Hospital Aggressive Medicine
Going to the hospital for something other than childbirth or a routine test is a serious event for anyone. The good news is that if you do get hospitalized, you will benefit from the amazing advances in medicine that have occurred over the past twenty years. The bad news is that you will enter a system, whether in a big teaching hospital or a small com- munity one, that is struggling with what the profession calls adverse events. The Inspector General’s Office at the Department of Health and Human Services describes an adverse event as harm to a patient as a result of medical care. In a million-patient study of Medicare beneficiaries discharged from US hospitals, the IG’s Office found 13% experienced an adverse event resulting in their four most serious categories of patient harm. “And an estimated 1.5% experienced an event that contributed to their death, which projects to 15,000 patients in a single month.”
The most distinguished and believable crusader for hospital safety today, Dr. Martin Makary of Johns Hopkins School of Medicine, has raised his estimate to 150,000 unnecessary deaths per year in American hospitals. And this is a conservative figure, he says.
Imagine what would happen if just one hundredth of that total, 1,500 deaths, occurred in the domestic airline industry each year. Would you take a flight to California if you knew 1,500 people died last year in airplane crashes?
Going to the hospital is a serious event because of the risks and also because you do not go to the hospital for trivial complaints. With the exception of the maternity ward and certain outpatient or low-risk elective procedures, you are likely to be concerned about your condition, concerned about the risks, and turning to prayer for comfort and protection. This chapter is not intended to indict the caring and highly trained professionals in charge of your care at a hospital but to inform you about the undeniable risks and give you a strategy for reducing them. But first a little more background.
Back in 1999 the Institute of Medicine attributed between 44,000 and 98,000 deaths per year in America to hospital mistakes. That is the equivalent to a jumbo jet crashing every day in the US.
Hospital safety is not a new topic. In 1999, the Institute of Medicine issued a report (actually based on then fifteen-year-old data) that attributed between 44,000 and 98,000 deaths per year in America to hospital mistakes. That is the equivalent of a jumbo jet crashing every day in the US, the report said, in boldface headlines.
Since that blockbuster report, twenty years have passed, and laudable progress has been made in preventing the simplest of mistakes, like performing the wrong procedures or treating the wrong patient or wrong side of the body, etc. Many hospitals have adopted safe surgery programs. Yet despite these publicized programs, despite more than ten schol- arly and popular books on this topic listed in this guide, and despite countless journal articles about many aspects of the problem, unnecessary deaths in hospitals have grown relentlessly.
But, as reformers like Dr. Makary of Johns Hopkins have continued to discover, few preventable deaths are actually reported as such.
The affluent people I know make a comforting assumption: they assume that the death rates are higher in community hospitals than in academic centers and take pride in being able to gain admission into one of the renowned centers. They are dead wrong. In fact, they risk being both dead and wrong at the same time.
Dr. Robert Wachter bursts that bubble in his book Internal Bleeding through comparison studies. He then tells ten highly mediagenic stories, pointing out that all of them took place at teaching hospitals. Here’s one of his stories:
Dr. Don Berwick, the Boston pediatrician who has emerged as another one of the nation’s most passionate spokesmen for health care quality, speaks eloquently of his wife Ann’s harrowing string of hospitalizations for an obscure progressive neurological illness. Berwick took her to some of America’s greatest teaching hospitals, where, as the wife of a famous physician and patient safety advocate, she was greeted as a super VIP. You can be sure that everybody treating Ann felt they were under a microscope. But here’s Dr. Berwick’s account of his wife’s harrowing hospitalization:The errors were not rare, they were the norm. During our admission, the neurologist told us in the morning, “By no means should you be getting anticholinergic agents (a medication that can cause neurological and muscle changes),” and a medication with profound anticholinergic side effects was given that afternoon. The attending neurologist in another admission told us by phone that a crucial and potentially toxic drug should be started immediately. He said, “Time is of the essence.” That was on Thursday morning at 10:00 am. The first dose was given sixty hours later—Saturday night at 10:00 pm. Nothing I could do, nothing I did, nothing I could think of, made any difference. It nearly drove me mad. Colace (a stool softener) was discontinued by physician’s order on day one and was nonetheless brought by the nurse every single evening throughout a 14-day admission. Ann was supposed to receive five intravenous doses of a very toxic chemotherapy agent. But dose #3 was labeled “dose #2.”
For half a day, no record could be found that the #2 dose had ever been given, even though I had watched it drip in myself. I tell you from my personal observation, no day passed, not one, without a medication error.
The possibilities for harm are endless; there are zero hospitals that don’t have fatal adverse events every year. The estimate is that every patient will have some mistake made on his or her behalf. Some will be trivial, some will be easily fixable, some will be serious, and some will change their lives forever, like the incident recounted by Joe and Teresa Graedon in their book.
