Team 4 Investigation: Medical Mistakes At Hospitals

Everybody makes mistakes. But when those mistakes are made by doctors and nurses, patients' lives are at risk.

A Team 4 investigation uncovers medical mistakes made in hospitals in western Pennsylvania and arms you with information you need to protect yourself and loved ones.

Team 4 Investigation: Medical Mistakes At Hospitals
July 10, 2008

Norma Terry said she felt fine following coronary bypass surgery. It wasn't until she went home from the hospital that she really felt poorly.

"I never felt that bad in my life. I started bleeding from my nasal passages and then my lips," Terry said. "They became all blistered-like and bled."

Norma's bleeding worsened over several weeks until she went to another hospital, where the ER doctor told her, "I had Methotrexate toxicity," she said.

Terry and her son, Marty Martino, say the first hospital gave her a prescription for the anti-cancer drug Methotrexate that was seven times stronger than normal for a cancer patient. But Terry wasn't a cancer patient.

"This was all happening for no good reason," Marty Martino said.

And it happens more often than you might think.

Nationally, 1.5 million patients are harmed by medication errors every year, according to the National Academies of Science.

"There are arguably 3 million medication errors in southwestern Pennsylvania every year," said Paul O'Neill, of Value Capture Consulting.

O'Neill, a former U.S. Treasury Secretary, now spends his time advising hospitals how to reduce errors.

"An awful lot of them are errors of the first order, so that when there's a written prescription, it can't be read," O'Neill said.

Take a look at this actual handwritten prescription for Xanax. Is that a 1 at the end, or a 7?

If it's a one, "it means I'm going to give one dose of 15 milligrams to a patient one time," said Joan Garzarelli, a registered nurse at Lifecare Hospitals.

But if it's a 7, the patient gets seven doses.

Another common cause for medication mistakes? Labels.

These two IV bags appear to contain the same formula of potassium chloride, but one has dextrose and the other doesn't.

These two packages of the steroid Kenalog 40 appear identical, but the dosages are different.

"It's very easy to pick up the wrong thing," Garzarelli said. "I kind of make an analogy when I talk about patient safety to people who cook. You think you know what you're going to put in your recipe, and you go to reach for the baking soda and you see the baking powder and so you take that instead."

Team 4 found every hospital in our area has made mistakes. Here are some examples.

A July 2007 state health department inspection report at Allegheny General Hospital revealed 55 syringes filled by anesthesia pharmacy were labeled incorrectly. The report concluded that 10 of the incorrectly labeled syringes were not recovered.

A year earlier, according to state records, a patient at Allegheny General was ordered the blood-thinning drug Heparin and received 14,000 units rather than 1,400 units.

In a statement to Team 4, Allegheny General said, "Each year, healthcare professionals at Allegheny General Hospital administer more than 5 million doses of medication to patients. The two incidents at AGH cited by the Department of Health in 2006 and 2007 respectively were discovered by AGH staff through standard protocols and reported to the appropriate agency by AGH. No patients were harmed in either incident. Nevertheless, as with every such incident, the errors were thoroughly evaluated and, if warranted, additional safeguards were put in place to prevent future occurrences. These facts are not evident in the DOH report."

"Medication errors are so prevalent, and they happen for reasons that are so curable and so simple, yet they continue to happen every day in hospitals," personal injury attorney John Gismondi said.

Hospital inspection reports show a litany of other kinds of errors besides medication mistakes.

In March 2008 at UPMC South Side, "...a surgical instrument was identified to have bone and tissue in the instrument, from a previous surgery," according to a report. It's not clear if that unclean instrument was used on a patient.

During an eight-month period in 2006, UPMC McKeesport recorded 17 serious events -- mistakes in which patients were harmed. Making matters worse, state inspectors say there are records that the hospital failed to notify all but two of those 17 patients that errors had occurred. The state fined the hospital $13,000.

And at Ohio Valley Hospital, a patient returned to the nursing floor following surgery. There was no record that anyone checked on the patient until four hours later, "...at which time the patient was found without respirations," according to a report.

"We're really striving to create a culture of safety," Garzarelli said.

Garzarelli is a board member for Pennsylvania's six-year-old Patient Safety Authority, an independent agency that recommends solutions to eliminate medical errors to the state Health Department. But the agency does not have the authority to require changes.

"We issue advisories," Garzarelli said.

"Well, has the Department of Health ever acted on any of those advisories to make the Authority's recommendation mandatory?" Parsons asked.

"Not to my knowledge," Garzarelli said.

As for Terry, she wants somebody to help patients like her.

"It needs to be corrected," Terry said. "I mean, how many people died because of these errors? I mean, I was lucky."

UPMC issued a statement to Team 4 about our story that says, "Patient safety was never at risk in any of the incidents in question. These involved record-keeping, not patient safety, issues. Our hospitals have implemented improvements in their processes to address these issues, as detailed in plans accepted by the Pennsylvania Department of Health."

Ohio Valley Hospital did not respond to our questions.

As for what you can do to protect yourself in the hospital, our experts say the best advice is to bring a loved one with you -- someone who is not afraid to ask questions -- as an advocate for your health care.