By Rosette Royale, Contributing Writer, Street Roots, Mar. 28 2012.
Doctors determined that due to the kidney stone’s size — 9 millimeters by 7 millimeters, roughly the size of a raisin — it was too large to pass through his ureter, into his bladder and out his urethra. So they scheduled George for a lithotripsy, a procedure that would use acoustic shock waves to “blast” the stone to bits, the easier for it to pass. It was supposed to be an easy procedure.
It wasn’t.
Somehow, during the process, a tear developed in George’s kidney. Could it have been the result of stone fragmentation during the procedure? No one knows. But as a result, George lost two quarts of blood. Doctors worried about complications. George had to wear special “socks” to massage his calves, to prevent blood clots. He wondered if something else would go wrong. Luckily, it didn’t. And after spending several days in the hospital, he went home, where, for a couple weeks, he battled through waves of pain. A follow-up visit with a new doctor revealed that his urologist had prescribed an improper dosage of pain medication. His new doctor tweaked his medication. Finally, after a month, George seems to be on the mend.
Did my friend George experience a medical error? Maybe. It’s impossible to know. But the whole time I spoke with William Charney, I couldn’t stop thinking about George.
With 30 years experience as a health and safety officer in the health care industry, including five years as the safety coordinator for the Washington Hospital Association, Charney has become a vocal activist for health care reform. Recently, his attention has been drawn to medical errors, those events that occur in health care settings that impact patients’ health. By Charney’s reckoning, some of those impacts have deadly consequences. Through research he’s gathered, he believes that medical errors lead to more than 788,000 deaths a year, making them the leading cause of death in the United States.
For proof, he points to a new book he edited, “Epidemic of Medical Errors and Hospital-Acquired Infections: Systemic and Social Causes” (CRC Press, $99.95). A collection of 19 essays written by Charney and a group of doctors, nurses and health care professionals, the book relates sobering stories from a nurse on the front lines, how medical errors affect marginalized populations and how hospitals can be breeding grounds for infections. It’s enough to make you feel ill.
But if he and his colleagues are right that medical errors kill more people than anything else, then why don’t we know about it? Charney has a few ideas. And, while sitting over a lunch at the Salmon Bay Café in Ballard, Wash., he spoke about what causes medical errors, who suffers because of them and what people — meaning all of us who seek out medical care — can do to stop them.
Rosette Royale: What does the term medical error mean?
William Charney: We define it as a combination of medical errors where the doctors, nurses or health care workers make mistakes: health care acquired infections, misdiagnoses, medication errors, surgical errors that produce either fatality or some form of morbidity, blood clots, hospital-acquired diarrheas that they can’t control. A lot of studies, like in the Institute of Medicine (the nonprofit health-focused branch of the Academy of Sciences), they come out every once and a while (and report) we have 100,000 medical errors. But people get misled by that number. These are means, these are scientists picking out the middle value. So, picking the middle value, you still get 788,558. If you look at the CDC data of people who died in 2009, it’s 2.4 million who died of all causes. A third of people who are dying are dying because they’ve had some kind of relationship with their health care delivery system. I mean, it’s an epidemic of grotesque proportions. It’s an earthquake.
R.R.: Sometimes when there’s an earthquake, there’s an indication the earthquake is coming. So, has there been an indication this was coming?
W.C.: There has been. Five years ago, various institutions, especially the American Hospital Association, started the 100,000 Lives Campaign because they started to get embarrassed by the numbers of medical errors. There was a good national effort to see if they could reduce the damage, reduce the amount of harm. And they came up with some ideas.
But if you look at the data, they’re mostly going after low-hanging fruit, which is my criticism. They’re not taking on the strategic or the systemic causes. That would mean they would have to change health care, and the way we deliver it. They have some nice ideas, and they’re kind of warm and fuzzy: computerized medical records, IT solutions, team medicine, computerizing pharmaceutical interventions. But I call the systemic causes the real causes of this epidemic.
R.R.: And what are they?
W.C.: Your list starts with for-profit medicine. When you are in business to make a profit, certain things get left behind. And the data shows that a for-profit hospital has up to two to four times the rates of medical errors as not-for-profit hospitals. Which doesn’t mean the not-for-profit hospitals don’t have high rates, but the for-profit hospitals, they’re trying to save money in medicine and have a negative patient effect.