M. described the sad consequences of a mistake during her husband’s carotid artery surgery. The doctor came to tell her that the surgery had been successful, but while they were talking, her husband nearly died. It took more than twenty minutes to revive him, and he suffered severe brain damage as a result of that lengthy oxygen deprivation.
M. was initially told that her husband’s heart had just stopped on its own. But once he was in rehab, she started reviewing his case with several cardiologists. They concluded that there was nothing wrong with his heart.
When she finally requested his medical records, she hired an expert to help her review it. They discovered that the anesthesiologist had removed the breathing tubes and all monitors in the operating room before her husband was moved to the recovery room. When his throat swelled shut, no one noticed. He was blue and in serious trouble when the staff began reviving him. Since his throat had swelled shut, it was nearly impossible to replace the breathing tube for the oxygen.
M.’s husband had a history of sleep apnea, so the usual procedure would have been to keep him intubated until he was fully awake. Because the anesthesiologist did not follow the appropriate protocol, this fifty-seven-year-old man has no short-term memory, can’t initiate simple tasks, does not speak, and cannot be left alone.
Hospitals have become aggressive places in America. Everyone means well, and there is no intent to harm of course, but the system has its own incentives to overtreat, undertake unnecessary procedures, and administer a bewildering variety of medications that often interact. Patients without advocates or a strong sense of defending themselves can be swept up in a cascade of events they might never have imagined. It seems like a daunting and impractical suggestion to find an advocate or to become one. But when top doctors start recommending it, as they have, as the only way to move the odds of a good outcome into your favor, I think you have to consider it.
It’s true even for end-of-life patients in hospitals. The prestigious Journal of the American Medical Association (JAMA) recently released a disturbing study showing that patients with serious diseases and end- of-life issues in the hospital who had formally requested either “limited additional interventions” or “comfort measures only” were routinely treated in contravention to their stated desires.
In those two groups, 41% were admitted to the ICU and 18% received treatments such as mechanical ventilation or CPR resuscitation. JAMA called these results “sobering.” I could think of more appropriate words.
I’m sure none of these patients had anyone with them to enforce their wishes. They needed an advocate. A hospital is a place where you really need allies to help you with medical wisdom. Hospitals themselves have begun to formally recognize this, as most of them now employ designated “patients’ advocates,” also known as “patient liaisons” or “ombudsmen.”—They are available upon request, but rarely advertised. Many patients prefer to bring their own advocates, sometimes even hiring professionals.
The “Path to Wisdom” to follow outlines some specific actions you can take to arm yourself against the possibility of a serious adverse event during a hospitalization. I recognize that some readers will see having an advocate as an impractical suggestion, and I wish it were easier.
The Facts
- Although the estimates vary widely depending on who compiles them, at least 200,000 hospital patients die unnecessarily every year.
- Approximately one out of every three operations performed in US hospitals is unnecessary, says one of our authors.
- If you learn about the common mistakes in drugs and proce- dures and take a family member or a trained advocate with you or request one from the hospital, your chances of dying while a hospitalized patient are much less.
The Path of Wisdom
- Hospitalizations are the most difficult emergency to prepare for because they require having a plan in advance. The ideal is this: have someone who believes in the principles of this guide, has a serious (or paid) commitment to you, and agrees to be with you as often as possible should you be hospitalized. Determination, courage, and grit as well as knowledge are necessary qualities for this person.
- Take your advocate to the hospital with you, and make it clear they have your confidence. Make sure that you and your advocate expect mistakes. There will be many.
- Verify drugs. Ask about the reason for the drug, the dosage, and any potential interactions for every drug administered.
- Insist on true informed consent for every procedure: benefits, risks, percent of complications, and ability to reverse adverse reactions.
- If you don’t like what you hear, say no. It’s your right. That stops the parade and gets everyone’s attention in a hurry.
- Track the transitions and hand-offs that happen multiple times a day. Did all the right information get passed? Usually, it doesn’t. Does the new shift know all the facts? (Recognize that you can’t stop every error that occurs in the middle of the night.)
- Get help fast if you see something you don’t like. Do not be afraid to be assertive.
- Make sure discharge instructions are clear and detailed. Get the name of the person to call if things go badly after discharge.
- If you have a portable set of wishes for end-of-life treatment, like a do not resuscitate (DNR) order or a physician order for life-sustaining treatment (POLST) agreement, make sure it is enforced.
- End-of-life patients should stay out of hospitals, if possible. I recognize that this may not always seem economically feasible for some. This is where compassionate alternatives like hospice can be wonderful relief for a dilemma.