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."
Gregerson said he is not sure whether the hospital charged insurance companies for the cost of dealing with the errors.
The state review early this year was triggered after Doctors reported just three errors since 2005. Health officials said they did a thorough review of 30 patient records.
A few other hospitals that were slow to submit paperwork -- including Prince George's and Laurel Regional Medical Center -- also attracted the state's attention and were subjected to reviews, but none of them was fined.
Maryland hospitals last year reported 182 "preventable" errors. Health experts have dubbed them "never events" because they are never supposed to happen. The state does not name individual hospitals or patients, but last year 15 hospitals with 100 to 200 beds, including Doctors, reported a total of 44 mistakes that led to death or serious injury, most from falls.
More than 20 states have passed laws requiring hospitals to report mistakes or preventable infections.
Mistakes are routine at almost every hospital. Some do not lead to serious harm, and some do, such as the 36-hour delay in giving fluids to a woman admitted to Doctors' emergency in February 2008 with uncontrollable nausea and vomiting. According to state records, the woman became so dehydrated that her blood pressure spiked, putting her at risk of a stroke. She was transferred to the intensive care unit, where she eventually recovered. The hospital did not identify the error internally and did no follow-up, records show.
The patient who died was a 46-year-old man who was admitted in January 2008 with a severe blood stream infection and liver disease that caused him to be confused, records show. A nurse's entry in the records says he was out of bed and sitting on the floor. The nurse put him back in bed, but he complained of a severe headache. Shortly after that, the nurse could not wake him. A CT scan revealed bleeding in his brain from a fall. He died the next morning. Records show the hospital failed to identify the fall, did not investigate and failed to report the death to the state.
"The patient fell at the hospital, exactly where medical attention should have been most available and where it did not occur," Kronmiller said.
In another case, records show, doctors did not properly perform a knee replacement on a 58-year-old woman admitted in June 2008. They realized the error and operated again to fix it. But the physician discharge summary indicated no complications, and nowhere was the second procedure noted or discussed, records show.
In March 2008, a man with dangerously low blood pressure and a low white blood cell count who was having trouble breathing was admitted to the intensive care unit at 10 p.m. But his blood pressure was not checked again for more than eight hours, at which point he was in acute distress. The nurse's overnight notes indicate only that at 2 a.m. the man was in "no acute distress," records show. The patient eventually recovered.