Those risks include:

• Giving the patient the wrong type of blood. The
  blood should be checked several times to make sure it is a type compatible with
  the patient receiving the transfusion.
• Failing to monitor the patient for an adverse
  reaction after the transfusion.

Blood transfusions can be lifesaving. However, it is important to be aware of the risks so that you can confirm the type of blood  you are receiving and report any adverse symptoms as soon as possible.

Recently, Medicare released its first official report identifying hospitals with high complication rates. The findings of that report may surprise you.

Many of what are considered to be Pennsylvania’s best hospitals have many more serious complications than the average hospital, according to the report. The specific hospitals identified as having serious medical complications in the report include: Temple University Hospital, Hahnemann University Hospital, Thomas Jefferson University Hospitals, the Hospital of the University of Pennsylvania, and Geisinger Medical Center in Danville.

There are concerns not just about the hospitals identified, but about how Medicare reached its conclusions. Many hospitals and independent health care professionals are questioning whether the Medicare data is reliable and whether it took into account the level of illness of the patients admitted to hospitals. For example, they argue that many of the large teaching hospitals
included in Medicare’s list of hospitals with high complication rates receive the most complicated cases and the most critically ill patients. Thus, they  argue, it makes sense that their complication rates are higher.

What do you think? Are these Medicare ratings useful to you as a patient?

Patients in pediatric intensive care units (pediatric ICUs) are at greater risk of developing a dangerous infection than patients in adult intensive care units (adult ICUs) according to a new study conducted by Consumer Reports. The study found that pediatric ICUs had a 20% higher rate of dangerous infections than adult ICUs.

As a parent there are steps that you can take to help protect your child from dangerous infections. Specifically, you can:

• Talk to the pediatric ICU staff about the steps they take to control infection.
• Make sure everyone who comes near your child, and especially near your child’s central line, is scrubbed and uses sterile equipment.
• Ask if the central line is still necessary for your child’s care and ask that it be removed as soon as it is safe to do so.
• Keep your own hands clean and insist on the same from all visitors.
• Speak up if you think something is wrong.

Remember, that while these steps may help protect your child, it is the hospital’s responsibility to prevent infections. If the hospital has failed to use reasonable care in the treatment of your child, including protecting your child from dangerous infections, then your family may have the right to recover damages for the injuries suffered by your child due to the hospital medical malpractice.

Last week the results of a federal investigation were released. Federal investigators found that hospital workers only report about 1 in 7 errors, accidents, and other adverse events that harm Medicare patients. What’s more hospitals rarely change their practices when they do report and investigate errors.

The problem is not that hospitals lack appropriate reporting systems. The systems are in place, but workers are allegedly not using the systems. In the past errors often went unreported because staff were afraid to report the errors. Now, the problem seems to be one of recognizing when an error has occurred rather than fear. Investigators found that staff were not reporting errors because they:

• Were unaware what constituted patient harm.
• Assumed someone else would make the report.
• Felt the error was so common that it did not need to be reported.
• Felt the error was an isolated event unlikely to recur so that there was no need to report it.

Medicare has indicated that it will provide guidance to hospitals to clear up any reporting confusion and to help prevent the underreporting of medical errors in the future.