Julia Ann Coleman was a 66-year-old woman whose chief medical problem was a sudden onset of alcoholic tremors, or "the shakes," when she checked into D.C. General Hospital on April 30, 1985.
Although sedated, she was not physically restrained, and nurses found her the next morning, dazed and sitting on the floor, with a three-inch gash in her forehead.
From there, Coleman's problems grew worse, according to her physician and written reviews of her case obtained by The Washington Post. After two brain operations, a postoperative infection and seven weeks at two hospitals, Coleman died of complications from the injury and not from her underlying alcoholism.
Coleman's case was uncovered by an investigation by the local peer review organization, one of 54 contracted with nationwide by the federal government to oversee the quality of care being delivered by the nation's hospitals to patients who receive Medicare -- primarily people 65 years of age and over.
And while the Coleman case is an extreme, a six-month study scheduled for release today by the House human relations subcommittee asserts that almost 900,000 Medicare patients receive dangerous, and sometimes life-threatening, treatment at American hospitals each year.
Rep. Ted Weiss (D-N.Y.), chairman of the subcommittee, said the estimate, which was derived from Medicare records, "suggests a crisis in medical care." Medicare patients typically represent about one-third of most hospital cases, so the total number of such lapses in care could be much greater, Weiss said.
"Even if the number of life-threatening Medicare cases were half our projection, there would still be nearly a half million patients at risk," he said. Weiss' estimate is based on reports filed with the U.S. Department of Health and Human Services by peer review organizations.
The cases are screened against six criteria: inadequate planning for the discharge of patients; unstable vital signs at the time of discharge; unexpected death; hospital-related infection; unscheduled surgery, and hospital-related injury. If a case meets any of the criteria, it is investigated to see whether there is a reasonable explanation for the problem.
In Julia Coleman's case, the Delmarva Foundation for Medical Care -- the peer review organization for the District -- found that the treatment represented a "gross and flagrant" violation of standards of proper care, and it recommended that D.C. General Hospital be fined $54,418. Only two hospitals in the United States have ever been sanctioned by the government.
However, HHS officials have rejected the proposed fine, apparently in part because the hospital has agreed to correct deficiencies in its treatment programs. Hospital officials refused to discuss the Coleman case, but they said D.C. General now has written guidelines on the treatment of alcoholics.
An HHS spokesman said yesterday that the department has received 138 requests for sanctions against physicians and hospitals from peer review organizations. Of those, 77 physicians and two hospitals have received sanctions and 13 cases are still being reviewed.
A sanction can be in the form of a monetary penalty or an outright exclusion of a hospital or physician from the Medicare program. Only one hospital, the County Mental Health Hospital in San Diego, and 53 physicians have received the more severe penalty.
Also, HHS officials dispute Weiss' estimate of the number of problem cases in the nation's hospitals, calling it too high.
Tom Morford, an official of the Health Care Financing Administration, the HHS agency in charge of reviewing the quality of treatment provided to Medicare patients, said, "It's inherently dangerous to make that kind of extrapolation, but I don't want to say there's no problem."
Of the 1.6 million cases screened by peer review organizations, 132,902 -- or 8.1 percent -- had confirmed problems. If that percentage were applied to the 11 million Medicare admissions each year, Weiss said, the total number of problems would be about 891,000. The Medicare statistics do not provide hospital-by-hospital information on confirmed problems.
Morford said in an interview that it was "somewhat fallacious" to expect that the same percentage of problems would occur in the total annual caseload because many of the cases that are examined are suspect from the start for such things as exceeding the normal length of stay or the expected cost based on the particular illness.
"It's not a randomized sample," Morford said.
However, other Medicare officials noted that a smaller, but randomized, sample of patients during a similar time period showed virtually the same incidence of confirmed problems. In fact, the rate was a slightly higher 9.5 percent.
"The bottom line of this debate should be that we have a problem delivering safe medical care in our hospitals, that quality assurance programs are not working and that we should do something about it," said a Medicare official who declined to be identified.
John Rother, legislative director for the American Association of Retired Persons, said that the number of people who become ill because of their hospitalization "can never be zero," but he said that 8 percent is too high.
"That figure is consistent with what other studies have shown, so it doesn't surprise me," Rother said. "But most people would be surprised if they think hospitals are a place you go to get well and not a place where you contract another problem."
Rother said he supports the government's efforts to determine how many patients might be at risk, but he said that the government should go further and release statistics for each hospital.
"Hospitals are inherently dangerous places. There's never going to be a risk-free hospital," Rother said.
Andrew Webber, executive vice president of the American Medical Peer Review Association, the trade organization for the peer review groups, said the screening criteria were faulty because more serious cases, such as unexpected deaths, were counted alongside minor ones, such as failures to consider the emotional needs of the patient in writing a discharge order.
"We are not seeing a pattern of poor quality care" by hospitals, Webber said. "Rather, we see individual cases of clinical mismanagement."
In the Coleman case, Dr. Charles Mosee, chief of neurosurgery at D.C. General, said he was called into the case after her fall. Doctors conducted X-ray exams to make sure that there was no skull fracture, then closed her head wound with stitches, Mosee said.
The next day, Coleman did not respond to voices or stimuli, Mosee said, and he was called into the hospital early on a Sunday morning to perform the first of two emergency operations to relieve pressure on her brain from blood clots under the skull.
Although the operations were a technical success, Coleman's condition did not improve, Mosee said.
In fact, her surgical wound became infected. At her family's request, and against Mosee's advice, Coleman was transferred to Howard University Hospital after almost a month at D.C. General. She died three weeks later.
The reviewing agency did not find that Mosee did anything improper in the case.
In an interview yesterday, Mosee said Coleman's condition was grave from the moment she developed the clot on her brain.
Her alcoholism had damaged her liver, he said, and it had rendered her susceptible to profuse bleeding during the operation and to infection afterward.
Although he was not involved in her initial treatment, Mosee defended the decision not to restrain her physically.
Alcoholics who develop tremors often become agitated, he said, and tying her down could have led to injury.