Report: No Drop In Medical Errors, But Their Human Toll Endures

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A cremation box with the ashes of Elaine Whitney sits on a table in the home of her daughter, Diana Mamouni. (Jesse Costa/WBUR)
A cremation box with the ashes of Elaine Whitney sits on a table in the home of her daughter, Diana Mamouni. (Jesse Costa/WBUR)

Diana Mamouni is a nurse, but she says she couldn’t get her mother’s caregivers to provide important basic care. She attributes her mother’s decline and death to a series of crucial lapses in care over a six-month period.

“When people think ‘medical error’ they're like, ‘Oh, they were supposed to get this drug, and they got this instead.’ Or they think of a one-time thing,” Mamouni says. But she says her mother’s case was “a whole systemic ‘Eh... I don't care.’ It's like she was ‘meh'd’ to death, you know?”

A key point of Mamouni’s story is that medical errors don't always involve flashing neon mistakes. They often involve a cascade of omissions that never get acknowledged, much less counted.

Think about that as you consider a new report from state officials on the frequency and costs — financial and human — of medical errors in Massachusetts. The report estimates that at least 62,000 medical errors occur every year — 170 a day on average. Almost a third cause serious harm. And an additional 12% — many thousands every year — involve death.

And the emotional trauma medical errors inflict on patients and their loved ones often endures for years, officials found.

The extra care required following medical injuries adds up to at least $617 million a year in excess health care costs. This number does “not come close to representing the full financial cost of medical care,” the report says, because it doesn’t account for lost income, malpractice claims and other indirect costs.

And even though the report finds that one of every five Massachusetts residents, or someone in their family, has suffered a medical error, this too is almost certainly an underestimate.

Some medical injuries, like the errors of omission that Mamouni’s mother suffered from, don’t show up in medical claims data or any official count. Others, such as missed diagnoses, misdiagnoses and delayed diagnoses, never get recorded.

“It's reasonable to conclude that these numbers are actually a significant underestimate of the numbers of errors you would find statewide if you could,” says Barbara Fain, executive director of the Betsy Lehman Center for patient safety, which compiled the report.

Comparing these numbers to the Betsy Lehman Center’s last report on medical errors in Massachusetts nearly five years ago, it’s clear the problem hasn’t improved.

“We are working hard but not making progress at the pace … we can as an industry,” says Kim Hollon, CEO of Signature Healthcare in Brockton. “I don’t think we’re even halfway where we can be.”

The Betsy Lehman Center is named for a Boston Globe health columnist who died from a catastrophic chemotherapy overdose nearly 25 years ago. Lehman’s tragedy is widely considered to have marked the beginning of a movement to stop preventable medical injuries.

The report draws on massive amounts of health insurance claims, studies on the frequency of errors that don’t show up in bills and a survey of 5,000 Massachusetts residents on their own experiences of medical injury, the largest statewide survey so far.

“Errors happen in all health care settings — basically anywhere health care is delivered,” Fain says. “They happen in medical offices. They can happen in a retail pharmacy. They happen in nursing homes. And they happen in … what should be very routine care.”

Diana Mamouni on the balcony of her condominium in North Andover. (Jesse Costa/WBUR)
Diana Mamouni on the balcony of her condominium in North Andover. (Jesse Costa/WBUR)

That’s what happened to Elaine Whitney, Mamouni’s mother. The North Shore woman developed congestive heart failure, or CHF, in her early 70s. It’s a very common condition among people like her who’ve survived heart attacks. And that means caregivers should be familiar with how it should be treated.

“It's not an automatic death sentence, or ‘Oh, CHF, you have six months.’ It's not that sort of thing,” Mamouni says. “People live with this for years.”

As a nurse, Mamouni knew the main danger for her mother was that fluid could build up in her lungs and throughout her body. So it was vital that she be weighed regularly — preferably every day — to see if fluid was accumulating. If it were, medicines could drain off excess fluid, ease breathing and lessen the burden on her heart.

“If you have congestive heart failure, no matter what stage you’re in, [it’s] daily weight, daily weights. It is that basic,” Mamouni says.

The problem was, Whitney wasn’t getting weighed. When Mamouni asked why, she says, “I get the response: ‘Daily weight? We don’t do that in this facility.’”

By the time Whitney was weighed, she’d put on 30 pounds of excess fluid.

“She’s lying in bed, she’s using all her extra muscles to breathe, she has no energy, she is literally gasping like a fish on the dock,” Mamouni recalls. “It’s heartbreaking.”

At one point, Whitney began complaining of intestinal pain. But the problem wasn’t picked up until she ran a high fever — a sign of sepsis, or generalized infection.

“It turned out there was an obstruction in her intestines,” Mamouni says. “And when … they realized she was septic, she’s shipped off to St. Elizabeth’s [Medical Center] where they do an emergency resection and colostomy. And that emotionally for her was a big kick. She never recovered from that surgery.”

Whitney died in October 2017. More than a year and a half later, her daughter is clearly anguished about what happened.

And that brings us to another important point in the new report. The 5,000 interviews the Betsy Lehman Center commissioned show that people who’ve suffered medical injuries, or are close to someone who has, experience long-term effects.

As long as six years after the error occurred, 21% of victims or their relatives were still depressed. More than a quarter were still angry, anxious or felt abandoned or betrayed by caregivers.

And a substantial number of error victims — more than one in three — say they still avoid medical care years afterward.

Dr. Thomas Gallagher of the University of Washington is a leading proponent of what he calls “disclosure and resolution” following medical harm. “We don’t do a good job in health care of responding to these events and communicating about them with patients,” he says. “And that just compounds their suffering.”

But the emotional effects were sharply reduced among the minority of people who said care providers communicated openly after an injury and offered apology and support. So that’s one big thing caregivers and institutions can do to reduce the lasting toll that medical injuries impose on patients and families — at least after they’ve occurred, the report suggests.

Preventing them from happening in the first place is a bigger and more complex problem.

The first step is to track the injuries that occur. More than half happen in hospitals — at least 35,000 a year, the report estimates. But only a tiny fraction get reported — 922 “serious reportable events” in 2017, according to the most recent state data. That likely reflects both a failure to report and the limited kinds of things that must be reported, officials say.

Some hospitals are trying to stop errors from slipping through the cracks.

Hollon of Signature Healthcare in Brockton says staffers at his hospital gather routinely in “employee huddles that ask every day was there anyone that was harmed in the last 24 hours. And that rolls all the way up to our executive team every day at 4:30. And we keep track of that.”

More than they realize, patients and those close to them can play an important role. Studies show they’re very good at spotting problems in their care, but often don’t speak up if something doesn’t seem right.

Linda Kenney of the Betsy Lehman Center — a victim herself of a nearly fatal anesthesia error — says they should.

“And if somebody isn’t listening, there are things you can do,” Kenney says.

To get caregivers’ attention, she suggests using a magic phrase: “How do I get in touch with the risk manager?” Every hospital has one. Their job is to minimize the risk of harm — and of malpractice suits.

But what about patients outside of hospitals? Kenney urges them, or those close to them, to pick up the phone and call the Betsy Lehman Center.

“We have resources throughout the state,” Kenney says. “It's hard to find those unless you know, but we've been doing this for a long time, so we'll be easier to give them resources. And if we don't have the resources we'll find them. We know people who know people.”

This segment aired on June 10, 2019.


Richard Knox Senior Correspondent, CommonHealth
Richard Knox is a senior correspondent for WBUR's CommonHealth.



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