Monday, September 12, 2005

Cause for Alarm

Walking past the newspaper bins of the local supermarket last Saturday my eye was caught by the following headline on the front page of the Sunday edition of The Patriot Ledger (a regional newspaper serving the Boston area South Shore):

“Hospitals seek Rx for human error.”

The lead sentence was: “An elderly man died after receiving 60 times the recommended dose of a sedative at Brockton Hospital, a state investigation report says.” The town of Brockton is located some 40 miles or so south of Boston. The story also reported two medication errors that occurred in the South Shore Hospital located in South Weymouth.

A sidebar to the story reported citations for record keeping violations issued by the Massachusetts Department of Health to Jordan Hospital, located in Plymouth. The violations dealt with the use of patient restraints without properly documented physician orders.

Both stories appeared under the byline of a local reporter and were played “straight;” i.e., without editorial comment. In the Brockton case, the story reported deadpan fashion that the pharmacist had realized the mistake and telephoned the nurse to correct it, but the nurse wasn’t there and the pharmacist told investigators he “forgot to follow through.”

In the Jordan Hospital case, spokesman John Looney said that the hospital has rewritten its policy to conform to the rules and that the doctors would be informed. He went on to say that the hospital expects nurses to tell doctors if their orders don’t comply with the rules. (Some might think management ought to have some responsibility for enforcing policy.)

Surely confidence-destroying stories like this should be cause for alarm by hospitals. One wonders how bad it has to get before they are.

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