Lawyer Doctor
Law Offices
Types of Medical Errors
Wrong Side Surgery Wrong Procedure Medication Errors
ABO Mismatch
e.g. Jesica Santillan
Laboratory Errors Other Errors
Not Following Guidelines Hypertension Cholesterol
Diabetes Heart Attack Heart Failure
Asthma
Other Sources of errors
Reduced Staffing Greed
Deaths due to Cutbacks in Staffing
Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.

JAMA 2002 Oct 23-30;288(16):1987-93

Excess patient load for nurses associated with a 7% increase in the likelihood of death for each excess patient per nurse.

GREED
OPERATING PROFIT - Mining Medicare
: How One Hospital Benefited on Questionable Operations

New York Times

August 12, 2003 A-1; Jonathan Kirshner for The New York Times

Could it possibly be that doctors at his hospital in Redding, Calif., were cracking open the chests of perfectly healthy people?

Tenet Healthcare agreed to pay $54 million to the government to resolve accusations that Redding Medical doctors conducted unnecessary heart procedures and operations on hundreds of healthy patients.

Until federal agents raided Redding last fall, Tenet's business model was based on maximizing the dollars it could collect from Medicare, the nation's biggest buyer of health care. And Medicare's complex formulas — the template for private insurers, as well — reward some kinds of health care more richly than others, and few more richly than cardiac care.

On multiple occasions, staff cardiologists raised concerns about the heart program and asked for an independent peer review. None was undertaken.

JCAHO Sentinel Event Database (2005)

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reviewed Sentinel Events to study the root causes of adverse patient outomes. —See: The Joint Commission's Sentinel Event Database. 2005 .

Their 2966 sentinel events included:
415 inpatient suicides
370 events of surgery at the wrong site
365 operative/post op complications
326 events relating to medication errors
221 deaths related to delay in treatment
144 patient falls
124 deaths of patients in restraints
107 assault/rape/homicide
85 transfusion-related events
84 perinatal death/injury
57 infection-related events
57 deaths following elopement
51 fires
49 anesthesia-related events
511 other

    The following root causes were identified (in decreasing order of occurrence);
        Organization culture
        Care planning
        Continuum of care
        Leadership
        Environmental safety / security
        Procedural compliance
        Competency/credentialing
        Availability of information
        Staffing
        Patient assessment
        Orientation/training
        Communication

For more information, Visit the Joint Commission Web Site