Gerontologist sees higher medical error rate more likely under certain conditions

Where medical errors occur

■ In general hospitals 3,776

■ In psychiatric hospitals and units 1,157

■ In hospital emergency rooms 256

■ In home care settings 109

■ In office-based surgery centers 15

Reported sentinel events

Totals are per million population:

■ Florida 17

■ Washington, D.C. 96

■ Texas 18

■ California 12

Source: The Joint Commission on Accreditation of Healthcare Organization's list of sentinel events reviewed from January 1995 through December 2008. More information is available at

Minutes before Karen Landy went under the knife at a Naples surgery center in 2006 for removal of what turned out to be a non-cancerous cyst, her surgeon asked her to point to the breast with the lump. When she did, he used a marker to draw a small black X on her right breast.

A few minutes later, Karen's anesthesiologist arrived, asked her the same question, and marked a red X on the same breast.

The question was asked a third time by the operating room nurse, who penned a green X next to the other two markings.

"I felt reassured," Landy recalls, "because I knew what the guidelines were, to have three checks before surgery. And I was pleased they were doing that before administering any anesthesia."

Triple-checking the correct surgical site is now standard procedure as a safeguard against wrong-site surgery, the most commonly-reported medical error in the U.S. health-care system. Others include medication mix-ups, treatment delays, patient falls, lab mistakes and suicides when patients are released too soon from psychiatric treatment facilities.

Landy, an FGCU instructor and gerontologist, shared her perspective in an interview with the Naples Daily News from a talk she gave to 30 local health-care professionals attending her medical errors workshop at the Southwest Florida Conference on Aging held April 16 in Fort Myers.

From 1995 through 2008, Florida's medical error rate was the third-highest in the nation, topped only by Texas and Washington, D.C., according a listing from the nonprofit Joint Commission on the Accreditation of Healthcare Organizations (JCAHO.) Headquartered in Oakbrook Terrace, Ill., JCAHO is a nonprofit organization established in 1953 to "improve the quality of health care available to the public." JCAHO maintains a registry of medical mistakes it labels "sentinel events," defined as unexpected occurrences involving death or serious physical injury or psychological damage, including the loss of limb or bodily function.

JCAHO reviewed 313 sentinel events in Florida from 1995 through 2008. Nationally, nearly 5,000 sentinel events were logged in general hospital or psychiatric treatment settings during that time period; the safest health-care providers were home health-care agencies with 109 sentinel events and office-based surgery centers with 15.

Health-care facilities accredited by JCAHO are required to provide a non-threatening atmosphere for staff members to report their own medical mistakes without fear of punishment or job loss.

Under Florida law, Landy says, hospitals will not be reimbursed when mistakes result in a patient's death or loss of limb, and they cannot bill the patient or survivors for services provided.

Locally, according to Landy, "I think we're getting better at reporting errors and creating a culture of safety in the environment. The emphasis has shifted from blaming the individual to identifying and correcting the root cause of the error and preventing it from happening again. It's the ethical thing to do, and it's in the best interest of patient safety."

When a health-care worker observes someone else making a mistake, she adds, "even if the co-worker is a friend, you need to report the error. You may have seen them do it only once, but how many other times has it happened?"

Landy told the nurses and other licensed health-care professionals attending her workshop that the likelihood of surgical error increases when more than one surgeon is working on the patient, when more than one procedure is being performed at the same time, and when there is time pressure to clear the operating room for the next patient.

Illegible physician handwriting can lead to patient injury and death, she cautioned, when the wrong prescription drug or medical procedure is ordered. Recently, however, many local health-care providers have reduced the potential for such errors by installing computer systems to generate printed orders.

When nurses and other caregivers make mistakes, Landy reported, the most likely causes are fatigue, heavy patient loads, "floating" nurses from one unfamiliar station to another, abuse of alcohol or drugs, and working despite feeling ill.

Medical errors have occurred throughout history in hospitals, clinics, labs, nursing homes and other settings. Years after World War II ended, veterans were finding fabric shreds left inside them during do-or-die battlefield surgeries.

A local case of medical error occurred in November 2009 when 77 Community School of Naples students were given the seasonal flu shot instead of the H1N1 swine flu vaccine, resulting in letters of reprimand for six nurses who did not check vial labels before administering the injections.

One controversial aspect of managing medical errors is whether to say "We're sorry" when a mistake causes patient death or serious harm.

"That reluctance could be based upon fear of civil or criminal reprisal," Landy says.

"An apology might not head off a lawsuit, but what we do know is that the patient appreciates full disclosure of what went wrong, why it happened, and what's being done to prevent that error from happening again."