The second cause is patient-to-staff ratio. Now when they are higher than 1:5 nurse to patients, your mortality rate goes up. When they get to be about 1:8, you have 31 percent higher potential for mortality on any given day than you would have if you had a 1:4 ratio.
It’s also housekeeping. We don’t know how to clean hospitals in this country, and we cut back on housekeepers. They clean the stretchers, they clean the beds, they clean the rooms. Because we don’t have enough of them, and because we don’t take enough time, (we’re) not killing germs. There is a study in Britain that came out six months ago that shows if you hire one extra housekeeper, on a Monday-to-Friday shift, you reduce the amount of hospital acquired infections by 38 percent. I was in the hospital taking care of a friend last week, at Virginia Mason. On her ward, the (nurse-to-patient-ratio seemed high). We’re supposed to have a ratio bill in this state, but it’s not being applied. (The Nurse Staffing Law, passed by the state legislature in 2008, requires hospitals to develop a nursing staff plan for each unit and shift.)
The third systemic cause would be shift work: health care workers working too many hours. After a certain amount of hours you lose your cognitive ability, your rational thought. And on a shift in any health care institution, you need your cognitive ability. You need your rational thought. Yet we still are working too many hours because we don’t want to hire enough people to do the job.
The fourth, health care working conditions. Health care workers are working under too much stress, under conditions that are not ergonomically suitable. One out of 10 health care workers applies for workers’ compensation every year. And when you injure a health care worker, you have a downstream negative patient effect.
Bullying is huge.
R.R.: When you say bullying, I think, “Don’t bully people in school.”
W.C.: Well, one form is being dressed down by your superior, being yelled at, being ganged up on by your peers. It’s very similar to bullying in the schoolyard. The studies show that it lowers cognitive capacity. Doctors dressing down nurses, nursing supervisors dressing down nurses, nurses dressing down licensed (practical) nurses or orderlies. There’s a pecking order in hospitals, a class system that’s very clear. But each time a health care worker gets bullied, they lose their ability to do their job. We can’t get health care workers to wash their hands when they come out of the bathroom. Systems are not being accountable through the basics of health care delivery and infection control.
R.R.: But there are always those signs that say, “Employees must wash hands.”
W.C.: They don’t do it. There’s no peer pressure. There was just an article in The New York Times, where during operations, doctors have their cell phones in the OR (“As Doctors Use More Devices, Potential for Distraction Grows,” NY Times, Dec. 14, 2011). And during an operation, they’re making calls to their travel agents to book vacations. Nurses were doing the same thing. So there’s a lack of accountability.
R.R.: One of the hot topics a couple years ago was MRSA (Methicillin-resistant Staphylococcus aureus) How’s MRSA tied into this?
W.C.: MRSA is a bacterium, and it becomes a problem when health care workers and hospitals aren’t diligent enough to prevent transmission, either from a patient or a surface in the hospital, which has not been cleaned properly to eradicate the MRSA. Then they touch another patient who’s immuno-compromised. Most people in the hospitals are immune compromised. The germs, the bacteria, the viruses, the pathogen will spread. And they’ll spread because the basic infection control paradigms are not being rigidly enforced. So MRSA — Methicillin-resistant Staphylococcus aureus — has been killing patients for years now in hospitals.
These are not easy bugs to kill. You can, if you clean properly. In America we don’t know how to clean hospitals. We’re letting the housekeeper in a room for 20 minutes or 15 minutes or 10 minutes, and then they gotta go to the next room. That’s not enough time. They’re not using the right kinds of products that actually kill them. We don’t understand survival times of these germs, these pathogens. We’re not cleaning nursing stations where they can accumulate. You know, about 100,000 people are dying every year of hospital-acquired infections and MRSA is one of them. Not the only one, but certainly one.
R.R.: This might sound a little naïve, but hospitals are projected as this place where you go to get better. But I know so many people who are terrified to go into a hospital.
