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Specimen labeling still a major risk for ID errors and huge liability

Patient identification errors continue to plague the healthcare industry despite years of efforts to eradicate this potentially disastrous problem. Understanding why patients and specimens are misidentified is key to reducing or eliminating errors, and risk managers can make progress by focusing on the human behavioral components of healthcare work.

PA hospitals cut label errors by 37%

A project designed to analyze labeling errors and devise solutions resulted in a 37% decrease in errors across nine hospitals in Pennsylvania.

Reduce ID errors with 24/7 phlebotomy

There are ways to minimize labeling errors.

Bedside barcodes reduce pharm errors

Barcoded wristbands can greatly reduce the opportunity for patient identification errors, says David Grant, RPh, MBA, vice president of pharmacy and clinical process improvement at Summit Health in Chambersburg, PA.

ECRI PSO issues caution on cardiac monitoring ID

The ECRI Institute Patient Safety Organization (PSO) recently issued a warning about a patient safety issue involving cardiac monitoring of incorrect patients. The issue was brought to ECRI Institute PSO's attention in its analysis of reports submitted by participating healthcare providers.

Surgeon whistleblower awarded $4.7 million

Cedars-Sinai Medical Center in Los Angeles will have to pay almost $4.7 million to a surgeon who claims the hospital retaliated against him for blowing the whistle on unsafe practices in his department, unless the hospital manages to have the award overturned. The hospital already has spent as much as $1 million to appeal the arbitration decision, according to the informed estimate of the plaintiff's attorney.

Clash with hospital led to restriction of duties

Court records indicate that Cedars-Sinai recruited Hrayr K. Shahinian, MD, to establish and direct its skull-base surgery program in 1996. The doctor's experience at the hospital was rocky from the start, says his attorney Robert C. Baker, JD, a partner with the law firm of Baker, Keener & Nahra in Los Angeles.

Surgeon's competence claimed to be the issue

In challenging the arbitration award of $4.7 million to a surgeon whose privileges were restricted, Cedars-Sinai Medical Center in Los Angeles alleges that the doctor's competence was in doubt.

OIG advises caution with joint ventures

The Office of Inspector General (OIG) of the Department of Health & Human Services has clarified when certain health care joint venture arrangements might be problematic and in violation of federal health care statutes and regulations.

Referrals are obstacle in joint venture plans

The Office of Inspector General (OIG) stated in its recent opinion that it has "longstanding concerns" about joint venture arrangements between a party that is in a position to refer patients to receive certain items or services and a party that is already in the business of providing such items or services, explains Brandy L. Rea, JD, an attorney with the law firm of Lathrop & Gage in Overland Park, KS.

Watch for risk factors in a joint venture

When helping to vet a proposed joint venture, watch for these red flags that government regulators have said will receive their attention, suggests Brandy L. Rea, JD, an attorney with the law firm of Lathrop & Gage in Overland Park, KS:

AHRQ: Good teamwork but weak in handoffs

When it comes to measuring patient safety, hospitals tend to receive good scores for teamwork and education, but there still is considerable room for improvement with handoffs and other concerns.

LRC: Failed coiling procedure and inadequate follow-up leads to partial paralysis, $23 million verdict

News: A 34-year-old nursing student complaining of headaches presented at a local university hospital. Diagnostic testing showed a small aneurysm. During a procedure intended to repair the aneurysm, the woman's brain was pierced.

LRC: Diagnosis delay leads to permanent blindness

A 56-year-old man with complaints of impaired balance and light headedness presented to his local hospital. A resident and attending radiologist interpreted the man's CT scan and read the scan to show old lesions. A physician assistant at the hospital diagnosed the man with vertigo and discharged him with medication. As the symptoms became more severe, the man approached his primary care physician, who completed a more thorough workup.

Healthcare Risk Management – July 1, 2011

July 1, 2011