Utah Hospitals Saw Nearly 60 “Never Events” in 2006
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Last December, a patient was admitted to Uintah Basin Medical Center’s emergency room, complaining he was weak, tired and out of breath. He was found to be severely anemic and needed a blood transfusion. While the man’s blood type was O+, staff at the hospital gave him A+ blood and he was dead in seven hours. He had been given the blood meant for a patient with a similar name. A state health department review showed hospital staff did not match the blood’s label to the patient’s name at the hospital blood bank or when they brought it to his room. This horrible case resulted in the hospital settling with the family out of court and the FDA investigated, causing them to demand an overhaul in the hospital’s transfusion policies.
Although tragedies like these, often called “never events”, are never supposed to happen, these most serious medical errors occurred, on average, about once every six days in Utah hospitals and surgical centers. At least fifty-seven of these egregious mistakes were reported last year; twenty-seven of the patients died and twenty-eight of the patients were seriously injured, losing physical or mental functions. One of these errors involved a ten-month-old baby who was dropped on her head, causing her to suffer a skull fracture. Most of the errors reportedly happened to men and occurred in operating rooms.
The state of Utah started tracking never events after a 2001 landmark study estimated that medical errors may cause about 98,000 deaths annually. The number of errors, which are reported voluntarily by Utah facilities, has continued to rise especially since Utah has increased the numbers of errors that qualify. The annual report does not list the facility names where the errors occur because the state says its goal is not to penalize the hospitals but to find solutions to the problems. The state tracks thirty-two types of serious errors, which it classifies as unanticipated deaths or major permanent loss of function that is not contributed to a patient’s condition or illness. This includes surgeries performed on a wrong person or body part, medication errors and criminal activities. Last year nine surgeries in Utah were performed on the wrong site or the wrong surgery was performed; in seven surgeries, a foreign object was left inside the patient; six patients had serious injuries from falls; also one staff member criminally withheld medication from a patient.
While researchers from the study ensure that patients have a 99% chance of coming through surgery completely fine, surgical errors are still continuing at staggering numbers. One explanation could be the fact that hospitals are now reporting errors throughout facilities, such as emergency rooms. Many malpractice lawyers, however, argue there are probably many more cases of medical errors than are reported since hospitals usually settle the egregious cases and patients are required to sign confidentiality agreements as part of the deal.
The general public is able to see the names of Utah hospitals that have committed serious errors through reports of violations of federal health and safety codes. These reports cover both never events and patient safety violations that do not rise to the level of never events but are still problems to regulators.
It seems obvious that Utah is not alone here. This data from Utah can likely be extrapolated, to some extent, to the rest of the country. Medical errors are not uncommon in any state, or any hospital. They occur because doctors and health care providers are human and they make mistakes. The latter, however, is little consolation to those affected by these mistakes. This strong data lends no support to "tort reformers", like the Chamber of Commerce, who argue that health care providers should be, essentially, immune from lawsuits. Clearly, justice would not be served if health care providers, or any professionals, are immune from law suits, and thereby immune from accountability, and responsibility.