Med Mal News

Transplant Patients Die From Rodent-Borne Disease

Three transplant patients died in April and May from lymphocytic choriomeninaitis virus (LCMV), a rodent disease they contracted from an organ donor who died of causes unrelated to the disease. LCMV infection usually is either asymptomatic or causes mild self-limited illness in otherwise healthy people. This complication is very rare. In 2003, a cluster of solid organ transplant-associated meningoencephalitis deaths in Wisconsin was determined to be associated with LCMV infection.

Joint Commission's 2006 National Patient Safety Goals

The Joint Commission on Accreditation of Healthcare Organizations announced on May 31 the 2006 National Patient Safety Goals and related Requirements for each of its accreditation programs and its Disease-Specific Care certification program. The Goals and Requirements, approved by the Joint Commission's Board of Commissioners, apply to the more than 15,000 Joint Commission-accredited and certified health care organizations and programs.

Major additions to this fourth annual issuance of National Patient Safety Goals include a new Requirement in all of the programs that “hand-offs” of patients between caregivers be standardized, with particular attention to assuring the opportunity for asking and responding to questions. This Requirement is part of the Goal: “Improve the effectiveness of communication among caregivers.”

In addition, a new Requirement, for all types of accredited organizations that provide surgical or other invasive services, specifies that all medications, medication containers and other solutions used in perioperative settings are to be labeled. This Requirement is part of the Goal: “Improve the safety of using medications.”

New Goals in other selected programs address the prevention of pressure ulcers and encourage the active involvement of patients and their families in the patient's care as a patient safety strategy. The full text of the 2006 Goals and Requirements is posted on the Joint Commission Web site, www.jcaho.org. Compliance with the Requirements or alternatives judged to be acceptable is a condition of continuing accreditation or certification for Joint Commission-accredited or certified organizations and programs.

Medical Records Must Be Released to IN Attorney General

Indiana's Attorney General, Steve Carter, has won his bid to force Indiana Planned Parenthood to turn over to his office medical records on teenaged girls who sought treatment there. He wants the records so that his office can investigate child abuse, but Planned Parenthood has fought him in a bid to protect the privacy rights of the patients whose records were sought as well as to make sure that young girls do not forgo seeking medical treatment in future for fear their medical histories will not be protected. Judge Kenneth Johnson of Marion Superior Court, who heard the case, stated that disclosure would benefit both the state and the children whose records are being sought. Planned Parenthood's representative, an attorney from the Indiana Civil Liberties Union, said he plans to appeal.

Bronx Facility Did Not Tell Patients They Might Have Cancer

Hospital officials at Jacobi Medical Center in the Bronx, NY, were fired in May after it was discovered that hundreds of women whose Papanicolaou tests (Pap tests) were taken there were never informed when those tests came back with abnormal readings. The problem was discovered when a woman whose test showed problems sought treatment for an unrelated reason. When she was informed of her Pap test result, she was surprised. During the period of time when the unfavorable results went unreported, only one clerk was in charge of reviewing the thousands of test results the hospital generated and of informing patients of a need for follow-up visits.

IHI Campaign for Patient Safety Underway

In less than 5 months, the Institute for Healthcare Improvement's (IHI) “100,000 Lives Campaign” has surpassed its goal of enlisting up to 2200 U.S. hospitals in a commitment to implement changes in care that have been proven to prevent avoidable deaths. The 100,000 Lives Campaign aims to get hospitals across the country to commit to implementing the changes, which so far include six interventions: 1) Deploy Rapid Response Teams; 2) Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction; 3) Prevent Adverse Drug Events; 4) Prevent Central Line Infections; 5) Prevent Surgical Site Infections; and 6) Prevent Ventilator-Associated Pneumonia. Downloadable “how-to” guides for implementing the six interventions are available at: http://www.ihi.org/IHI/Programs/Campaign/.

Rhode Island Joins 'States In Crisis'

On May 16, the American Medical Association added another state to its list of states in crisis due to the rising cost of medical malpractice insurance. The AMA noted that a recent survey by the Rhode Island Medical Society reported 49% of Rhode Island doctors saying they have stopped performing certain high-risk services or are considering doing so, while 48% are considering leaving the state or giving up clinical practice there. In a statement, AMA Trustee Dr. William G. Plested said, “It's time for Rhode Island's state and federal representatives to stand up and do what is necessary to ensure that when patients need care, physicians are there to provide it.”

The states already designated by the AMA as 'states in crisis' are Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Massachusetts, Mississippi, Missouri, New Jersey, Nevada, New York, North Carolina, Ohio, Oregon, Pennsylvania, Washington, West Virginia and Wyoming.

HHS Secretary Calls Health IT Implementation 'Urgent Priority'

HHS Secretary Mike Leavitt issued a report on May 11 citing investment in information technology (IT) as an essential, high priority for the American health care system and the U.S. economy. Secretary Leavitt said, “Working in close collaboration, the federal government and private sector can drive changes that will lead to fewer medical errors, lower costs, less hassle and better care.” In April 2004, President Bush called for personal electronic health records for most Americans within 10 years and nationwide adoption of health IT.

