Kaiser learns from tragic medical errors


In 2004 and 2005 South Bay /*Kaiser*/ facilities were facing a stunning medical emergency. In less than a year's time, there were four preventable deaths.

In October of 2004, a 77-year-old man died when he was given solid food against doctor's orders. On Christmas Eve, a 64-year-old man died after getting a double dose of stroke medication.

In July of 2005, a 12-year-old girl died after she received a double dose of her drug. In august, 21-year-old Chris Wibeto died after getting a chemo drug intended for another patient.

Barbara Crawford joined /*Kaiser Permanente*/ in 2005 as Vice President of Kaiser's Quality and Regulatory Services.

"These were not just human errors but they were errors associated with our systems where we had system breakdowns," said RN Barbara Crawford of Northern California.

It was not just the internal breakdowns and tragic consequences that rocked the medical care system. Just as shocking was the way medical errors were reported, investigated and buried in mounds of paperwork.

Hospitals routinely delayed the reporting of medical errors and when they did, the state Department of Public Health had six months to carry out an investigation and no authority to fine a hospitals.

The only way anyone found out about a deadly mistake is to do what ABC7 News did. Go through hospital files held at one of 17 district offices around the state.

It was only then that preventable deaths came to light. The deaths and the reporting system outraged State Senator Elaine Alquist from San Jose.

"The problem has been buried and so we try to get to the bottom of it which is a hard thing and certainly you helped a lot on that and to have a plan and fix it," said Alquist.

The senator authored two pieces of legislation signed by the governor that went into affect last year.

SB 1301 requires hospitals to report so called "adverse events" within 24 hours to five days depending on the nature of the error. It also requires the state to respond quickly and finish its investigation in 45 days, not six months.

SB 1312 gave the state the ability to fine hospitals up to $25,000 for deficiencies and the department can increase that fine to $50,000 in the future.

The first ever fines went out last October to nine hospitals.

This March, another round of fines were imposed on 11 hospitals. Just as important, the reasons for those administrative penalties were made public through press releases and on the web.

Kathleen Billingsley is the deputy director for /*California's Department of Public Health*/.

"We believe all providers benefit from seeing the type of enforcement activities that we conduct because we have found that the hospitals are going back and looking that their own systems to see if they have systems in place that can prevent medication errors," said Billingsley.

The state and hospitals are now sharing best practices to reduce medication errors.

In responding to its own problems, Kaiser is now widely regarded as a leader in adopting both low and high tech solutions to improve patient safety.

One idea came from the nurses themselves.

"They said tape off a quiet zone for us and when we're in a quiet zone no one can talk to us while were preparing medications," said Crawford.

A Kaiser video shows how yellow vests are also used to alert colleagues not to talk to or distract nurses carrying out certain duties.

High risk medications are clearly marked and Kaiser is investing in bar coding patients and medications.

The technology has worked for decades in grocery stores and provides a number of checks to make sure the right medication has been ordered for the right patient and is delivered at the right time, in the right dose and right manner.

The computerized system helps to eliminate mistakes.

"It will alert the nurse that this is perhaps the wrong time and the wrong dose or the wrong medication for the wrong patient," said Jennifer Reber, RN from Kaiser Antioch.

Kaiser is on track to have all of its Northern California hospitals using bar coding by 2010.

Jonah Frohlich is with the California Healthcare Foundation. He says only 11 percent of hospitals have implemented this proven technology.

"So without these kinds of systems in place, it's more challenging for hospitals to provide better quality and safer care in hospitals," said Frolich.

Until expensive bar coding systems become more common, the state says it beefed up inspections and training programs are making a difference.

It is now working on putting more of that hospital safety information in the hands of the public.

"We are creating the infrastructure that will allow us to communicate with consumers and all of the public information regarding our findings and the status of the hospitals," said Billingsley.

Alquist says she will be pushing the department to meet or beat a requirement to have a transparent rating system for hospitals in place by 2015.

"I'm going to be here awhile and it's really important that we do this as quickly as possible because we are talking about saving people's lives," said Alquist.

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