W.C.: Well, we have to keep in mind the denominator. The number of cases they treat are in the billions; number of people they harm are in the millions. They’re only harming about maybe a third or more patients, according to some studies. One out of three has an adverse affect, according to Health Science, which is a journal that’s published. So you justify the epidemic in terms of the good that they do to two-thirds of the population that they don’t harm. However, when you look at the number of fatalities and the number of people they hurt, but don’t kill, it’s really becomes an epidemic of harm.
R.R.: Is there somewhere where the harm isn’t as extreme?
W.C.: I think European hospitals tend to have lower medical error rates. Scandinavian hospitals have lower rates. That’s a guess on my part. I’ve seen some comparable data.
But we don’t want to turn this into a numbers game because Europe may be counting differently than the U.S. is counting. And that’s one of the big problems we have: In 27 states in the U.S. — Washington is one of them — we have laws that say they have to report medical errors. Twenty-three states don’t have rules. But we don’t know how they’re counting, we don’t know what they’re calling a medical error or what they’re not. There’s no standardization of approach of epidemiology, which tells you events that are supposed to be reported. We don’t really have a mathematical way of comparing the numbers.
R.R.: Why did you start researching this data?
W.C.: Well I became horrified when I saw the data. I got angry. I know so many people who, in my own life, have sustained a medical error, who will never be the same. And the more I researched it, the more I realized there was an epidemic. (Then) I realized that the people who are in charge of fixing it are also the people in charge of breaking it. And that’s a relationship that never works. It just never works.
The Society for Actuaries, which is a national society that actually counts money, says — and this is a very low figure — we’re spending $20 billion a year on medical errors. So if you take the number of hospital beds we have in this country, which are about 1 million, and you divide those numbers — $20 billion by 1 million — you get $20,000 per bed that we’re spending on medical errors. Even before a patient is put in the bed. And nobody’s taking responsibility for that kind of cost. I mean, we can’t afford to insure 50 million people in this country, and there’s millions of others who are under-insured, who are making medical decisions because they can’t afford it. Somebody has to radicalize the process, somebody’s got to get out there and shout from the rooftops and the treetops that this is untenable. And patients, especially patients of color, poor patients — we’re killing 134,000 Medicare patients a year in this country through medical error.
R.R.: So many statistics point to how people of color, poor people, are adversely impacted in law enforcement, educational opportunities, unemployment. So how does it happen with medical errors? How would it be any different, if I were black or poor, that I might undergo more medical errors? I mean, we’re in the same hospital, theoretically.
W.C.: Well, in terms of social approach to medicine, the U.S. is behind Brazil and a lot of other third world countries, second world countries, in how we apply the umbrella of medicine. And certainly, people of color, people of poverty, receive the lowest amount of any type of intervention than people who are more able to pay for whatever intervention they are trying to receive. And that’s true in medicine. If you go into the same hospital and you’re black and you have no insurance, you’re going to get a certain quality of care. I mean, they’ll deny this ’til they’re blue in the face, but that’s what the data shows: that you will not get the same care as somebody who is fully insured. You may get fewer tests, you may get fewer interventions, you may get less personal care. The metrics of the care become lower for people who have less money or are people of color.
R.R.: Earlier you mentioned someone needs to radicalize (health care). Let’s say you’re that radical individual. What do you decide to do?
W.C.: One of the things I’ve decided to do is publish this book. It’s a conversation changer, because we’re saying that (medical errors are) the leading cause of death. And nobody knows that. I mean, Americans are dumbed down in practically every category you can think of at this particular moment in history, which is one of the reasons the empire is declining. Some people see that as a good thing and some people don’t. But in health care it’s never a good thing. So, we want to change the conversation. We want to change how we approach this.
The second thing is we’re gonna try and create a North American alliance and social movement around trying to create the change. If every state had a law, every hospital had to apply a ratios bill — like Kaiser (Permanente), in California, which is a big HMO. They’re doing it voluntarily, their rates have really come down. They’re a leader in this field. So we’re gonna introduce legislation. And we’re gonna try to get people angry. Because hospitals are literally getting away with murder.
Rosette Royale is the assistant editor for Real Change News, Street Roots sister paper in Seattle, Wash. Reprinted from Real Change News.
Photo by Jon Williams
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