Max Ortiz / The Detroit News Joan Belknap of Taylor found out medical instruments used in a recent operation may not have been sterilized, exposing her to diseases like AIDS. Medical mistakes are more common than once thought, according to a report.

Hospitals hide errors that kill, injure patients

Report blames fear of lawsuits for health industry’s silence

By Sarah A. Webster / The Detroit News

    Imagine automobiles that routinely malfunctioned, killing so many people that quality glitches in cars were the nation’s eighth leading cause of death.

    Envision car companies that didn’t install safety features, such as seat belts or air bags, because they might be expensive and establish a paper trail that would encourage lawsuits.

    Say the automakers’ failure to report these hazards caused you to drive around in a death trap — not knowing enough to demand better.

    Remarkably, this scenario is real — not in the auto industry, but in hospitals.

    As many as 3,534 state residents died last year in Michigan hospitals, based on one estimate, because of errors, without any requirement that state officials be notified. Nationwide, the estimated death toll is as high as 98,000.

    While the issue of medical mistakes has played out for decades in malpractice lawsuits, it is now drawing unprecedented national attention — due to the widely accepted findings of a report entitled “To Err is Human,” issued by the Institute of Medicine.

    The scathing, but forward-looking report has shaken the medical establishment, causing everyone from nurses to President Clinton to take a new look at patient safety, which may fare even worse in nursing homes and clinics.

    Joan Belknap of Taylor is among the Michiganians who know firsthand about hospital errors.

    “I don’t have the confidence in hospitals I once did,” said Belknap, 66. She was called back to a Dearborn hospital in December, after questions arose about the safety of instruments used to remove a kidney stone.

Al Goldis Cassandra Branch said her daughter, Kimmietta, died because doctors failed to diagnose meningitis. The Flint girl was in a coma for six years.

    Medical tools usually are hand-washed with disinfectant before they are processed in a sterilization machine to kill all residual organisms.

    It is standard procedure for hospitals not to await the results of a bacteria test, which shows whether the sterilization was successful, before reusing the instruments.

    Test results on instruments used on Belknap and 20 other patients later indicated they might not have been sterilized, potentially exposing the patients to AIDS and other diseases.

    The day Belknap found out, her daughter, Carol Kochanski of Romulus, recalls her mother walking through the door and bursting into tears.

    “My dad couldn’t talk. He had to turn his head away to fight the tears,” Kochanski said.

    Belknap must now have her blood tested every six weeks, indefinitely, to make sure she hasn’t contracted HIV or some other disease. She still has difficulty understanding how a standard hospital procedure put her at risk.

    “This is standard procedure?” she asked. “They’re in the business of making you healthy, not sick.”

A call for change

    The three Michiganians who sat on the 19-member Institute of Medicine committee that wrote the report said the shameful status quo at American hospitals is no longer tolerable in a medical system claiming to be the world’s best.

    “Despite the cost pressures, liability constraints, resistance to change and other seemingly insurmountable barriers,” the institute wrote, “it is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing and comfort.”

    William Richardson, president and chief executive officer of the W. K. Kellogg Foundation in Battle Creek; Gail Warden, president and chief executive officer of Henry Ford Health System in Detroit; and Dr. Rhonda Robinson-Beale, a medical director with Blue Cross Blue Shield Michigan, recently talked to The Detroit News about their committee’s findings.

    They discussed how errors could run so rampant in an industry that is already heavily regulated and is subjected to accreditation and licensure. They also explained why their recommendations are critical to ending this deadly pattern of inaction, which annually costs the nation at least $37 billion; a priceless amount in patients’ lost trust; and between 44,000 and 98,000 in lost lives.

    The institute's high estimate of error-related hospital deaths is based on an extrapolation from the most extensive research on medical errors, called the Harvard Medical Practice Study. That review of 30,000 hospitalizations in New York found errors occurred in 3.7 percent of cases, and that 13.6 percent of those led to death.

    Those findings were also corroborated by a 15,000-case study in Colorado and Utah. When applying that study's finding to the 33.6 million annual hospital admissions in the U. S., the institute concluded that at least 44,000 of U.S. hospitalizations result in death.

    The lower death estimate, 44,000, would make hospital mistakes the eighth leading cause of death in America. The higher estimate, 98,000 would make it the fifth — killing more people than car accidents or diabetes.

Charles V. Tines / The Detroit News Dr. Rhonda Robinson-Beale, a medical director with Blue Cross-Blue Shield Michigan, helped write a report estimating that medical errors cost the nation at least $37 billion annually, and untold family grieving.

    The institute blames budget constraints and many other problems for the deplorable amount of mistakes. But mostly, it blames litigation.

