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Maryland Hospital Patient Safety Report

Earlier this month the Maryland Department of Health and Mental Hygiene Office of Health Care Quality published a report regarding medical malpractice in Maryland hospitals. The report is a review of the safety and care provided to patients in Maryland hospitals. The report compiles information collected by the OHCQ in 2010 relating to serious adverse events that affected patients or their families. A copy of the report can be found here.

The adverse events that hospitals are required to report include a rather long list of mistakes that are possible because of hospital error, medical malpractice (negligence), or inattention. Patient falls are the most frequently reported event. In 2010, there were 88 reported cases resulting in serious disability or death. Of these 88 reported cases, 10 resulted in loss of limb or function of limb, 52 required surgical interventions, 20 required medical intervention and 6 resulted in death of the patient.

Hospital-acquired pressure sores / ulcers, which are associated with high morbidity (medical complications) and mortality (death) once they reach Stage 3 and 4, were reported 59 times in 2010 making it the second most frequently reported event. However, none of the reported cases in 2010 resulted in death.

The third most frequently reported event was delay in providing needed treatment leading to a patient suffering death or serious disability. There were 20 of these reported in 2010. Delays in treatment that result in an adverse event often cause hospital protocols to be revised and changes in hospital policies and procedures to take place. In 2010, there were 17 cases where a delay in treatment resulted in death.

Adverse events related to the failure of doctors to maintain a patient’s airway or to supply an adequate level of oxygenation increased in 2010. A basic medical intervention is a procedure to keep a patient’s airway open. However, there were still 9 reported “airway misadventures” in 2010; 8 were fatal and the other left the patient in a persistent vegetative state.

Delays in treatment and failure to maintain a patient’s airway are the medical errors that most frequently fatal. Over the past six years, 83 of 102 patients whose medical treatment was delayed died, and 51 of the 58 patients whose airway was not maintained.

Surprisingly, adverse events related to foreign bodies being retained within a patient following surgical procedures continue to occur on a regular basis. In 2010, there were 15 reports which is a 250% increase over any previous year. However, the number of reports of wrong patient surgeries, wrong side surgeries, and wrong surgical procedures is low; there were only 4 reported cases in 2010. When these errors are made, the root cause is often the consent or pre-operative forms prepared in doctor’s offices.

There were only 9 reported cases of physician errors resulting in the wrong medication being administered to a patient that resulted in death or serious disability. This includes patients who have adverse drug reactions.

Misdiagnosis was only responsible for 2 reported cases of death or serious disability, whereas failure to act accounted for 3 cases.

We handle cases like these all of the time in my practice. It’s nice to see a government agency reporting on these things. Hopefully, this report will encourage hospital administrators and doctors to take action to try and prevent these things in the future.

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