Target 11 Investigates Medical Mistakes

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None - What types of mistakes are happening in the operating room and how often are they occurring??

You're sick or injured and you have to go to the hospital. Chances are it's happened to most of us at one time or another. And when you go to the hospital, you expect to get the best treatment.

But a Target 11 investigation discovered that's not always the case.

The statistics are staggering. By some estimates, nearly 100,000 people die every year from medical mistakes in the United States.

PDF: PSRS Reports of Retained Foreign Objects in the Southwest Region of Pa. 2007-2009

A decade ago, an eye-opening medical report raised questions and offered solutions about medical mistakes. What's happened since then? Has the medical field made improvements? What's being done to address the problems?

Gregg McCandless suffered severe facial injuries and needed surgery. He said a doctor completed the surgery, but something went wrong. The doctor lost a small sponge in his head. After X-rays and another surgery, McCandless said it took the doctor nearly seven hours to find and remove the sponge. McCandless said he's suffered from health problems ever since.

"I can't feel my lip nor the teeth behind it. He rooted and rooted a total of six of seven hours around in my head," said McCandless.

Target 11 discovered sponges are the most popular item left behind by doctors. During the last three years, 93 sponges or towels were left inside patients during procedures in southwestern Pennsylvania, according to the Pennsylvania Patient Safety Authority.

"Frequently, they will make them very small and pack them into a tight place and if they do it in the beginning of the procedure and it's a lengthy procedure, it can be left behind. It can be forgotten," said John Farneth, who works for a company that sells a device aimed at eliminating lost sponges.

The company is called the RF Surgical Detection System. It was designed by a former surgeon and an electrical engineer. A small RF chip, about the size of a tic-tac, is sewn into the sponge. A doctor moves a circular wand device over the patient and an alarm sounds, alerting the doctor that a sponge is still in the patient.

Target 11 Investigator Rick Earle put the system to the test. He placed the sponge with the RF chip in his belt below his back. Farneth then moved the wand over Earle's front, and the system sent out an audio alert.

However, Target 11 discovered sponges are only part of the problem.

Earle obtained the statistics of medical mistakes in Pennsylvania. According to the Pennsylvania Patient Safety Authority, 209 patients in Pennsylvania died from medical mistakes last year, and nearly 5,000 suffered injuries.

"Miners are protected, people working on construction sites are protected, but patients aren't, and the real failing is that many people will die before a correction that is known to prevent the harm is put in place," said Karen Feinstein, president and CEO of the Pittsburgh Regional Health Initiative.

For more than a decade, Feinstein's organization has been working with hospitals and health professionals to improve patient safety. The PRHI relies on quality control system used in other businesses and industry. The groups most noted accomplishments was reducing central line bloodstream infections, something many doubted they could ever do.

While Feinstein said many in the medical profession have come a long way, she told Earle that there is still plenty of work to be done. And she said often times it starts at the top.

"You need leadership at the top of an institution that says margin be damned." Bottom line, who cares? We are going to take every bit of energy we have and we're going to devote our entire team every worker three shifts a day to quality improvement," said Feinstein.

Target 11 contacted several hospitals in the area including the one where McCandless experienced problems, but didn't hear back from any of them.

Information provided by the Pennsylvania Patient Safety Authority.

2009 Medical Mistakes in Pennsylvania:

• Equipment, Supplies, Devices: 3 deaths, 60 ‘serious events', 3,455 'incidents.' • Medication Errors: 2 deaths, 296 "serious events", 48,881 ‘incidents.' • Adverse Drug Reactions (not medication error): 3 deaths, 292 ‘serious events', 4,464 ‘incidents.' • Errors Related to Procedure, Treatment, Test: 19 deaths, 747 ‘serious events', 50,203 ‘incidents.' • Complications of Procedure, Treatment, Test: 182 deaths, 3,529 ‘serious events, 24,577 ‘incidents.'

Definitions:

Serious Event - An adverse event resulting in patient harm. The legal definition, from Act 13, reads: "An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an Incident."

Incident - A "near miss" in which the patient was not harmed. Act 13 defines this as: "An event, occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. The term does not include a Serious Event."

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