Md. Fines Doctors Community Hospital for Failing to Report Serious Errors

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By Lisa Rein
Washington Post Staff Writer
Monday, June 15, 2009

Doctors Community Hospital in Prince George's County has been fined by Maryland health regulators after failing to notify them that a patient had died and that at least seven others suffered serious harm last year as a result of mistakes by the medical staff.

The 185-bed medical surgical hospital in Lanham paid the $30,000 fine last month for violating a Maryland law that requires hospitals to report serious medical errors. State officials agreed to reduce a proposed penalty of $95,000 as long as the hospital uses the remaining $65,000 to develop a patient safety program.

A top state regulator described Doctors' system of reporting errors as "seriously deficient" because of understaffing, a lack of attention to what caused patients to be injured or to die, and the absence of a system to prevent recurrences.

"We expect errors to occur," said Wendy Kronmiller, director of the state Office of Health Care Quality. "But we expect systems in place to catch them. What we found at Doctors is that the systems essentially didn't exist."

Administrators at Doctors have acknowledged their failure to comply with the law and called the state's action a wake-up call to sharpen the hospital's focus on patient safety.

"Our biggest challenge is making sure that someone is stepping back and saying, 'This isn't acceptable. I'm going to focus on dealing with this issue,' " Scott Gregerson, the hospital's vice president for strategy, said Friday. "Everybody in the institution needs a fundamental understanding of what is an error and what are the state's expectations for reporting."

The fine is the first in the five years that Maryland has required its 69 hospitals to make public any serious errors that affect patients during treatment. Hospitals are supposed to report such occurrences as surgery on the wrong limb, a patient's taking the wrong medication, a fall, an infection from an IV line and a delay in treatment.

The law, the result of a patient safety movement gaining steam in the Washington region and elsewhere, requires hospitals not only to report mistakes but also to analyze how and why the system broke down.

In some cases, state regulators found, Doctors did minimal investigations to determine what went wrong and did not classify the errors by their level of seriousness, as required by law. A few near misses, in which patients escaped serious harm, were never investigated, documents show. Those included a reported assault on one patient by another's visitor, an eight-day delay in getting medication to a 49-year-old man with a history of heart failure, and a case in which an antibiotic was given to a 65-year-old woman by a technician who mistook it for plain IV fluid.

Kronmiller said her staff will return to Doctors in a few months to make sure changes are being made. Gregerson said the hospital is looking to hire a registered nurse to lead patient safety efforts. I

In a letter to Kronmiller, Philip B. Down, the hospital president, said Doctors has seen a surge in indigent patients because of "deteriorating conditions" at the financially troubled Prince George's Hospital Center. Gregerson said Doctors expects 60,000 emergency room admissions this year.

"We are working very hard to make sure errors aren't repeated," he said. "But you have substantial demand. Care is not always predictable."


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