Medical mistakes, or “adverse events” are the leading cause of death in the US after heart attacks and cancer. According to a new study from the Journal for Patient Safety, up to 400,000 people die each year from "adverse events" or medical mistakes.
State law requires hospitals to report medical errors to the California Department of Public Health, but the department only publishes the total numbers in an annual report. The official definition of “adverse events” is in the Health and Safety Code.
The state’s report does not identify the hospitals responsible, dates of the occurrences or corresponding fines. The NBC Bay Area Investigative Unit discovered that meaningful details about adverse events are not readily available or easily searchable for California consumers.
The Investigative Unit filed a public records request to CDPH obtain this information and have now posted it online as well as the database of fines levied for adverse events and fines for failing to report adverse events to the state. It’s a process that took nearly nine months to complete.
According to the data, hospitals in California have reported 6,282 adverse events to the state in the last four fiscal years. They range from “death associated with an error”, to “stage 3 or 4 decubitus ulcer,” or bedsores. However, the state has no way of ensuring that every hospital is reporting every error that occurs.
A half-dozen medical experts told NBC Bay Area they believe not all hospitals report adverse events to the state. And there is no mechanism to ensure that they do.
Deadly Knee Surgery
When Holly Stewart’s mother, Diane Stewart, had double knee replacement in 2007, she was 72-years-old, a mother of four and grandmother to seven. Just one day after the surgery she began complaining of a severe pain unrelated to her knees.
“She said my knees don’t hurt, it’s my stomach,” Holly told the Investigative Unit. “It still shocks me to think she was going in for common knee surgery.”
Diane Stewart died days after the surgery when she became septic from a twisted intestine.
Holly recalled her last moment with her mother: “I gave her a big hug and she opened her eyes and then she closed them and she didn’t open them again.”
“We’re going to live with this forever,” Holly said. “It’s like it happened yesterday and we are learning to live with our grief and disappointment.”
Brain Surgery Infection
Chris Canevaro had a brain tumor removed last year. He is 42 years old, a Santa Clara law graduate and yoga instructor.
“The doctors did a wonderful job,” he told the Investigative Unit. But just days after returning home, he experienced seizures and blindness on his right side.
He returned to the hospital, where doctors discovered an infection in his brain where the surgery had been performed.
“Everything went to hell,” said Chris.
Because the infection created so much damage, doctors had to remove part of Chris’ skull. He now wears a helmet to protect his head. He also suffered brain damage and continues to have speech issues.
“You carry that extra burden of knowing what it could’ve been, what it might’ve been like if this hadn’t happened. If the infection hadn’t happened,” said Kathy Canevaro, Chris’ mother.
Chris was given only a few months to live, but he has surpassed survival expectations.
“We are already on borrowed time,” Kathy said. “Every day is a gift.”
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Both the Canevaros and the Stewarts believe serious medical errors were made, but we will never know for certain if their cases were reported as adverse events to the state. California law says hospitals must report adverse events within five days of knowing about them. If there is a failure to report, the state can fine the hospitals.
According to the state data obtained by the Investigative Unit, over the past four fiscal years, two bay area hospitals, Stanford Medical Center and UCSF, lead the state in total number of adverse events. However, the majority of the adverse events at both of these facilities were bedsores.
When we asked about these adverse events, Stanford Hospital issued this written statement and also said:
“Patient safety is always our top priority at Stanford Health Care. A variety of factors can make patients more susceptible to pressure ulcers, including having multiple medical conditions, being bedridden, and being on certain medications. As a leading academic medical center, Stanford Health Care (SHC) treats some of the sickest patients in the nation, many of whom have much more complex medical conditions than typically seen at community hospitals.”
Statewide, the most prevalent adverse event across all hospitals was bedsores with 3,959 reported cases. Next was “retention of a foreign object in a patient” with 986 reports.
Some hospitals have fewer total numbers but also have the highest numbers in more serious categories.