The ability of computer technology to prevent adverse drug reactions was called into question, however, by a study published in The Archives of Internal Medicine. Nebeker, Hoffman, Weir, Bennett, Hurdle: High Rates of Adverse Drug Events in a Highly Computerized Hospital. Arch. Intern. Med. 5/23/05. The study found that while computers help reduce errors when prescribing drugs, they do not significantly reduce the adverse drug reactions that occur because of drug selection, dosage and monitoring.

Transplant Patients Die From Rodent-Borne Disease

Three transplant patients died in April and May from lymphocytic choriomeninaitis virus (LCMV), a rodent disease they contracted from an organ donor who died of causes unrelated to the disease. LCMV infection usually is either asymptomatic or causes mild self-limited illness in otherwise healthy people. This complication is very rare. In 2003, a cluster of solid organ transplant-associated meningoencephalitis deaths in Wisconsin was determined to be associated with LCMV infection.

Joint Commission's 2006 National Patient Safety Goals

The Joint Commission on Accreditation of Healthcare Organizations announced on May 31 the 2006 National Patient Safety Goals and related Requirements for each of its accreditation programs and its Disease-Specific Care certification program. The Goals and Requirements, approved by the Joint Commission's Board of Commissioners, apply to the more than 15,000 Joint Commission-accredited and certified health care organizations and programs.

Major additions to this fourth annual issuance of National Patient Safety Goals include a new Requirement in all of the programs that “hand-offs” of patients between caregivers be standardized, with particular attention to assuring the opportunity for asking and responding to questions. This Requirement is part of the Goal: “Improve the effectiveness of communication among caregivers.”

In addition, a new Requirement, for all types of accredited organizations that provide surgical or other invasive services, specifies that all medications, medication containers and other solutions used in perioperative settings are to be labeled. This Requirement is part of the Goal: “Improve the safety of using medications.”

New Goals in other selected programs address the prevention of pressure ulcers and encourage the active involvement of patients and their families in the patient's care as a patient safety strategy. The full text of the 2006 Goals and Requirements is posted on the Joint Commission Web site, www.jcaho.org. Compliance with the Requirements or alternatives judged to be acceptable is a condition of continuing accreditation or certification for Joint Commission-accredited or certified organizations and programs.

Medical Records Must Be Released to IN Attorney General

Indiana's Attorney General, Steve Carter, has won his bid to force Indiana Planned Parenthood to turn over to his office medical records on teenaged girls who sought treatment there. He wants the records so that his office can investigate child abuse, but Planned Parenthood has fought him in a bid to protect the privacy rights of the patients whose records were sought as well as to make sure that young girls do not forgo seeking medical treatment in future for fear their medical histories will not be protected. Judge Kenneth Johnson of Marion Superior Court, who heard the case, stated that disclosure would benefit both the state and the children whose records are being sought. Planned Parenthood's representative, an attorney from the Indiana Civil Liberties Union, said he plans to appeal.

Bronx Facility Did Not Tell Patients They Might Have Cancer

Hospital officials at Jacobi Medical Center in the Bronx, NY, were fired in May after it was discovered that hundreds of women whose Papanicolaou tests (Pap tests) were taken there were never informed when those tests came back with abnormal readings. The problem was discovered when a woman whose test showed problems sought treatment for an unrelated reason. When she was informed of her Pap test result, she was surprised. During the period of time when the unfavorable results went unreported, only one clerk was in charge of reviewing the thousands of test results the hospital generated and of informing patients of a need for follow-up visits.

IHI Campaign for Patient Safety Underway

In less than 5 months, the Institute for Healthcare Improvement's (IHI) “100,000 Lives Campaign” has surpassed its goal of enlisting up to 2200 U.S. hospitals in a commitment to implement changes in care that have been proven to prevent avoidable deaths. The 100,000 Lives Campaign aims to get hospitals across the country to commit to implementing the changes, which so far include six interventions: 1) Deploy Rapid Response Teams; 2) Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction; 3) Prevent Adverse Drug Events; 4) Prevent Central Line Infections; 5) Prevent Surgical Site Infections; and 6) Prevent Ventilator-Associated Pneumonia. Downloadable “how-to” guides for implementing the six interventions are available at: http://www.ihi.org/IHI/Programs/Campaign/.

Rhode Island Joins 'States In Crisis'

On May 16, the American Medical Association added another state to its list of states in crisis due to the rising cost of medical malpractice insurance. The AMA noted that a recent survey by the Rhode Island Medical Society reported 49% of Rhode Island doctors saying they have stopped performing certain high-risk services or are considering doing so, while 48% are considering leaving the state or giving up clinical practice there. In a statement, AMA Trustee Dr. William G. Plested said, “It's time for Rhode Island's state and federal representatives to stand up and do what is necessary to ensure that when patients need care, physicians are there to provide it.”

The states already designated by the AMA as 'states in crisis' are Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Massachusetts, Mississippi, Missouri, New Jersey, Nevada, New York, North Carolina, Ohio, Oregon, Pennsylvania, Washington, West Virginia and Wyoming.