Article - August 19, 2008 - Salt Lake Tribune
'Never events': Utah hospitals saw nearly 60 serious errors in 2007
By Heather May
Last December, a man entered Uintah Basin Medical Center's emergency room feeling weak, tired and out of breath. He was severely anemic and needed a blood transfusion.
Staff started a unit of A+ blood at noon. Seven hours later the man, whose blood type was O+, was dead. He had been given blood meant for another patient with a similar sounding name.
The hospital blamed complacency: Staff didn't match the blood's label with the patient's name at the hospital blood bank or when they brought it to his room, according to a state health department review.
Tragedies like that are never supposed to happen. But these so-called "never events," the most serious medical errors, occurred - at least - an average of once every six days in Utah hospitals and surgical centers, with 57 reported last year.
And what happened to the patients? Twenty-seven died and 28 were severely injured, losing physical or mental function, according to health department data requested by The Salt Lake Tribune. Another patient disappeared, and one case involved nonconsensual sexual contact in a hospital.
The errors include a 10-day-old baby who suffered a skull fracture after staff dropped her and a patient with a severe bed sore that spread deep beneath the skin.
Deadly errors. Utah started tracking never events, also called sentinel events, in 2001, after a landmark study by the Institute of Medicine titled "To Err is Human: Building a Safer Health System." The IOM estimates medical errors may cause 98,000 deaths a year.
The number of serious errors - which are reported voluntarily by Utah facilities - has continued to increase, partly because the state last year increased the number of errors that qualify. There are about 272,000 hospital discharges a year in Utah.
Still, Iona Thraen, director of patient safety for the health department, said federal estimates indicate hundreds more happen - for an estimated 350 deaths a year in Utah.
"The whole experience of medicine is risky," she said, adding doctors and nurses are "as distraught about the experience as the patients and families who experienced it."
Utah tracks 32 types of these serious errors, which it defines as unanticipated deaths or major permanent loss of function, not related to the patients' illness or condition. Examples include surgeries performed on the wrong patient or body part, medication errors and any criminal event.
The annual report on these errors does not identify the facilities, although the names are sometimes included in other documents. The state says its goal is not to penalize hospitals, but ferret out systemwide problems and find fixes.
Scott Williams, chief medical officer for the six Mountain Star-owned hospitals in Utah, including St. Mark's in Salt Lake County, developed the reporting system when he previously worked for the state.
"The citizens should be reassured there's a system in place to monitor this," Williams said. "You have a 99 percent chance of going into hospitals and coming out without having had a serious mistake being made."
Wrong surgery, wrong drug. Still, the numbers are sobering. Surgical errors continue, despite a 2005 statewide campaign to standardize the way surgeries are performed in operating rooms. One explanation could be that hospitals are now reporting errors throughout facilities, such as emergency rooms, Thraen said.
Last year, nine Utah surgeries were either done on the wrong site, or the wrong surgery was performed. In seven surgeries, foreign objects were accidentally left inside a patient. In one case, surgeons discovered a hemostat, which resembles scissors, from a surgery years earlier.
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