For example, during the past four years, according to the state’s data, Santa Clara Valley Medical Center (SCVMC) had a total of 64 adverse events, but 30 of those were “retention of a foreign object” in a patient during surgery, the most in the state during that time period.
When asked about this, SCVMC issued this written statement:
“Our focus remains patient safety and since 2011 we have had a significant and steady decrease in the number of retained foreign objects. In 2014, there have been only two (2) such events. As always the safety of our patients is our priority and we continue to make improvements to the care we provide to every person in need of our services."
Feather River Hospital near Chico had 22 adverse events in the same time period and one event at the Feather River Hospital Health Center and 10 of them were listed as “performing the wrong surgical procedure,” the most in this category in the state.
Feather River Hospital said, “Because it is not always black and white as to whether something meets the definition for reporting, we make the report if there is any possibility that there might be a reportable adverse healthcare event.”
Arrowhead Regional Medical Center in San Bernardino County had 110 total errors and 32 of them were death or serious disability from the use of restraint or bed rails which is more than any other hospital statewide, according to the data. The hospital told the Investigative Unit that none of these events resulted in death and that “the patients died from the underlying medical illness that prompted restraints and not from the restraints.” Click here for the hospital’s full statement.
All hospitals mentioned told the Investigative Unit that reporting adverse events triggers an on-site inspection by the California Department of Public Health.
California consumers would never know about these events from looking at the state website. When the Investigative Unit searched for “adverse events” on the Department of Public Health’s Website, the report where the department annually publishes total numbers does not appear.
States such as Washington and Minnesota have specific sections on their public health websites dedicated to adverse event reporting.
California Department of Public Health declined the Investigative Unit’s repeated requests for an interview. The department also failed to respond to our requests for backup documentation related to the numbers.
More Transparency and Better Reporting
“Patients have a right to know what the quality of care is in their institutions,” said Dr. Jay Wolfson, an ethicist and medical doctor at University of South Florida.
“Unless we’re transparent in hospitals,” Wolfson said, “we can’t make informed decisions about what the best place to get care is and we’re never sure what’s happening when we’re inside a facility.”
“It is absolutely important to track them, particularly preventable adverse events,” said Dr. Josh Adler, Chief Medical Officer at UCSF.
Adler said his staff is dedicated to tracking every error that occurs in order to better prevent them in the future and improve care for patients. He said that’s part of the reason UCSF is second highest in the state with number of errors over the last four fiscal years and the reason why they’ve received the most fines from the state for adverse events.
“I believe we are a very safe hospital and part of the reason we are safe is that we have been in the error-finding and resolving business for a long time,” Dr. Adler said. “We are dedicated to finding all our errors if we can, and then reporting them”
The Investigative Unit found several hospitals with very low numbers.
197 of the states 410 hospitals in the database report having 5 or fewer mistakes in the four year time period. Some said they had only made one mistake in that time period.
“I can’t emphasize enough how challenging it is to actually count and monitor and know when those things are happening,” Dr. Adler continued. “I certainly think we need to be more transparent as a medical community even to the point of, is everyone doing their best to report adverse events.”
Adler said UCSF has come up with solutions for preventing certain types of adverse events, like retention of foreign objects. The hospital now employs sponge counting so that all sponges are counted before and after a procedure. Adler says the hospital has had zero sponges left in patients since implementation of the policy.
“We were watching what we were doing. We found problems and we have implemented a solution that so far is operating extremely well,” Adler said.
“I think transparency helps generate action because you are exposing yourself to public scrutiny,” he added.
Chris and Holly
Both families the Investigative Unit spoke to have endured loss and pain that caused them to turn to legal action for help.
Holly, whose mother suffered problems after a knee surgery, said she only got her mother’s medical records through a subpoena. Her mother’s case was settled.
Chris, who suffered an infection after brain surgery, cannot drive a car or work. His case is currently under litigation.
“Life gave me this hand,” Chris said. “So I’m living this hand to the best that I can. This is my hand.”