    “There’s a belief that if there’s any kind of error, that it’s a reason for a lawsuit,” Warden said.

    Health professionals are so afraid of lawsuits, the authors say, that they hide errors rather than report and find ways to prevent them — a cover-up that leaves consumers too uninformed to demand better and too ignorant to protect themselves.

    “People are very, very reticent about reporting anything that could be misconstrued,” Robinson-Beale said.

    Americans, Richardson added, need to be warned of hospital hazards so they can protect themselves with smart questions and critical minds.

    “I think the public assumed because there are accrediting agencies and there are other mechanisms like licensure, that there would be more focus on safety and quality,” he said. “But that’s not the case.”

    The institute’s goal is for hospitals to reduce deadly medical error by 50 percent in the next five years. It defines an error as the failure of a planned action to be completed as intended (an error in execution) or the use of a wrong plan to achieve an aim (an error in planning).

    The institute’s flagship recommendation is asking Congress to establish a federal Center for Patient Safety, with an annual budget of $35 million to $100 million, to find ways to make health care safer.

    In making this recommendation, the report notes, deadly medical errors are far more prevalent than aviation or workplace injuries. The likelihood of dying in a domestic flight is about one in 8 million, while the chance of dying from a medical error is about 36 in 100,000. Meanwhile, about 7,000 Americans die from medication errors alone every year — that’s 1,000 more deaths than occur in U.S. workplace injuries every year.

    Yet about $60 million is invested in research for aviation safety and more than $200 million is invested in workplace safety research.

    “It’s way out of proportion,” Richardson said.

Roadblocks for injured

    Lawyers are bitterly offended that they’re somehow blamed for medical errors. Rather, lawyers like Lee Turner of Southfield use the institute’s report as evidence that accusations of “frivolous” lawsuits are not as rampant as it seemed to state legislators in 1996, when they tightened restrictions on medical malpractice rules and put limits on financial settlements.

    “They made the strongest roadblocks for people who’ve really been injured,” said Southfield attorney Bob Gittleman, who specializes in medical malpractice.

    “The state doesn’t do anything for people who are really injured, even if they kill you,” said Nicole Newton, 27, of Auburn Hills.

    Following a car accident, she was treated by a chiropractor. During her second treatment, he adjusted her neck and vertebrae, and she had a stroke.

    “I was sure I was going to die,” she said.

    Her stroke was immediately followed by “locked-in state,” a rare condition in which a person is lucid but cannot move or speak. About a month later, when she came out of it, she had to learn to sit up and walk again. Her case was settled for an undisclosed amount of money, but the chiropractor maintained his innocence.

    “In fact, when I was in the hospital, he told my parents that if they let him crack my neck again, it would cure me. That would have killed me,” Newton said.

John M. Galloway Michelle and Bill Hall of Clarkston with their son Tyler, 18, hold a picture of their daughter Elizabeth, who died of cancer.

    The law office of Southfield attorney Michael Cunningham is filled with file drawers and boxes full of sad stories: a man who had the wrong type of kidney transplanted; a child whose leg was amputated due to a misdiagnosis; and people who’ve been killed by too much medicine.

    The malpractice lawyers believe it’s high time the institute concede what they’ve said for years: “There’s a conspiracy of silence among medical professionals, where they cover up and protect each other,” Gittleman said. “It’s malicious to patients, and they have some horrible injuries. They’re suffering.”

    Among those who are suffering are Bill and Shelly Hall of Clarkston. The Halls lost their daughter, Elizabeth, who they say was the victim of a series of medical mistakes.

    The young woman had a rare skin disease that left her prone to skin cancer. After doctors biopsied a sore on Elizabeth’s foot and scalp — only after Shelly Hall, a nurse, said she fought for four years for the test — the young woman was diagnosed with cancer on her scalp.

    After removing part of her scalp and skull, doctors admitted the biopsy samples had been confused. The cancer was actually on the foot, not the head, forcing Elizabeth to have her left leg amputated and unnecessarily disfiguring her.

    “They said, We’re really sorry,’” Shelly Hall said. “They took off the top of her head for no reason.”

    Elizabeth, an honor student at Michigan State University, eventually had her right leg amputated, too, because the cancer on her foot had progressed so rapidly. She died in July, six hours short of her 22nd birthday.

    Had doctors caught the cancer early, Shelly Hall said, “it was the most basic curable cancer you can get.”

    “There should have been no mistake,” Shelly Hall said. “On her dying bed, she told people to question their doctors.”

Contact reporter Sarah Webster at sawebster@aol.com or call her at (313) 222-1463